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    Prevention of Gastric Cancer

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    Andhika Bintang Mahardhika
    This year, it is estimated that more than 700 000 people will die of gastric cancer, making this disease the third most common cause of cancer death globally. 1 Al- though gastric cancer rates have been declining by ap- proximately 2% per year, the numbers of cases and deaths are expected to increase in coming years, reflect- ing increasing numbers of older (and thus, higher-risk) individuals in the world. Despite its importance, gastric cancer receives little attention from research funding agencies or public health organizations. For example, the National Cancer Institute annually spends approxi- mately $12 million on programs directly related to gas- tric cancer, just 0.2% of its budget, and only 10% of this amount is allocated for prevention research. 2 In con- trast, the annual cost of treating gastric cancer in the United States, a lower-risk country, is estimated at ap- proximately $2 billion.

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    Prevention of Gastric Cancer

    Uploaded by

    Andhika Bintang Mahardhika
    29 views2 pages
    This year, it is estimated that more than 700 000 people will die of gastric cancer, making this disease the third most common cause of cancer death globally. 1 Al- though gastric cancer rates have been declining by ap- proximately 2% per year, the numbers of cases and deaths are expected to increase in coming years, reflect- ing increasing numbers of older (and thus, higher-risk) individuals in the world. Despite its importance, gastric cancer receives little attention from research funding agencies or public health organizations. For example, the National Cancer Institute annually spends approxi- mately $12 million on programs directly related to gas- tric cancer, just 0.2% of its budget, and only 10% of this amount is allocated for prevention research. 2 In con- trast, the annual cost of treating gastric cancer in the United States, a lower-risk country, is estimated at ap- proximately $2 billion.

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    This year, it is estimated that more than 700 000 people will die of gastric cancer, making this disease the third most common cause of cancer death globally. 1 Al- though gastric cancer rates have been declining by ap- proximately 2% per year, the numbers of cases and deaths are expected to increase in coming years, reflect- ing increasing numbers of older (and thus, higher-risk) individuals in the world. Despite its importance, gastric cancer receives little attention from research funding agencies or public health organizations. For example, the National Cancer Institute annually spends approxi- mately $12 million on programs directly related to gas- tric cancer, just 0.2% of its budget, and only 10% of this amount is allocated for prevention research. 2 In con- trast, the annual cost of treating gastric cancer in the United States, a lower-risk country, is estimated at ap- proximately $2 billion.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    29 views2 pages

    Prevention of Gastric Cancer

    Uploaded by

    Andhika Bintang Mahardhika
    This year, it is estimated that more than 700 000 people will die of gastric cancer, making this disease the third most common cause of cancer death globally. 1 Al- though gastric cancer rates have been declining by ap- proximately 2% per year, the numbers of cases and deaths are expected to increase in coming years, reflect- ing increasing numbers of older (and thus, higher-risk) individuals in the world. Despite its importance, gastric cancer receives little attention from research funding agencies or public health organizations. For example, the National Cancer Institute annually spends approxi- mately $12 million on programs directly related to gas- tric cancer, just 0.2% of its budget, and only 10% of this amount is allocated for prevention research. 2 In con- trast, the annual cost of treating gastric cancer in the United States, a lower-risk country, is estimated at ap- proximately $2 billion.

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    of 2

    Opinion

    VIEWPOINT

    Rolando Herrero, MD,


    PhD
    Section of Early
    Detection and
    Prevention,
    International Agency
    for Research on Cancer,
    Lyon, France.
    Julie Parsonnet, MD
    Department of
    Medicine, Stanford
    University Medical
    Center, Stanford,
    California.
    Edwin Robert
    Greenberg, MD
    Division of Public
    Health Sciences, Fred
    Hutchinson Cancer
    Research Center,
    Seattle, Washington.

    Corresponding
    Author: Rolando
    Herrero, MD, PhD,
    Section of Early
    Detection and
    Prevention,
    International Agency
    for Research on Cancer,
    150 Cours Albert
    Thomas, 69372 Lyon,
    France (herreror@iarc
    .fr).

    Prevention of Gastric Cancer


    This year, it is estimated that more than 700 000
    people will die of gastric cancer, making this disease the
    third most common cause of cancer death globally.1 Although gastric cancer rates have been declining by approximately 2% per year, the numbers of cases and
    deaths are expected to increase in coming years, reflecting increasing numbers of older (and thus, higher-risk)
    individuals in the world. Despite its importance, gastric
    cancer receives little attention from research funding
    agencies or public health organizations. For example, the
    National Cancer Institute annually spends approximately $12 million on programs directly related to gastric cancer, just 0.2% of its budget, and only 10% of this
    amount is allocated for prevention research.2 In contrast, the annual cost of treating gastric cancer in the
    United States, a lower-risk country, is estimated at approximately $2 billion.3
    Of the 989 000 gastric cancer cases in the world
    in 2008, an estimated 770 000 could be attributed to
    chronic infection with Helicobacter pylori.4 Although
    there have been calls to prevent gastric cancer by
    screening for this infection and treating individuals
    who test positive, no randomized trial had shown a
    clear benefit of this approach until recently. In 2012, a
    trial in a general population of adults in China reported
    a statistically significant reduction in gastric cancer risk
    following treatment (4.6% in the control group vs
    3.0% in the treated group; odds ratio, 0.61 [95% CI,
    0.38-0.96]),5 and a meta-analysis of 6 reported randomized trials among asymptomatic adults has estimated a similar benefit (2.4% in the control group vs
    1.6% in the treated group; relative risk, 0.66 [95% CI,
    0.46-0.95]).6 Reduced risk of subsequent gastric cancer was also seen in 2 randomized trials of H pylori
    treatment after endoscopic mucosal resection of early
    gastric cancer.6
    Although these data support screening for and treating H pylori infection, important uncertainties remain.
    The trials, even viewed in aggregate, do not permit precise estimation of the benefits or possible harms of the
    interventions, and the relative lack of success of antibiotic regimens used in some trials likely attenuated observed effects. Trial participants were principally middleaged Asian adults, so the generalizability of results to
    other populations is uncertain and no trial provided direct data on the performance of programs applied in
    community settings.
    Population-based H pylori treatment has been
    shown to reduce clinical visits for dyspepsia symptoms7
    and may also prevent peptic ulcers. Possible harms include increased risk of esophageal adenocarcinoma. Reported protective associations between H pylori infection and asthma, other allergic diseases, obesity, diarrheal
    diseases, and activation of latent tuberculosis are of uncertain significance and may not reflect a causal role.

    Population-based H pylori treatment could select for antibiotic-resistant pathogens in the community, although in many countries, such an effect might be overshadowed by indiscriminate use of antibiotics for other
    human and veterinary purposes. Treating H pylori will alter the overall composition of the intestinal flora; the
    health consequences are unknown.
    Screening and treatment for H pylori is generally acceptable and affordable. An inexpensive serological test
    can determine who may be infected, with a sensitivity
    and specificity that could be sufficient for populationbased prevention programs. Low-cost treatment regimens using 2 or 3 generic antibiotics plus a proton pump
    inhibitor for 7 to 14 days can eradicate the infection in
    more than 80% of cases, depending on the antibiotic resistance patterns of H pylori within the population.8 Economic modeling studies indicate that H pylori screening and treatment strategies are cost-effective under a
    large range of assumptions about effectiveness and
    costs.9 However, the models are limited by reliance on
    observational data rather than randomized trial results, by a lack of information on possible adverse effects of treatment, and by limited data from lowerincome countries.
    In December 2013, a working group meeting convened by the International Agency for Research on
    Cancer reviewed evidence regarding eradication of
    H pylori as a strategy for gastric cancer prevention and
    prepared a technical report.10 The participants in the
    working group concluded that the large global burden
    of gastric cancer and the feasibility of treating its principal cause make this disease a logical target for intervention. They further called for countries with high
    rates of gastric cancer to focus more resources on this
    condition, to include it within their national cancer
    control programs, and to assess its human and economic effects and the potential value of prevention
    strategies.
    Within the next 10 years, results from several
    ongoing randomized trials will likely resolve many
    uncertainties about H pylori screening and treatment.
    Nevertheless, practical questions about the implementation and outcomes of population-based gastric
    cancer prevention programs could best be answered
    by direct observation in the communities where they
    are applied. National health authorities should consider conducting demonstration programs of H pylori
    screening and eradication using designs that can provide an unbiased assessment of program effectiveness. The determination of whether and how to
    undertake such programs will require population data
    about gastric cancer rates and H pylori infection
    prevalence, information that also may identify subpopulations at particularly elevated risk (eg, immigrants from high-risk countries). From a practical

    jama.com

    JAMA September 24, 2014 Volume 312, Number 12

    Copyright 2014 American Medical Association. All rights reserved.

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    Opinion Viewpoint

    standpoint, many countries will first need to develop more effective systems for determining and tabulating causes of death and
    for cancer registration. Locally derived data on antibiotic resistance in H pylori, treatment regimen effectiveness, and reinfection rates will also be useful for planning.
    The particular features of an intervention, such as the target age,
    screening approach, and treatment regimen, can be adapted based
    on the results of cost-effectiveness models, available resources, and
    prevailing medical and public health practices. Any programs that
    ARTICLE INFORMATION
    Conflict of Interest Disclosures: All authors have
    completed and submitted the ICMJE Form for
    Disclosure of Potential Conflicts of Interest and
    none were reported.
    REFERENCES
    1. International Agency for Research on Cancer.
    Stomach cancer. Estimated incidence, mortality and
    prevalence worldwide in 2012. http://globocan.iarc
    .fr/old/FactSheets/cancers/stomach-new.asp.
    Accessed April 25, 2014.
    2. National Cancer Institute at the National
    Institutes of Health. A snapshot of stomach cancer.
    http://www.cancer.gov/researchandfunding
    /snapshots/stomach. Accessed July 22, 2014.
    3. Mariotto AB, Yabroff KR, Shao Y, Feuer EJ,
    Brown ML. Projections of the cost of cancer care in

    1198

    are implemented should include objective assessments of feasibility, acceptance, costs, effectiveness, and adverse consequences;
    these results must be made available in the public domain. A clusterrandomized trial design with staged implementation is a possible assessment strategy.
    Ignoring gastric cancer in the hope that it will soon disappear is
    not a tenable health policy. Implementing large, population-based
    evaluationprogramsofHpyloriscreeningandtreatmentoffersapromising opportunity to prevent deaths from this important cancer.

    the United States: 2010-2020. J Natl Cancer Inst.


    2011;103(2):117-128.
    4. Plummer M, Franceschi S, Vignat V, Forman D,
    de Martel C. Global burden of gastric cancer
    attributable to Helicobacter pylori [published online
    May 29, 2014]. Int J Cancer. doi:10.1002/ijc.28999.
    5. Ma JL, Zhang L, Brown LM, et al. Fifteen-year
    effects of Helicobacter pylori, garlic, and vitamin
    treatments on gastric cancer incidence and
    mortality. J Natl Cancer Inst. 2012;104(6):488-492.
    6. Ford AC, Forman D, Hunt RH, Yuan Y, Moayyedi
    P. Helicobacter pylori eradication therapy to prevent
    gastric cancer in healthy asymptomatic infected
    individuals: systematic review and meta-analysis of
    randomised controlled trials. BMJ. 2014;348:g3174.
    7. Lane JA, Murray LJ, Noble S, et al. Impact of
    Helicobacter pylori eradication on dyspepsia, health

    resource use, and quality of life in the Bristol


    helicobacter project: randomised controlled trial.
    BMJ. 2006;332(7535):199-204.
    8. Gatta L, Vakil N, Vaira D, Scarpignato C. Global
    eradication rates for Helicobacter pylori infection:
    systematic review and meta-analysis of sequential
    therapy. BMJ. 2013;347:f4587.
    9. Lansdorp-Vogelaar I, Sharp L. Cost-effectiveness
    of screening and treating Helicobacter pylori for
    gastric cancer prevention. Best Pract Res Clin
    Gastroenterol. 2013;27(6):933-947.
    10. International Agency for Research on Cancer.
    IARC Working Group Reports. Helicobacter pylori:
    eradication as a strategy for preventing gastric
    cancer. http://www.iarc.fr/en/publications
    /pdfs-online/wrk/wrk8/. Accessed August 28, 2014.

    JAMA September 24, 2014 Volume 312, Number 12

    Copyright 2014 American Medical Association. All rights reserved.

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