Compared with placebo, Helicobacter pylori eradication treatment in patients with the infection and a first-degree relative with gastric cancer reduced the risk of gastric cancer in a randomized trial. Researchers in South Korea enrolled 1,838 patients ages 40 to 65 years and randomly assigned them to receive either eradication treatment (amoxicillin, 1000 mg; clarithromycin, 500 mg; and lansoprazole, 30 mg) or placebo twice per day for seven days. The modified intention-to-treat population included 1,676 participants, 832 in the treatment group and 844 in the placebo group. During a median follow-up of 9.2 years, gastric cancer developed in 10 participants (1.2%) in the treatment group and in 23 (2.7%) in the placebo group (hazard ratio, 0.45; 95% CI, 0.21 to 0.94; P=0.03). While adverse effects were more common in the treatment group compared with the placebo group (53.0% vs. 19.1%; P<0.001), patients usually rated them as mild.
The study was published online on Jan. 30 by the New England Journal of Medicine. The following commentary, by ACP Member Joseph J. Jennings, MD, appeared in the ACP Journal Club section of the June 16 Annals of Internal Medicine.
The trial by Choi and colleagues showed a reduction in gastric cancer with treatment of H pylori infection in patients with a family history of gastric cancer in a first-degree relative. Previous studies have supported the connection between H pylori and gastric cancer and showed that H pylori eradication is associated with reduced risk for gastric cancer. There are no current guidelines in the USA for routine screening for gastric cancer or asymptomatic H pylori status, although the current American College of Gastroenterology guidelines recommend eradication treatment when H pylori is identified to reduce the risk for gastric cancer.
Results of the trial support the argument for a test-and-treat screening approach for patients with a first-degree relative with gastric cancer, but there are some limitations. The study population was from a single center in South Korea, so generalizability of the results to other populations will need to be evaluated in further studies. Patients received biennial endoscopy, which is not the current standard of care for patients with a family history of gastric cancer. This and the median follow-up of 9.2 years may have affected the low rates of mortality from gastric cancer. Although cost-effective methods for identifying H pylori infection exist (e.g., breath testing, stool testing), expanded use of endoscopy to follow up patients as in this trial may increase costs and adverse events related to procedures and sedation. The treatment group had a higher rate of any adverse event, which is expected given the side effects of H pylori eradication therapies. No complications related to endoscopy were reported, and adverse events were all classified as mild.
Ultimately, given the mortality associated with gastric cancer, the trial by Choi and colleagues identified a high-risk population for whom identification and eradication of H pylori may be beneficial. Further studies in more diverse populations with longer follow-up are needed before we consider universal H pylori screening and treatment in patients with a first-degree relative with gastric cancer.