First-of-kind guideline outlines surveillance of premalignant gastric conditions
Goals of the new guideline from the American College of Gastroenterology include reducing gastric cancer incidence, improving the detection of early-stage disease, and significantly increasing five-year survival rates.
A first-of-its-kind guideline outlines surveillance strategies for patients with gastric premalignant conditions.
The guideline by the American College of Gastroenterology advises on endoscopic surveillance and diagnosis for high-risk patients with gastric premalignant conditions (GPMC), including use of high-quality and image-enhanced endoscopy. It addresses histology criteria and reporting, endoscopic treatment of dysplasia, the role of Helicobacter pylori eradication, general risk reduction measures, and management of autoimmune gastritis and gastric epithelial polyps. The guideline was published by the American Journal of Gastroenterology on March 12.
The guideline notes that gastric cancer (GC) incidence rates are two- to 13-fold greater in non-White patients in the U.S., especially early-generation immigrants from regions of high incidence. The five-year survival rate of these cancers in the U.S. is 36%, driven by the small percentage diagnosed in early, curable stages.
The guideline recommends against routine screening with upper endoscopy for GC and GPMC in the general population (very low quality of evidence, conditional recommendation). It did not make a recommendation on opportunistic screening in high-risk individuals based on immigration status, race and ethnicity, or certain environmental factors (insufficient evidence, no recommendation). The guideline recommended against using noninvasive biomarker screening or surveillance (very low quality of evidence, conditional recommendation).
Patients undergoing upper endoscopy should receive high-quality endoscopic evaluation using high-definition white light endoscopy and image-enhanced endoscopy (low quality of evidence, conditional recommendation).
High-risk patients with gastric intestinal metaplasia should undergo endoscopic surveillance at three-year intervals. Risk is judged based on histology, but also a family history of GC in a first-degree relative, born outside the U.S. with emigration from a high-incidence nation, and high-risk race or ethnicity, including East Asian, Latino/a, Black, and American Indian and Alaska Native individuals (very low quality of evidence, conditional recommendation).
The guideline recommends testing for and eradicating H. pylori in patients with GPMC and resected early GC to reduce the risk for progression to GC and metachronous early GC, respectively (moderate quality of evidence, strong recommendation). It did not suggest the use of aspirin, NSAIDs, cyclooxygenase-2 inhibitors, or antioxidants for chemoprevention (very low quality of evidence, conditional recommendation).
“These ACG Guidelines for the management of GPMC are a paradigm shift in US clinical practice,” the guideline concluded. “Implementation and change in clinical practice will require concrete targets and include training and quality initiatives. It is anticipated that this will begin to address the marked US GC disparity, and the burden on minority and marginalized populations.”