BMJ  2004;328 (24 April), doi:10.1136/bmj.328.7446.0-e

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Eradication of chronic H pylori reduces risk of gastric cancer

Question Does treatment of Helicobacter pylori infection reduce the risk of gastric cancer?

Synopsis Although chronic H pylori infection is associated with an increased risk of gastric cancer, it is uncertain whether treatment reduces risk. A total of 1630 healthy, asymptomatic, adult carriers of H pylori were identified by screening in the Fuzian province of China, a high risk area. All subjects underwent endoscopy and 988 did not have precancerous lesions on entry to the study. Patients were randomly assigned in a double blind fashion (uncertain allocation assignment) to receive H pylori eradication treatment with a two week course of 20 mg omeprazole, a 750 mg combination product of amoxicillin and clavulanate (Augmentin), and 400 mg metronidazole, all twice daily, or placebo. Individuals assessing outcomes were blinded to treatment group assignment. Ninety per cent of patients were available for the primary analysis (receiving treatment) after eight years of follow up. A total of 18 new cases of gastric cancer were diagnosed. The risk of developing cancer was not significantly reduced in participants who received H pylori eradication treatment compared with those who did not (7 cases v 11 cases; P = 0.33). In the subgroup who had no precancerous lesions on presentation, H pylori eradication treatment did significantly reduce the risk of gastric cancer compared with placebo (0 cases v 6 cases; P = 0.02).

Bottom line Asymptomatic carriers of Helicobacter pylori with no endoscopically determined precancerous gastric lesions are less likely to develop gastric cancer after eradication treatment. For most primary care clinicians, these patients will rarely, if ever, fall under their purview (most tests are ordered for patients with symptoms). We will need more evidence regarding long term outcomes and cost-benefit analyses before we can justifiably screen all adults for H pylori infection.

Level of evidence 1b (see www.infopoems.com/levels.html). Individual randomised controlled trials (with narrow confidence interval).

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Wong BC, Lam SK, Wong WM, et al. Helicobacter pylori eradication to prevent gastric cancer in a high-risk region of China. A randomized controlled trial. JAMA 2004;291; 187-94[Abstract/Free Full Text].

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^* Patient-Oriented Evidence that Matters. See editorial ( BMJ 2002;325: 983[Free Full Text])

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