BACKGROUND The magnitude of the association between Helicobacter pylori and incidence of gastric cancer is unclear.H pylori infection and the circulating antibody response can be lost with development of cancer; thus retrospective studies are subject to bias resulting from classification of cases as H pylori negative when they were infected in the past.

AIMS To combine data from all case control studies nested within prospective cohorts to assess more reliably the relative risk of gastric cancer associated with H pylori infection. To investigate variation in relative risk by age, sex, cancer type and subsite, and interval between blood sampling and cancer diagnosis.

RESULTS Twelve studies with 1228 gastric cancer cases were considered. The association withH pylori was restricted to non-cardia cancers (OR 3.0; 95% CI 2.3–3.8) and was stronger when blood samples for H pylori serology were collected 10+ years before cancer diagnosis (5.9; 3.4–10.3). H pylori infection was not associated with an altered overall risk of cardia cancer (1.0; 0.7–1.4).

CONCLUSIONS These results suggest that 5.9 is the best estimate of the relative risk of non-cardia cancer associated with H pyloriinfection and that H pylori does not increase the risk of cardia cancer. They also support the idea that when H pylori status is assessed close to cancer diagnosis, the magnitude of the non-cardia association may be underestimated.