Summary of consensus recommendations for screening and eradication of H. pylori for gastric cancer prevention
| No. | Statement | Agree | Evidence level | Limitations of current evidence and areas for future research |
| Disease burden of H. pylori infection-associated gastric cancer | ||||
| 1 | Although the global age-standardised incidence and mortality rate of gastric cancer is decreasing, the number of new cases of gastric cancer remains high due to an increase of the elderly population | 96% | Moderate | Lack of cancer registration database in many countries or regions; updated prevalence of H. pylori needed for more accurate estimation of future disease burden |
| 2-1. | Although the prevalence of H. pylori is decreasing in most Western countries, it remains high in populations with a high incidence of gastric cancer | 96% | Low | Lack of updated prevalence in many countries; potential selection bias, age-standardised prevalence not reported and accuracy of test not validated in some studies |
| 2-2. | The prevalence of H. pylori in children has fallen below 10% in some populations, but remains high in many parts of the world | 96% | Low | Lack of updated prevalence in many countries and potential selection bias |
| 3. | The worldwide attributable fraction for H. pylori in gastric cancer (GC) is higher than 85%, indicating that the majority of GC can be prevented if H. pylori infection is eliminated from a population | 88% | Moderate | Estimation based on nested case–control studies in Western populations |
| 4. | Eradication of H. pylori reduces the risk of gastric cancer in infected subjects | 92% | Moderate | Trials conducted in Eastern populations, except one from Columbia, number of cases of gastric cancer relatively small; progression of gastric precancerous lesions as primary outcome in several trials, risk reduction for intestinal type and diffuse type not known, long-term adverse consequences not assessed, eradication rate ~70%, reinfection rate ~2–7%/year |
| 5. | Eradication of H. pylori after resection of early gastric cancer is recommended because it reduces the risk of metachronous gastric cancer | 96% | High | Nearly all were intestinal type gastric cancer |
| Implementation of H. pylori screening and eradication programme at population level | ||||
| 6. | Screening and eradication of H. pylori for gastric cancer prevention is recommended in populations with a high incidence or high risk of gastric cancer | 84% | Low | Estimation derived from cost-effectiveness analysis, lack of direct evidence from randomised trial, prevalence of H. pylori should also be considered |
| 7. | Screening and eradication of H. pylori before the development of atrophic gastritis and intestinal metaplasia is recommended | 84% | Low | Lack of direct evidence from randomised trials, the age of development of precancerous lesions varies according to gender and ethnicity |
| 8. | The strategy of screen-and-treat for H. pylori infection is most cost-effective in young adults for gastric cancer prevention in regions with a high incidence of gastric cancer | 84% | Low | Assumption based on observational studies rather than randomised trials, saving related to dyspepsia or peptic ulcer disease rarely considered in the models, benefit reported by life-years saved rather than QALYs |
| 9. | Young individuals would benefit most from H. pylori eradication because it cures H. pylori related gastritis, reduces the risk of gastric cancer and reduces transmission to their children | 92% | Low | Lack of randomised trials showing the reduction of gastric cancer risk in young individuals and the transmission |
| 10. | A urea breath test or H. pylori stool antigen test are the preferred tests for mass screening, but a locally validated serology test may be considered | 88% | Moderate | Lack of direct comparison of the accuracy and acceptability of three non-invasive tests in mass screening |
| 11. | In H. pylori infected individuals, endoscopy is additionally recommended for those with a higher risk for gastric cancer | 100% | Low | Prospective studies needed for risk stratification in populations with different incidence of gastric cancer |
| 12. | Population-wide screening and eradication of H. pylori infection should be integrated or included in national healthcare priorities to optimise the resources | 92% | Low | Population-wide screening and eradication programme only in Japan and some regions in China, Korea and Taiwan |
| Treatment of H. pylori infection in mass eradication programmes | ||||
| 13. | There is a trend of increasing resistance rates to clarithromycin and levofloxacin worldwide | 100% | Low | Treatment-experienced subjects not excluded in some, different breakpoint of MICs used, lack of updated data in many countries |
| 14. | The antibiotic resistance profile of H. pylori in different regions, efficacy, adverse effects and cost should be taken into account in choosing the optimal regimens in the community | 100% | Low | Priority of efficacy, adverse effects and cost in community settings remains debatable |
| 15 | Reliable locally effective regimens based on the principles of antibiotic stewardship are recommended | 92% | Moderate | The impact of following the antibiotic stewardship principle needs to be assessed in the community |
| 16. | Surveillance of the local antibiotic resistance of H. pylori is recommended to identify the optimal empirical therapy for mass eradication of H. pylori in that population | 96% | Moderate | Resistance rate might vary in different regions in the same country and may change with time |
| 17. | The reinfection rate after H. pylori eradication is very low | 96% | Moderate | Few studies reported the reinfection rate in the mass screening and eradication in the community |
| 18. | Confirmation test of H. pylori eradication is not mandatory in mass screening, but should be performed in subsets of the population for assessment of treatment efficacy | 96% | Low | Formal cost-effectiveness analysis using data from prospective trials is needed to assess the necessity of confirmation test in all subjects |
| Potentially adverse consequences of H. pylori eradication | ||||
| 19. | As with all antibiotic treatments, H. pylori eradication may lead to an increase in antimicrobial resistance, but it should not preclude its use for gastric cancer prevention | 92% | Very low | Scarce evidence regarding the long-term impacts of eradication therapy on the antimicrobial resistance at individual and population levels |
| 20. | Short-term perturbation of faecal microbiota diversity occurs after H. pylori eradication, which largely recovers subsequently | 88% | Low | Scarce evidence regarding the long-term impacts of eradication therapy on the composition of human microbiota, especially at species level |
| 21–1. | Eradication of H. pylori does not increase the risk of new onset GORD | 92% | High | |
| 21–2. | H. pylori eradication therapy does not increase the risk of relapse of GORD | 96% | Moderate | |
| 22. | H. pylori eradication may be associated with a small increase in body weight, but does not increase the risk of metabolic syndrome | 80% | Low | Well-designed randomised trials are needed to assess the impacts of eradication therapy on human metabolism and metabolic disorders |
| 23. | H. pylori eradication does not increase the risk of asthma, inflammatory bowel disease and other immune-related diseases | 80% | Very low | Lack of evidence from randomised trials or large-scale prospective cohort studies |
| Endoscopic surveillance for gastric cancer after H. pylori eradication | ||||
| 24. | Subjects with advanced gastric atrophy or intestinal metaplasia should receive surveillance endoscopy to detect gastric cancer after H. pylori eradication | 92% | Low | Evidence from retrospective studies with relatively small sample size. Eradication not confirmed in some studies |
| 25. | Surveillance endoscopy is suggested every 2 to 3 years for subjects with advanced gastric atrophy or intestinal metaplasia, and every 12 months after the removal of neoplasia | 92% | Low | Large-scale prospective cohort studies/randomised trials/cost-effectiveness analysis are warranted to assess the optimal surveillance interval |
| 26. | Genetic and epigenetic markers show promise in stratifying gastric cancer risk after H. pylori eradication, but require further validation in prospective studies | 92% | Low | Studies are needed to assess the role of serum markers, endoscopic features, histological grading and molecular markers in risk stratification |
GORD, gastro-oesophageal reflux disease; MICs, minimum inhibitory concentrations; QALYs, quality of life years.