Table 1

Summary of consensus recommendations for screening and eradication of H. pylori for gastric cancer prevention

No.StatementAgreeEvidence levelLimitations of current evidence and areas for future research
Disease burden of H. pylori infection-associated gastric cancer
1Although 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 population96%ModerateLack 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 cancer96%LowLack 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 world96%LowLack 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 population88%ModerateEstimation based on nested case–control studies in Western populations
4.Eradication of H. pylori reduces the risk of gastric cancer in infected subjects92%ModerateTrials 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 cancer96%HighNearly 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 cancer84%LowEstimation 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 recommended84%LowLack 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 cancer84%LowAssumption 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 children92%LowLack 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 considered88%ModerateLack 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 cancer100%LowProspective 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 resources92%LowPopulation-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 worldwide100%LowTreatment-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 community100%LowPriority of efficacy, adverse effects and cost in community settings remains debatable
15Reliable locally effective regimens based on the principles of antibiotic stewardship are recommended92%ModerateThe 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 population96%ModerateResistance 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 low96%ModerateFew 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 efficacy96%LowFormal 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 prevention92%Very lowScarce 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 subsequently88%LowScarce 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 GORD92%High
21–2. H. pylori eradication therapy does not increase the risk of relapse of GORD96%Moderate
22. H. pylori eradication may be associated with a small increase in body weight, but does not increase the risk of metabolic syndrome80%LowWell-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 diseases80%Very lowLack 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 eradication92%LowEvidence 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 neoplasia92%LowLarge-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 studies92%LowStudies 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.