Clinical and economic effects of population-based Helicobacter pylori screening to prevent gastric cancer.

BACKGROUND Helicobacter pylori infection has been identified as a risk factor for certain types of gastric cancer. However, the extent to which H. pylori eradication decreases the risk of gastric cancer is unknown, raising the question of whether population-based H. pylori screening should be undertaken. OBJECTIVE To compare clinical and economic effects of H. pylori screening, with and without confirmatory testing, with no screening to prevent gastric cancer. DESIGN Decision analysis incorporating a Markov simulation. PATIENTS Simulated cohorts of men and women with varying risk of gastric cancer. INTERVENTION Three strategies were evaluated: (1) no screening; (2) H. pylori serologic testing, treat those positive for H. pylori, no follow-up testing; and (3) H. pylori serologic testing, treat those positive for H. pylori, followed by a test to confirm H. pylori eradication, retreat those who test positive. In the principal analysis, the risk of gastric cancer after H. pylori eradication was assumed to be similar to that for those without H. pylori infection. Scenarios with less optimistic assumptions regarding risk reduction of cancer were evaluated. MAIN OUTCOME MEASURES Gastric cancer rates, discounted cost per life-year saved. RESULTS If H. pylori eradication reduced the risk of cancer to that of people never infected, both H. pylori intervention strategies reduced gastric cancer rates so that each yielded at least 12 additional life-years per 1000 40-year-old white men screened when compared with no screening. Helicobacter pylori serologic testing without posttreatment confirmatory testing resulted in the lowest cost per additional life-year saved (S6264). The cost-effectiveness of the H. pylori screening strategies varied substantially as the level of risk reduction of cancer was varied, but remained cost-effective even at moderate rates (<30%) of excess risk reduction of cancer in all cohorts evaluated. CONCLUSIONS Population-based H. pylori screening has the potential to produce important health benefits at a reasonable cost at moderate rates of excess risk reduction of cancer. Controlled studies are necessary to confirm and quantify the impact of H. pylori eradication on the risk of gastric cancer.

[1]  G. Friedman,et al.  Helicobacter pylori infection and the risk of gastric carcinoma. , 1991, The New England journal of medicine.

[2]  G. Tytgat,et al.  Cure of duodenal ulcer associated with eradication of Helicobacter pylori , 1990, The Lancet.

[3]  S. Eberhardt,et al.  Life Expectancy in Four U.S. Racial/Ethnic Populations: 1990 , 1995, Epidemiology.

[4]  A. Zinsmeister,et al.  Comparison of commercial serological tests for detection of Helicobacter pylori antibodies , 1992, Journal of clinical microbiology.

[5]  M. Blaser,et al.  Prevalence of Helicobacter pylori infection and histologic gastritis in asymptomatic persons. , 1989, The New England journal of medicine.

[6]  D. Graham,et al.  Epidemiology of Helicobacter pylori in an asymptomatic population in the United States. Effect of age, race, and socioeconomic status. , 1991, Gastroenterology.

[7]  J. Thijs,et al.  Efficacy and side effects of a triple drug regimen for the eradication of Helicobacter pylori. , 1993, Scandinavian journal of gastroenterology.

[8]  W. Leung,et al.  Effects of curing Helicobacter pylori infection on precancerous gastric lesions: One-year follow-up of a prospective randomized study in China , 1998 .

[9]  C. Fuchs,et al.  Gastric carcinoma. , 1995, The New England journal of medicine.

[10]  D. Peura,et al.  Diagnosis of Helicobacter pylori infection. , 1993, Gastroenterology clinics of North America.

[11]  Alter Mj,et al.  Association between infection with Helicobacter pylori and risk of gastric cancer: evidence from a prospective investigation. , 1991, BMJ.

[12]  D. Forman,et al.  H pylori and gastric cancer , 1994, The Lancet.

[13]  U. G. Dailey.  Cancer,Facts and Figures about. , 2022, Journal of the National Medical Association.

[14]  J. Ferlay,et al.  Estimates of the worldwide incidence of eighteen major cancers in 1985 , 1993, International journal of cancer.

[15]  T. Borody,et al.  Helicobacter pylori reinfection rate, in patients with cured duodenal ulcer. , 1994, The American journal of gastroenterology.

[16]  Douglas K Owens,et al.  Modelling cost-effectiveness of Helicobacter pylori screening to prevent gastric cancer: a mandate for clinical trials , 1996, The Lancet.

[17]  Fred E. Silverstein,et al.  Helicobacter pylori in peptic ulcer disease. , 1994, NIH consensus statement.

[18]  J R Beck,et al.  Markov Models in Medical Decision Making , 1993, Medical decision making : an international journal of the Society for Medical Decision Making.

[19]  K. Haruma,et al.  Effect of Helicobacter pylori eradication on subsequent development of cancer after endoscopic resection of early gastric cancer. , 1997, Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology.

[20]  P. Chyou,et al.  Helicobacter pylori Infection and the Risk for Duodenal and Gastric Ulceration , 1994, Annals of Internal Medicine.

[21]  Brown Ke,et al.  Diagnosis of Helicobacter pylori infection , 1993 .

[22]  A. Bowden,et al.  Helicobacter pylori eradication: efficacy and side effect profile of a combination of omeprazole, amoxycillin and metronidazole compared with four alternative regimens. , 1993, The Quarterly journal of medicine.

[23]  A. Soll.  Consensus conference. Medical treatment of peptic ulcer disease. Practice guidelines. Practice Parameters Committee of the American College of Gastroenterology. , 1996, JAMA.

[24]  A S Detsky,et al.  Cost and Health Implications of Cholesterol Lowering , 1992, Circulation.