Int J Cancer. 2013 Mar 15;132(6):1272-6. doi: 10.1002/ijc.27965.

A new approach for elimination of gastric cancer deaths in Japan.

Asaka M.

Department of Cancer Preventive Medicine, Hokkaido University Graduate School of Medicine, Kita-Ku, Sapporo, Japan. maasaka@med.hokudai.ac.jp

 

Abstract

We explore a strategy for the elimination of gastric cancer deaths in Japan. Most gastric cancer is due to H. pylori infection in Japan. The effect of H. pylori eradication therapy on gastric cancer prevention in younger people is excellent, but it declines along with advancing age. Therefore, a test-and-treat approach to H. pylori infection is recommended in younger people, while for people aged 50 years or older a combination of countermeasures for H. pylori eradication that includes primary prevention and secondary prevention by endoscopic examination will reduce gastric cancer deaths, since this method will increase early detection if the disease occurs. In this paper, I described a new strategy of elimination of gastric cancer deaths in Japan due to such a high quality of diagnosis and treatment for gastric cancer. If this strategy succeeds, the incidence of gastric cancer in Japan may decrease much longer than 10 years.

Copyright © 2012 UICC.

PMID: 23180638

 

Supplement

 In Japan, gastric cancer screening has long been done by using barium contrast images. However, evidence that H. pylori infection played an important role in the development of gastric cancer and that H. pylori eradication could prevent or reduce the incidence of gastric cancer suggested the need for a new strategy to eliminate gastric cancer in Japan. The new strategy could be one that combined primary prevention by H. pylori eradication with secondary prevention using surveillance with endoscopy of high risk patients. Japan is currently at the forefront of devising methods and procedures for the elimination of gastric cancer based on the current high level of knowledge and technology and experience in gastric cancer screening. We now know that more than 95% of gastric cancers are due to H. pylori infection in Japan and Korea. As a general rule for cancers caused by infections, such as liver cell cancer and cervical carcinoma, primary prevention based on preventing the infection or early eradication before significant damage is done is preferred over screening.

Gastric cancer elimination project in Japan

  It has been demonstrated that most gastric cancer is due to H. pylori infection and we believe it is time for a major strategic shift in the preventative measures for gastric cancer. Preventative measures for liver cancer have been conducted with the focus on hepatitis viruses since 2002 in Japan and this has succeeded in decreasing the mortalityIn marked contrast, annual deaths from gastric cancer have remained at around 50,000 for the last few decades suggesting that the current preventative measures have been less than satisfactory.Even though viruses and bacteria are not the same, completely different preventive measures should not be taken for liver cancer and gastric cancer when both are caused by infection. In 2012, the section on Current Status of the Basic Plan to Promote Cancer Control Programs of the Japanese Government issued a new plan to determine Cancer Control Programs for next 5 years in Japan including those caused by microorganisms such as cervical carcinoma, liver cancer, ATL, and H. pylori associated with gastric cancer..

  Meanwhile, the Japanese Society for Helicobacter Research published a guideline recommending that all H. pylori-infected people receive bacterial eradication therapy. In response to this, the Japanese government has expanded coverage by the national health insurance scheme. In addition to gastric and duodenal ulcer, three other indications for H. pylori treatment include mucosa-associated lymphoid tissue (MALT) lymphoma, post-endoscopic surgery for early gastric cancer, and idiopathic thrombocytopenic purpura (ITP) have been newly designated. Japanese insurance coverage for H. pylori eradication therapy for an indication other than gastric and duodenal ulcer is the first in the world.

 When H. pylori eradication therapy for chronic gastritis is covered by national health insurancedifferent measures should be taken for people under 20 years old and people aged 50 or over. Bacterial eradication in persons under 20 may achieve prevention of diseases such as peptic ulcer, gastric MALT lymphoma, functional dyspepsia, gastric polyps, idiopathic thrombocytopenic purpura (ITP), atrophic gastritis and gastric cancer associated with H. pylori related chronic gastritis. Thus, a test-and-treat approach is recommended for younger people that includes universal H. pylori testing and immediate bacterial eradication in those with a positive result.

  Because people aged 50 years or older frequently have atrophic gastritis and are likely to be at risk for cancer despite H. pylori eradication, we recommend that they will be referred for evaluation of the presence and severity of their H. pylori-related gastritis.  Those with H. pylori infection should receive endoscopic examination (which will be covered by Japanese medical insurance) to evaluate for the presence and severity of atrophic gastritis. If people have a family history of gastric cancer and/or have been diagnosed as having atrophic gastritis by previous endoscopic examination, additional endoscopic examinations will also be offered in cases without H. pylori infection.

We expect that many patients with gastric cancer will be discovered during this endoscopic examination. This project thus includes a form of endoscopic screening supported by medical insurance. Those without gastric cancer should receive bacterial eradication therapy. Persons whose endoscopic examination shows findings close to normal can be transferred to a no surveillance group. If atrophic gastritis is found a repeat endoscopic examination should be performed 1 to 2 years later and they should be considered for a surveillance program the frequency and nature of which will depend on the results of ongoing and subsequent research on surveillance based on risk stratification (Figure 1). As described above, the program combines primary prevention (H. pylori eradication) and surveillance with early cancer detection for those remaining at risk for development of gastric cancer despite H. pylori eradication.

Masahiro ASAKA-fig1Figure 1. A measure for elimination of gastric cancer deaths after 50 years in Japan.

 

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