Clinical Question: Does treatment of Helicobacter pylori infection reduce the risk of gastric cancer?

Setting: Population-based

Study Design: Randomized controlled trial (double-blinded)

Synopsis: Although chronic H. pylori infection is associated with an increased risk of developing gastric cancer, it is uncertain whether eradication treatment reduces this risk. A total of 1,630 healthy, asymptomatic adult carriers of H. pylori were identified by screening in the Fuzian province of China, a high-risk area. All of the patients underwent endoscopy, and 988 patients did not have pre-cancerous lesions on study entry.

Patients were assigned randomly in a double-blind fashion (uncertain allocation assignment) to receive H. pylori eradication treatment with a two-week course of 20 mg of omeprazole, a 750-mg combination of amoxicillin and clavulanate, and 400 mg of metronidazole, all twice daily, or placebo. Persons assessing outcomes were blinded to treatment group assignment.

Ninety percent of patients were available for the primary analysis (on treatment) after eight years of follow-up. The authors diagnosed 18 new cases of gastric cancer. The risk of cancer development was not significantly reduced in participants who received H. pylori eradication treatment compared with those who did not (seven versus 11 patients; P = .33). In the subgroup of patients with no precancerous lesions on presentation, H. pylori eradication treatment significantly reduced the risk of gastric cancer compared with placebo (zero versus six cases; P = .02).

Bottom Line: Asymptomatic carriers of H. pylori with no endoscopically determined precancerous gastric lesions are less likely to develop gastric cancer after eradication treatment. For most primary care physicians, these patients will rarely, if ever, fall under their purview (most tests are ordered for symptomatic patients). More evidence regarding long-term outcomes and cost-benefit analyses is needed before we can justify screening all adults for H. pylori infection. (Level of Evidence: 1b–)