Health economic evaluation on population-based Helicobacter pylori eradication and endoscopic screening for gastric cancer prevention

Gastric cancer is a global public health burden, nearly one million new cases are diagnosed per year worldwide, of which 44% of cases occur in China. The prognosis of gastric cancer varies remarkably by the stage of cancer, and most of the patients in China are diagnosed at advanced stages, resulting in poor prognoses. Effective strategies to reduce the burden of gastric cancer include primary prevention through testing and treatment of Helicobacter pylori(H. pylori) and secondary prevention by screening and early detection. Although many countries have issued management guidelines and consensus reports concerning these strategies, the limited availability of healthcare resources often precludes their widespread implementation. Therefore, assessing the costs, benefits, and harms of population-based intervention measures through health economic evaluation is necessary for informed health policy decisions. Accordingly, we synthesize management approaches from different countries on H. pylori eradication and endoscopic screening, and also summarize recent advancements in health economic evaluations on population-based preventive strategies. The goal of the review is to provide empirical evidence supporting optimal resource allocation, maximizing benefits for the population, and ultimately reducing the burden of gastric cancer.

NATURAL HISTORY OBSERVATION FOR ESOPHAGEAL AND CARDIA PRECURSORS BY REPETITIVE ENDOSCOPIC SCREENING OF 301 SUBJECTS IN SHEXIAN

OBJECTIVE To investigate the natural history of fast developing esophageal and cardia precursors.METHODS Repetitive endoscopic screenings were performed among 40-69-year-olds in the high-incidence areas for esophageal cancer in Shexian. RESULTS The initial diagnosis and the lag-time for 7 subsequently identified severe dysplasia （SD） subjects were as follows： in one subject 13 months after a baseline diagnosis of normal epithelium, in another subject 7 months after a baseline diagnosis of base cell hyperplasia （BCH）, in four subjects 3, 4, 4, and 10.5 months after baseline diagnosis of mild dysplasia （mD）, and in one subject 12.5 months after a baseline diagnosis of moderate dysplasia （MD）. The initial diagnosis and the lag-time for 6 subsequently identified carcinomas in situ or intramucosal carcinoma cases were： in one case 48 months after a baseline diagnosis of mD, in 2 cases 4 and 13 months after baseline diagnoses of MD, and in the other 3 cases 3.5, 9, and 17.5 months after baseline diagnoses of SD. The initial diagnosis and lag-time for 3 subsequently identified invasive cancer cases, were： in one case 50 months after a baseline diagnosis of MD, in 2 cases 14 and 19 months after baseline diagnoses of SD. In addition, during a 4-year-follow-up of 18 subjects after endoscopic mucosa resection, 9 of them were found to have developed precursors again at other sites, and also additional findings were obtained for 11 of the 16 dysplasia cases by repetitive biopsy in less than 2 months after the initial endoscopy. CONCLUSION A 5-year screening interval for BCH and mD, and a 3-year interval for MD may be too long for the fast developing precursors. Periodic screenings with shorter intervals should be considered to control the number of interval cases due to fast development, multifocal carcinogenesis, and false negative results inherent in one-time endoscopic biopsy sampling.

The Relationship between a Cohort Endoscopic Screening of 15,000 Subjects and the Death of Patients with Esophageal and Gastric Cancers in High-Risk Areas

OBJECTIVE Ci-xian County is located in the north of Chinaand is a high-risk area for esophageal cancer(EC).In 2004,theincidence rate of EC in the county was 127/100,000 and 93/100,000in the male and female population,respectively,and that ofgastric cancer(GC)was 72/100,000 and 36/100,000.Since 2001 acohort screening,supported by a special national fund,utilizingendoscopic examination with iodine staining for the targetpopulation at the age ranging from 40 to 69 years was carried out,so as to reduce the incidence and mortality rates in the high-riskareas of EC.METHODS In October 2001,4 townships in the Ci-xian County,Hebei,China were selected,with 22,016 cases in the interventiongroup(IVG)and 33,410 in the control group(CG).The totalpopulation coverage reached 55,000.There were 3257 males and3339 females in the IVG with the age ranging from 40 to 69 years,and 4299 males and 4430 females in the CG with the same rangeof the age.Endoscopic screening with iodine staining was used inthe IVG,with a screening rate of 53.2%.During the screening byendoscopic examination,97 cases were found to have esophagealsquamous epithelium,carcinoma-in-situ at the cardiac glandularepithelium or intra-mucosal carcinoma.Additionally,102cases were identified to have severe atypical hyperplasia in theesophagus and gastric cardia.The natural incidence rate of cancerand the mortality were observed in the CG.The ICD-0 version wasused in the tumor incidence and death registration coding.Duringa period from June to September 2008,based on the information ofthe tumor registration database of the incidence and mortality inthe Ci-xian County,the cohort groups were studied and followed.RESULTS There were 133 patients with untreatable EC and48 with GC in the IVG,while there were 259 and 37 patients inthe CG who died of esophageal and gastric cancer,respectively.The relative risk(RR)of death was 0.76 in the male patients withEC,95%CI(0.59-0.98),P=0.038,and in the female patients theRR was 0.51,95%CI(0.35-0.75),P=0.000.The RR of death in theGC patients was 2.45,(1.40-4.29)in the male,P=0.01,and 0.99,(0.47-1.99),in the female cases,P=0.906.CONCLUSION Six years after a cohort screening of a largepopulation by endoscopic examination with iodine staining inareas at high risk for EC,the death risk in the male and femalepatients with EC has decreased compared with that in the controlgroup.The difference between the 2 groups was statisticallysignificant.However,no protective method used to decrease thedeath risk in GC patients has been found during this period ofendoscopic screening.

Improved esophageal squamous cell carcinoma screening effectiveness by risk-stratified endoscopic screening:evidence from high-risk areas in China

Background:Risk-stratified endoscopic screening(RSES),which offers endoscopy to those with a high risk of esophageal cancer,has the potential to increase effectiveness and reduce endoscopic demands compared with the universal screening strategy(i.e.,endoscopic screening for all targets without risk prediction).Evidence of RSES in high-risk areas of China is limited.This study aimed to estimate whether RSES based on a 22-score esophageal squamous cell carcinoma(ESCC)risk prediction model could optimize the universal endoscopic screening strategy for ESCC screening in high-risk areas of China.Methods:Eight epidemiological variables in the ESCC risk prediction model were collected retrospectively from 26,618 individuals aged 40-69 from three high-risk areas of China who underwent endoscopic screening betweenMay 2015 and July 2017.The model’s performance was estimated using the area under the curve(AUC).Participants were categorized into a high-risk group and a low-risk group with a cutoff score having sensitivities of both ESCC and severe dysplasia and above(SDA)at more than 90.0%.Results:The ESCC risk prediction model had an AUC of 0.80(95% confidence interval:0.75-0.84)in this external population.We found that a score of 8(ranging from 0 to 22)had a sensitivity of 94.2% for ESCC and 92.5% for SDA.The RSES strategy using this threshold score would allow 50.6% of endoscopies to be avoided and save approximately US$0.59 million compared to universal endoscopic screening among 26,618 participants.In addition,a higher prevalence of SDA(1.7%vs.0.9%),a lower number need to screen(60 vs.111),and a lower average cost per detected SDA(US$3.22 thousand vs.US$5.45 thousand)could have been obtained by the RSES strategy.Conclusions:The RSES strategy based on individual risk has the potential to optimize the universal endoscopic screening strategy in ESCC high-risk areas of China.

Gastric Cancer Disparities in the United States: Overcoming the Barriers

In this narrative review, we highlight the disparities in the incidence and mortality of gastric cancer across various racial and ethnic populations in the United States (US). Despite the low and decreasing trend in the incidence of gastric cancer in the US, the incidence remains significantly high among Asian and Hispanic Americans, showing a striking racial and ethnic disparity. The low survival rate of gastric cancer further accentuates the magnitude of this disparity. In addition, there is a marked funding disparity among different cancers in the US, reflecting the significantly lower level of support for cancers, such as gastric cancer, which are more prevalent in minority populations, compared to the cancers more prevalent among non-Hispanic Whites (NHW). Moreover, the economic burden from health disparities remains high. Although studies from the US and Asia suggest that screening for stomach cancer may be cost-effective, there is no currently available guideline for scree-ning high-risk populations in the US. A multidimensional framework involving the community, physicians, and policymakers is proposed to tackle these gastric cancer disparities and to develop population-based screening and surveillance programs to reduce the burden of gastric cancer.

EPIDEMIC STRENGTH OF CARDIA AND DISTANT STOMACH CANCER IN THE HIGH RISK REGION OF ESOPHAGEAL CANCER AND THEIR IMPLICATION TO EDOSCOPIC SCREENING

Objective： To discuss the epidemic strength of cardia and distant stomach cancers in the high risk region of esophageal cancer along the south Taihang mountain such as in Shexian, Linxian, and Cixian Counties, and to clarify the tasks for the control of upper gastrointestinal tract cancer as a whole in the region. Methods： Comparisons of incidence and mortality rates of esophageal, cardia and stomach cancers were made between Cixian, Linxian and Shexian Counties with reference to detection rates of cancer in situ and precancerous lesions of the three upper gastrointestinal cancers by endoscopic screening. The screening was performed from 1999 through 2004 in the three adjacent counties including a total of 6233 local residents aged 40 to 69 years old. Results： The incidence rates for cardia cancer for the male and female from 2000 through 2004 were 69.9 and 41.5, and the mortality rates were 54.3 and 33.2 respectively in Shexian County. Esophageal, cardia, and stomach cancers constitute about 70～80 percent of all malignant disease by incidence or mortality rates. Endoscopic survey with iodine staining can effectively detect squamous cell precancerous lesions in the esophagus, but the method is inadequate for the detection of adeno precancerous lesions of the cardia and stomach. Conclusion： The south Taihang mountain region is a high risk area not only for esophagus cancer, but also for cardia and stomach cancers. To control upper gastrointestinal tract cancers as a whole in the region, special attention should be paid to the control of cardia and stomach cancers. Presently, to find effective screening methods for detecting cardia and stomach precancerous lesions is especially important.

Asymptomatic pancreatic lesions: New insights and clinical implications

Despite great efforts in experimental and clinical research, the prognosis of pancreatic cancer (PC) has not changed significantly for decades. Detection of pre-invasive lesions or early-stage PC with small resectable cancers in asymptomatic individuals remains one of the most promising approaches to substantially improve the overall outcome of PC. Therefore, screening programs have been proposed to identify curable lesions especially in individuals with a familial or genetic predisposition for PC. In this regard, Canto et al recently contributed an important article comparing computed tomography, magnetic resonance imaging, and endoscopic ultrasound for the screening of 216 asymptomatic high-risk individuals (HRI). Pancreatic lesions were detected in 92 of 216 asymptomatic HRI (42.6%). The high diagnostic yield in this study raises several questions that need to be answered of which two will be discussed in detail in this commentary: First: which imaging test should be performed? Second and most importantly: what are we doing with incidentally detected pancreatic lesions? Which ones can be observed and which ones need to be resected?