Gastric cancer screening by combined assay for serum anti-Helicobacter pylori IgG antibody and serum pepsinogen levels - "ABC method"

Parental Knowledge and Attitudes Towards Helicobacter Pylori Screening in Adolescents: A School-Based Questionnaire Study Among Guardians of Junior High School Students in Yokosuka City, Japan

PURPOSE

Helicobacter pylori (HP) infection, a risk factor for gastric cancer, is prevalent in Japan. Consequently, some municipalities across Japan are implementing HP screening and treatment programs for adolescents. However, little is known about parents' attitudes and awareness regarding HP screening for their children. This study aimed to elucidate parental perspectives on HP screening for their children and identify the factors influencing these attitudes.

METHODS

This study focused on the parents of first-year junior high school students in Yokosuka City, Kanagawa Prefecture, where an HP screening and treatment program had been implemented for adolescents. The survey questionnaire was distributed among parents in all 23 public junior high schools in Yokosuka City.

RESULTS

Among the 618 respondents, 86.4% supported HP screening for their children. Regression analysis identified sufficient knowledge about HP (adjusted odds ratio (aOR) = 5.80; 95% confidence interval (CI), 2.10-16.03) and being in their 40s (aOR = 2.25; 95% CI, 1.35-3.77) as significant factors influencing supportive attitudes. For parents favoring the screening, common reasons included perceiving it as a promising opportunity (53.2%) and considering the test necessary (44.0%). In contrast, those who opposed screening frequently cited it as unnecessary (66.7%) or believed that their children did not have HP.

CONCLUSIONS

A significant proportion of parents in Yokosuka City, Japan, demonstrated a good understanding of HP and expressed a high level of interest in HP screening for their children. Further investigation of parents' attitudes is essential for the effective implementation of adolescent HP screening programs.

PG I and PG II show unique value in diagnosing postoperative biochemical recurrence in patients with gastric cancer after total gastrectomy

OBJECTIVE

To investigate the potential of group I pepsinogen (PG I) and group II pepsinogen (PG II) as diagnostic markers for recurrence in gastric cancer (GC) patients post-total gastrectomy.

METHODS

Ninety-six patients who underwent total gastrectomy for GC between June 2022 and June 2023 were included in this study. Clinical data, serum samples, and ascites samples were collected. Patients were categorized based on recurrence status at the time of sample collection and the primary tumor site. PG I and PG II levels were determined using a chemiluminescent immunoassay, and their clinical utility following total gastrectomy for GC was evaluated via receiver operating characteristic (ROC) curve analysis.

RESULTS

This study included 96 GC patients who underwent total gastrectomy, 55 of whom experienced postoperative recurrence (57.29%). The levels of serum PG I (27.86 (27.04, 30.97) vs. 26.05 (24.16, 27.09) ng/mL; P < 0.0001) and PG II (1.95 (1.23, 3.05) vs. 0.63 (0.47, 0.90) ng/mL; P < 0.0001) were significantly greater in the recurrent group compared to the non-recurrent group. The secretion of PG I and/or PG II by metastatic cancer cells correlated with the primary lesion site. When the cut-off value for serum PG I was 26.93 ng/mL, the area under the curve (AUC) for PG I was 0.77. When the cut-off value for serum PG II was 0.96 ng/mL, the AUC reached 0.90. The combined AUC was 0.97.

CONCLUSION

These findings suggest that serum PG I and PG II are valuable biomarkers for identifying GC patients with biochemical recurrence post-total gastrectomy.

Enhancing gastric cancer early detection: A multi-verse optimized feature selection model with crossover-information feedback

Gastric cancer (GC), an acknowledged malignant neoplasm, threatens life and digestive system functionality if not detected and addressed promptly in its nascent stages. The indispensability of early detection for GC to augment treatment efficacy and survival prospects forms the crux of this investigation. Our study introduces an innovative wrapper-based feature selection methodology, referred to as bCIFMVO-FKNN-FS, which integrates a crossover-information feedback multi-verse optimizer (CIFMVO) with the fuzzy k-nearest neighbors (FKNN) classifier. The primary goal of this initiative is to develop an advanced screening model designed to accelerate the identification of patients with early-stage GC. Initially, the capability of CIFMVO is validated through its application to the IEEE CEC benchmark functions, during which its optimization efficiency is measured against eleven cutting-edge algorithms across various dimensionalities-10, 30, 50, and 100. Subsequent application of the bCIFMVO-FKNN-FS model to the clinical data of 1632 individuals from Wenzhou Central Hospital-diagnosed with either early-stage GC or chronic gastritis-demonstrates the model's formidable predictive accuracy (83.395%) and sensitivity (87.538%). Concurrently, this investigation delineates age, gender, serum gastrin-17, serum pepsinogen I, and the serum pepsinogen I to serum pepsinogen II ratio as parameters significantly associated with early-stage GC. These insights not only validate the efficacy of our proposed model in the early screening of GC but also contribute substantively to the corpus of knowledge facilitating early diagnosis.

Population effectiveness of endoscopy screening for mortality reduction in gastric cancer

Objectives

No randomized controlled trials have compared endoscopic screening with no screening for gastric cancer on an intention-to-screen basis, and the population-based evidence is insufficient. This study aimed to identify factors contributing to the population effectiveness of cancer screening, estimate the number needed to screen (NNS) to reduce one gastric cancer-related death, and evaluate the expected mortality-rate reduction in endoscopic screening for gastric cancer in 184 countries.

Methods

Factors contributing to the attributable risk, NNS, and mortality-rate reduction were identified. A rapid review was performed in PubMed to estimate the pooled relative risk of endoscopic screening compared to that of no screening for mortality reduction. NNSs and mortality-rate reduction were estimated using the pooled relative risk and GLOBOCAN data.

Results

The crude mortality rate, the effectiveness of the screening modality, and the screened rate contributed to the attributable risk, NNS, and mortality-rate reduction in cancer screening. The pooled relative risk was 0.58 in endoscopy screening compared to that in no screening. NNSs and expected mortality-rate reduction differed across countries and ranged from 2522 to 91,575 and 0.2 to 7.9 (per 100,000 individuals) for the screened rate of 20%, respectively.

Conclusions

In addition to the effectiveness of the used modality, the disease burden and screened rate were important in the population effectiveness of cancer screening. Regarding the high NNSs and the low expected mortality-rate reduction, population-based endoscopic screening seems not to be effective in many countries, and these results are meaningful in decision-making regarding the introduction of endoscopic screening.

The Efficacy of Chaihu-Guizhi-Ganjiang Decoction on Chronic Non-Atrophic Gastritis with Gallbladder Heat and Spleen Cold Syndrome and Its Metabolomic Analysis: An Observational Controlled Before-After Clinical Trial

Purpose

The aim of this study was to verify the effectiveness and explore the mechanism of Chaihu-Guizhi-Ganjiang decoction (CGGD) in the treatment of chronic non-atrophic gastritis (CNAG) with gallbladder heat and spleen cold syndrome (GHSC) by metabolomics based on UHPLC-Q-TOF/MS.

Patients and Methods

An observational controlled before-after study was conducted to verify the effectiveness of CGGD in the treatment of CNAG with GHSC from January to June 2023, enrolling 27 patients, who took CGGD for 28 days. 30 healthy volunteers were enrolled as the controls. The efficacy was evaluated by comparing the traditional Chinese medicine (TCM) syndrome and CNAG scores, and clinical parameters before and after treatment. The plasma levels of hormones related to gastrointestinal function were collected by ELISA. The mechanisms of CGGD in the treatment of CNAG with GHSC were explored using a metabolomic approach based on UHPLC-Q-TOF/MS.

Results

Patients treated with CGGD experienced a statistically significant improvement in TCM syndrome and CNAG scores (p < 0.01). CGGD treatment evoked the concentration alteration of 15 biomarkers, which were enriched in the glycerophospholipid metabolism, and branched-chain amino acids biosynthesis pathways. Moreover, CGGD treatment attenuated the abnormalities of the gastrointestinal hormone levels and significantly increased the pepsinogen level.

Conclusion

It was the first time that this clinical trial presented detailed data on the clinical parameters that demonstrated the effectiveness of CGGD in the treatment of CNAG with GHSC patients. This study also provided supportive evidence that CNAG with GHSC patients were associated with disturbed branched-chain amino acid metabolism and glycerophospholipid levels, suggesting that CNAG treatment based on TCM syndrome scores was reasonable and also provided a potential pharmacological mechanism of action of CGGD.

Advanced Diagnostic and Therapeutic Endoscopy for Early Gastric Cancer

Endoscopy is mandatory to detect early gastric cancer (EGC). When considering the cost-effectiveness of the endoscopic screening of EGC, risk stratification by combining serum pepsinogen values and anti-H. pylori IgG antibody values is very promising. After the detection of suspicious lesions of EGC, a detailed observation using magnifying endoscopy with band-limited light is necessary, which reveals an irregular microsurface and/or an irregular microvascular pattern with demarcation lines in the case of cancerous lesions. Endocytoscopy enables us to make an in vivo histological diagnosis. In terms of the indications for endoscopic resection, the likelihood of lymph node metastasis and technical difficulties in en bloc resection is considered, and they are divided into absolute, expanded, and relative indications. Endoscopic mucosal resection and endoscopic submucosal dissection are the main treatment modalities nowadays. After endoscopic resection, curability is evaluated histologically as endoscopic curability (eCura) A, B, and C (C-1 and C-2). Recent evidence suggests that the outcomes of endoscopic resection for many EGCs are comparable to those of gastrectomy and that endoscopic resection is the gold standard for node-negative early gastric cancers. Personalized medicine is also being developed to overcome the unmet needs in treatments of EGC, for example the further expansion of indications and newer resection techniques, such as full-thickness resection.

A novel predictive formula for highly accurate discrimination between truly Helicobacter pylori-uninfected and currently infected/spontaneously eradicated individuals for gastric cancer screening

The ABC classification, which categorizes gastric cancer risk based on serum Helicobacter pylori (H pylori) antibody and pepsinogen levels, has a limitation of potentially misclassifying high-risk individuals as low risk. To overcome the problem, we previously developed a 4-parameter predictive formula (age, serum H pylori antibody, PGI, and PGII) using logistic regression analysis to accurately identify low-risk truly H pylori-uninfected status. Our predictive formula demonstrated superior sensitivity and specificity in distinguishing between low-risk truly uninfected individuals and high-risk currently/spontaneously eradicated status individuals, compared to the modified ABC classification based on latex immunoassay kits (traditional 3-parameter model). This study aimed to revalidate the diagnostic accuracy of the predictive formula in a new and different study population. We applied the predictive formula to the target population and compared the sensitivity and specificity with those of the traditional 3-parameter model. A total of 788 enrollees were analyzed: 703 were classified as truly uninfected, 45 as currently infected, and 40 as spontaneously eradicated according to the results of stool antigen testing and endoscopic findings. The sensitivities and specificities of the predictive formula and the traditional 3-parameter model were 89.5% and 87.1% versus 89.8% and 80.0%, respectively. The specificity of the predictive formula was superior in the 70 to 89 age range and H pylori antibody < 3 U/mL groups. The predictive formula had higher specificity than the traditional 3-parameter model. The results should contribute to efficient gastric cancer screening by predicting H pylori infection status.

Correlation of chronic atrophic gastritis with gastric-specific circulating biomarkers

BACKGROUND AND STUDY AIMS

It has been suggested that the combined detection of multiple serum biomarkers can effectively screen out the high-risk population of chronic atrophic gastritis in the general population. Therefore, it is necessary to establish an effective predictive model of chronic atrophic gastritis.

PATIENTS AND METHODS

Serum biopsies were assessed using five stomach-specific circulating biomarkers pepsinogen I (PGI), PGII, PGI/II ratio, anti- H. pylori antibody, and gastrin-17 (G-17) to identify high-risk individuals and evaluate the risk of developing chronic atrophic gastritis.

RESULTS

In the cross-sectional analysis, PGII, the PG ratio, G17, anti- H. pylori IgG were positively associated with the presence of chronic atrophic gastritis, and combined prediction of the five biomarkers was more accurate than single-factor prediction ((0.692 vs 0.54(PG1), 0.604 (PGⅡ), 0.616(PGI/II ratio), 0.629(G-17)).

CONCLUSION

The combination of PGI, PGII, the PGI/II ratio, G17, and anti-H. pylori antibodies for serological analysis are helpful to screen chronic atrophic gastritis high-risk subjects from the general population and recommend that these people carry out further endoscopy and biopsy.

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.

Comparison of different risk stratifications for gastric cancer and establishing a simplified risk-scoring model based on the Kyoto classification

BACKGROUND AND AIM

The study aims to assess the value of different risk stratifications in diagnosing early gastric cancer (GC) and explore risk factors based on Kyoto gastritis classification.

METHODS

This study was a single-centered cross-sectional study; all epidemiological data and endoscopic findings were obtained prospectively. To evaluate the proportion of GC in each risk stratification and to compare the diagnostic performance of different methods using the receiver operating characteristic curve, univariable and multivariable analyses were used to explore the correlation between endoscopic findings and GC.

RESULTS

A total of 240 subjects were enrolled, and the diagnostic efficacy of the Kyoto Classification Score was similar to Operative Link on Gastric Intestinal Metaplasia Assessment (OLGIM) stage, and the accuracy was higher than that of the Japanese scoring system and OLGA stage. Moderate atrophy (odds ratio [OR] = 3.52, 95% confidence interval [CI]: 1.52-8.16), severe atrophy (OR = 4.96, 95% CI: 1.75-14.04), map-like redness (OR = 9.89, 95% CI: 1.16-84.15), and xanthelasma (OR = 3.57, 95% CI: 1.15-11.15) were independent risk factors for GC. The simplified Kyoto classification (area under the receiver operating characteristic [AUROC] = 0.76, P = 0.58) based on multivariable analysis demonstrated favorable diagnostic value compared with traditional Kyoto classification score (AUROC = 0.74).

CONCLUSIONS

This study confirms the value of the Kyoto classification score and the OLGIM stage in the risk stratification of GC. Simplified Kyoto classification is also promising in risk assessment of GC but still requires validation in the population.

Endoscopic evaluation by the Kyoto classification of gastritis combined with serum anti-Helicobacter pylori antibody testing reliably risk-stratifies subjects in a population-based gastric cancer screening program

BACKGROUND

We previously demonstrated that the Kyoto classification of gastritis was useful for judging the status of Helicobacter pylori infection in a population-based screening program, and that adding H. pylori antibody test improved its accuracy (UMIN000028629). Here, we tested whether our endoscopic diagnosis of H. pylori infection status reliably estimated gastric cancer risk in the program.

METHODS

Data were collected from1345 subjects who underwent endoscopic follow-up 4 years after the end of the registration. We analyzed the association of three diagnostic methods of H. pylori infection with gastric cancer detection: (1) endoscopic diagnosis based on the Kyoto classification of gastritis; (2) serum diagnosis according to the ABC method (H. pylori antibody and pepsinogen I and II); and (3) endoscopic diagnosis together with H. pylori antibody test.

RESULTS

During the follow-up, 19 cases of gastric cancer were detected. By Kaplan-Meier analysis, the detection rates of cancer were significantly higher in the past or current H. pylori infection groups than in the never-infected group with all 3 methods. By the Cox proportional hazards model, the hazard ratio for cancer detection was highest in evaluation with the combined endoscopic diagnosis and the antibody test (method 3; hazard ratio 22.6, 95% confidence interval 2.99-171) among the three methods (the endoscopic diagnosis (method 1); 11.3, 2.58-49.8, and the ABC method (method 2); 7.52, 2.49-22.7).

CONCLUSIONS

Endoscopic evaluation of H. pylori status with the Kyoto classification of gastritis, especially combined with serum anti-Helicobacter pylori antibody testing, reliably risk-stratified subjects in a population-based gastric cancer screening program.

Application of serum gastric function markers and digestive tumor indices to the diagnosis of early gastric cancer and precancerous lesions

OBJECTIVES

To study the levels of carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 199, CA724, CA242, pepsinogen (PG) I, PGII, gastrin-17 (G-17), the PGI/PGII ratio (PGR), as well as the expression of p27 and Ki67, in patients suffering from early gastric cancer and intraepithelial neoplasia and to provide new markers for the diagnosis of early gastric cancer and precancerous lesions.

METHODS

A retrospective study where the blood serum concentration of CEA, CA199, CA724, CA242, PGI, PGII, G-17 and PGR were tested and also the protein expression of p27 and Ki67 was detected in patients tissues by immunohistochemistry in the Gastrointestinal Endoscopy Center of the Affiliated Hospital of Xuzhou Medical University, Xuzhou, China, from March 2018 to March 2021.

RESULTS

Carbohydrate antigen 242 and CA199 levels in tumor tissue significantly differed among the groups. Pepsinogen I levels decreased with increasing disease severity, G-17 levels increased with the aggravation of severity, and p27 expression decreased with the severity.

CONCLUSION

The combination of serum gastric function markers (PGI and G-17) and p27 digestive tumor indices can serve as markers for the diagnosis of early gastric cancer and intraepithelial neoplasia.

Clinical value of serum pepsinogen in the diagnosis and treatment of gastric diseases

Pepsinogen, secreted from the gastric mucosa, is the precursor of pepsin. It is categorized as pepsinogen 1 and pepsinogen 2 based on its immunogenicity. The pepsinogen content that can enter the blood circulation through the capillaries of the gastric mucosa is approximately 1% and remains stable all the time. The pepsinogen content in serum will change with the pathological changes of gastric mucosa. Therefore, the level of pepsinogen in serum can play a role in serologic biopsy to reflect the function and morphology of different regions of gastric mucosa and serve as an indicator of gastric disease. This study conducts relevant research on serum pepsinogen 1, pepsinogen 2, and the ratio of pepsinogen 1 to pepsinogen 2, and reviews their important value in clinical diagnosis of Helicobacter pylori infection, gastric ulcer, and even gastric carcinoma, providing ideas for other researchers.

Comparison of Gastric Cancer Risk Classifications Using Conventional and New Pepsinogen Criteria

Background

New serum pepsinogen (PG) criteria have been shown to indicate more accurately infection with Helicobacter pylori (H. pylori). We sought to improve risk classification for gastric cancer by adopting the new PG criteria with the addition of an H. pylori antibody test.

Methods

The study participants were 275 patients with gastric cancer and 275 apparently healthy controls from case-control study data. We cross-sectionally compared the results of gastric cancer risk classifications that were based on a combination of the new PG criteria (PG II ≥ 10 ng/mL or PG I/II ≤ 5) and an H. pylori antibody test with those that were based on a combination of the conventional criteria (PG I ≤ 70 ng/mL and PG I/PG II ≤ 3) and an H. pylori antibody test.

Results

Applying the conventional criteria resulted in 89 controls being classified as low risk. Applying the new criteria resulted in 23 controls (bootstrapped 95% confidence intervals [CI]: 14, 32) being additionally classified as high risk. Eight patients with gastric cancer were classified as low risk using the conventional criteria; however, six of these patients were classified as high risk by the new criteria (bootstrapped 95% CI: 2, 11).

Conclusions

Compared with the conventional criteria, the new PG criteria with H. pylori antibody reduced instances of gastric cancer cases being misclassified as low risk. These findings suggest that the new PG criteria may help identify individuals at high risk of developing gastric cancer.

Diagnostic performance of the normal range of gastrin calculated using strict criteria based on a combination of serum markers and pathological evaluation for detecting gastritis: a retrospective study

BACKGROUND

The ABC method, which combines the pepsinogen method and anti-Helicobacter pylori antibody titers, has been used for risk screening for gastric cancer in Japan. However, it has been reported that there are cases of gastritis and carcinogenesis risk even in group A, which is considered to be a low-risk group based on the ABC method. Currently, in group A, endoscopic examination is needed to strictly discriminate "patients without gastritis" (defined as true A patients) from those "with gastritis." A simple and minimally invasive diagnostic criterion for gastritis using serological markers is desirable. In this study, we aimed to identify the normal serum gastrin concentrations in normal stomach cases based on pathological diagnosis and investigate the usefulness of serum gastrin concentrations in diagnosing gastritis.

METHODS

Patients who underwent endoscopy and blood tests at Hiroshima University Hospital were enrolled in the study and categorized into the "pathologically-evaluated group" and "endoscopically-evaluated group," according to the evaluation method of atrophic gastritis. Initially, we measured serum gastrin concentrations in the normal stomach cases in the pathologically-evaluated group and calculated the normal range of serum gastrin concentrations. We used the upper limit of this normal range of serum gastrin concentrations and performed a validation study to determine its usefulness as a diagnostic marker for distinguishing between cases of gastritis and true A in the endoscopically-evaluated group.

RESULTS

The 95th percentile of serum gastrin concentrations in pathologically-evaluated normal stomach cases was 34.12-126.03 pg/mL. Using the upper limit of this normal range of serum gastrin concentrations, the sensitivity, specificity, positive predictive value, and negative predictive value for gastritis were 52.8%, 92.6%, 97.0%, and 31.0%, respectively. Additionally, the receiver operating characteristic (ROC) curve for the endoscopically-evaluated group showed an area under the ROC curve of 0.80.

CONCLUSION

The gastrin cut-off value of 126 pg/mL has a good positive predictive value (97.0%) for detecting gastritis positing its use as a marker for cases requiring endoscopy. However, the identification of patients with gastritis having normal serum gastrin concentrations due to insufficient sensitivity remains a challenge for the future.

Helicobacter pylori infection

Helicobacter pylori infection causes chronic gastritis, which can progress to severe gastroduodenal pathologies, including peptic ulcer, gastric cancer and gastric mucosa-associated lymphoid tissue lymphoma. H. pylori is usually transmitted in childhood and persists for life if untreated. The infection affects around half of the population in the world but prevalence varies according to location and sanitation standards. H. pylori has unique properties to colonize gastric epithelium in an acidic environment. The pathophysiology of H. pylori infection is dependent on complex bacterial virulence mechanisms and their interaction with the host immune system and environmental factors, resulting in distinct gastritis phenotypes that determine possible progression to different gastroduodenal pathologies. The causative role of H. pylori infection in gastric cancer development presents the opportunity for preventive screen-and-treat strategies. Invasive, endoscopy-based and non-invasive methods, including breath, stool and serological tests, are used in the diagnosis of H. pylori infection. Their use depends on the specific individual patient history and local availability. H. pylori treatment consists of a strong acid suppressant in various combinations with antibiotics and/or bismuth. The dramatic increase in resistance to key antibiotics used in H. pylori eradication demands antibiotic susceptibility testing, surveillance of resistance and antibiotic stewardship.

Cancer Progress and Priorities: Gastric Cancer

Gastric cancer, the fifth leading cause of cancer worldwide, is estimated to be responsible for approximately 1.4% of all new cancers and 1.8% of all cancer-related deaths in the United States. Despite declining incidence rates and improved survival rates, however, gastric cancer continues to disproportionately affect racial and ethnic minorities and individuals of lower socioeconomic status at higher rates than the general population. To improve outcomes globally and address disparities within the United States, continued improvements are needed in risk factor modification and biomarker development and to improve access to existing preventative measures such as genetic testing and H. pylori eradication testing, in addition to expanding upon current clinical guidelines for premalignant disease to address gaps in endoscopic surveillance and early detection.

Helicobacter pylori, Homologous-Recombination Genes, and Gastric Cancer

BACKGROUND

Helicobacter pylori infection is a well-known risk factor for gastric cancer. However, the contribution of germline pathogenic variants in cancer-predisposing genes and their effect, when combined with H. pylori infection, on the risk of gastric cancer has not been widely evaluated.

METHODS

We evaluated the association between germline pathogenic variants in 27 cancer-predisposing genes and the risk of gastric cancer in a sample of 10,426 patients with gastric cancer and 38,153 controls from BioBank Japan. We also assessed the combined effect of pathogenic variants and H. pylori infection status on the risk of gastric cancer and calculated the cumulative risk in 1433 patients with gastric cancer and 5997 controls from the Hospital-based Epidemiologic Research Program at Aichi Cancer Center (HERPACC).

RESULTS

Germline pathogenic variants in nine genes (APC, ATM, BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, and PALB2) were associated with the risk of gastric cancer. We found an interaction between H. pylori infection and pathogenic variants in homologous-recombination genes with respect to the risk of gastric cancer in the sample from HERPACC (relative excess risk due to the interaction, 16.01; 95% confidence interval [CI], 2.22 to 29.81; P = 0.02). At 85 years of age, persons with H. pylori infection and a pathogenic variant had a higher cumulative risk of gastric cancer than noncarriers infected with H. pylori (45.5% [95% CI, 20.7 to 62.6] vs. 14.4% [95% CI, 12.2 to 16.6]).

CONCLUSIONS

H. pylori infection modified the risk of gastric cancer associated with germline pathogenic variants in homologous-recombination genes. (Funded by the Japan Agency for Medical Research and Development and others.).

Performing the ABC Method Twice for Gastric Cancer Risk Stratification: A Retrospective Study Based on Data from a Large-Scale Screening Facility

The ABC method is a classification method used for stratifying the risk of gastric cancer. However, whether the ABC method should be performed only once or multiple times throughout an individual’s lifetime remains unclear. Therefore, this study aimed to analyze whether performing ABC screening twice in a lifetime is useful. We retrospectively analyzed the data of individuals who participated in health checkups in 2010 and 2015. We collected data on patient characteristics, pepsinogen levels, anti-Helicobacter pylori antibody titers, and the presence of gastric cancer. Overall, 7129 participants without a history of H. pylori eradication were included in this study. The participants’ average age in 2010 was 48.4 ± 8.3 years, and 58.1% were male. In addition, 11 and 20 cases of new H. pylori infection (0.15%) and spontaneous eradication (0.28%), respectively, were recorded. No significant difference was found in the incidence of gastric cancer between participants who underwent the ABC method once and those who underwent it twice (Group A: 0.16% vs. 0.16%; Group B: 0.47% vs. 0.39%; and Group C + D: 1.97% vs. 1.82%). Therefore, performing the ABC method twice, 5 years apart, does not significantly improve gastric cancer risk stratification.

Development of a modified ABC method among Helicobacter pylori infected but serum pepsinogen test-negative individuals

BACKGROUND

Although the ABC method for gastric cancer (GC) screening has been widely adopted in Japan, it may not be suitable for other countries due to population heterogeneity and different tumor histology. We aim to develop a modified ABC method to improve GC screening performance, especially among Helicobacter pylori (Hp) infected but serum pepsinogen (sPG) test-negative individuals.

METHODS

A total of 4745 participants were recruited from Tianjin, China, and were classified into four groups by combined assay for Hp infection and sPG concentrations: Group A (Hp [-], PG [-]), Group B (Hp [+], PG [-]), Group C (Hp [+], PG [+]), and Group D (Hp [-], PG [+]). We used receiver-operating characteristic (ROC) curves analysis and minimum p value method to determine the optimal cutoff point for PG II in Group B. We performed logistic regressions to examine the risk of GC across different subgroups. In addition to the derivation set, the performance of the modified ABC method was also evaluated in an external set involving 16,292 participants from Liaoning, China.

RESULTS

In the modified ABC method, we further classified Group B as low-risk (Group B1) and high-risk subgroups (Group B2) using optimal sPG II cutoff point (20.0 ng/mL) by ROC curves analysis and minimum p value method. Compared with Group B1, Group B2 had a significantly higher risk of GC (adjusted OR = 2.54, 95% CI = 1.94-3.33). The modified ABC method showed good discrimination for GC (AUC = 0.61, 95% CI = 0.59-0.63) and improved risk reclassification (NRI = 0.11, p < .01). Similar results were observed in the validation dataset.

CONCLUSIONS

The modified ABC method can effectively identify high-risk population for GC among Hp-infected but sPG test-negative participants in China.

Assessing the utility of pepsinogens and gastrin-17 in gastric cancer detection

OBJECTIVES

The aim of the study was to determine the proportion of gastric cancer patients with decreased levels of pepsinogen and gastrin-17 in plasma, with the goal of providing indirect evidence of the sensitivity of these biomarkers when applied in a cancer screening setting.

METHODS

The levels of pepsinogens I and II, gastrin-17, and Helicobacter pylori immunoglobulin antibodies in plasma samples of gastric cancer patients were evaluated using the GastroPanel test system (Biohit Oyj, Helsinki, Finland). A decreased level of the pepsinogen I/II ratio was defined as less than three, while a decrease in gastrin-17 was defined as less than 1 pmol/L. Univariate analysis using non-parametric tests was used to investigate differences between normal and low concentrations of biomarkers.

RESULTS

In total, 481 plasma samples from patients (59.9% male) with a median age of 64 years (ranging from 27 to 88 years) were analyzed. Out of the 400 cases of gastric cancer (83.2% of the total), 182 were categorized as the intestinal type, 141 as the diffuse type, 60 as the mixed type, and 17 as indeterminate according to the Lauren classification system. The H. pylori immunoglobulin test was positive in 74.0% of the patients. Pepsinogen I/II ratio was decreased in 32.4% (36.8% of the intestinal type); gastrin-17 in 12.3% (10.1% of the antral region) of all cases.

CONCLUSION

The majority of gastric cancer patients had normal levels of pepsinogen and gastrin-17, suggesting that these biomarkers have limited application as screening tools in the Caucasian population.

Investigation of the prevalence and risk factors of Helicobacter pylori infection and the value of different gastric cancer screening methods in a low-risk region of gastric cancer in China

BACKGROUND

The aim of this current study was to identify the prevalence and risk factors of H. pylori infection in the low-risk area of gastric cancer in China, and evaluate the value of different gastric cancer screening methods.

METHODS

An epidemiological study was conducted in Yudu County, Jiangxi, China, and participants were followed up for 6 years. All participants completed a questionnaire, laboratory tests and endoscopy. Patients were divided into H. pylori positive and negative groups, and risk factors for H. pylori infection were identified using multivariate logistic regression analysis.

RESULTS

A total of 1962 residents were included, the prevalence of H. pylori infection was 33.8%. Multivariate analysis showed that annual income ≤20,000 yuan (OR: 1.44, 95% CI: 1.18-1.77, p < 0.001), loss of appetite (OR: 1.71, 95% CI: 1.29-2.26, p < 0.001), PG II >37.23 ng/mL (OR: 2.11, 95% CI: 1.50-2.97, p < 0.001), G-17 > 1.5 and ≤5.7 pmol/L (OR: 2.52, 95% CI: 1.93-3.30, p < 0.001), and G-17 > 5.7 pmol/L (OR: 1.96, 95% CI: 1.48-2.60, p < 0.001) were risk factors of H. pylori infection, while alcohol consumption (OR: 0.70, 95% CI: 0.54-0.91, p = 0.006) was a protective factor. According to the new gastric cancer screening method, the prevalence of low-grade intraepithelial neoplasia in the low-risk group, medium-risk group and high-risk group was 4.4%, 7.7% and 12.5% respectively (p < 0.001).

CONCLUSIONS

In a low-risk area of gastric cancer in China, the infection rate of H. pylori is relatively low. Low income, loss of appetite, high PG II, and high G-17 were risk factors for H. pylori infection, while alcohol consumption was a protective factor. Moreover, the new gastric cancer screening method better predicted low-grade intraepithelial neoplasia than the ABC method and the new ABC method.

Serum pepsinogen level as a biomarker for atrophy, reflux esophagitis, and gastric cancer screening in Indonesia

Background

Chronic dyspepsia's symptoms are frequently seen in primary to tertiary healthcare in Indonesia. This study aimed to describe the potential usability of pepsinogen (PG) values in determining gastric mucosal conditions, including superficial gastritis and atrophic gastritis.

Materials and Methods

We recruited 646 adult dyspeptic patients and then analyzed PG values (including PGI, PGII, and PGI/II ratio) with endoscopic findings, gastric mucosal damages, and Helicobacter pylori infection. The gastric mucosal damage and H. pylori infection were evaluated using histological examination based on the updated Sydney system.

Results

Among 646 enrolled patients, 308 (47.2%), 212 (32.8%), 91 (14.1%), 34 (5.2%), and 1 (0.2%) patient were diagnosed with normal mucosa, gastritis, reflux esophagitis, peptic ulcer disease, and gastric cancer, respectively. Significant differences in PGI, PGII, and PGI/II ratio values were observed among ethnic groups (all P < 0.01). The PGI and PGII levels were significantly higher and PGI/II was significantly lower in H. pylori-infected patients than in uninfected ones (all P < 0.001). The optimal cutoff value for PGII and PGI/II was 12.45 ng/mL with an area under the curve (AUC) value of 0.755 (0.702-0.811), sensitivity 59.3%, and specificity 77.1%; and 4.75 with AUC value of 0.821 (0.763-0.855), sensitivity 81.5%, and specificity 78.7%, respectively, to determine moderate-severe atrophy.

Conclusion

Serum PG levels, a useful biomarker, represent the endoscopic findings, especially for reflux esophagitis. In addition, the benefits of PG values detecting atrophic gastritis were limited to moderate-severe atrophic gastritis. This usefulness requires careful attention for several ethnic groups in Indonesia.

The management of Helicobacter pylori infection and prevention and control of gastric cancer in China

Helicobacter pylori (H. pylori) infection, a type-1 carcinogen, was closely associated with gastric cancer (GC). Successfully eradicating H. pylori infection could reduce the incidence of GC. China was a country with high incidence of GC and high prevalence of H. pylori infection. Nearly half of worldwide GC new cases and deaths attributed to H. pylori infection occurred in China. H. pylori prevalence varied over time with the improvement of socioeconomic status and sanitary conditions. The knowledge of antibiotic resistance rate in time was important to guide the clinical choice of antibiotics use in the regimens. With the publication of five Chinese consensus reports on the management of H. pylori infection and the effort of public preach of H. pylori-related knowledge, the standardization of H. pylori diagnosis and treatment by clinicians was improved. Bismuth-containing quadruple therapy was widely applied in clinical practice of H. pylori eradication because of high efficacy and safety. High-dose Proton Pump Inhibitor-amoxicillin dual therapy or vonoprazan-amoxicillin dual therapy showed comparable efficacy and lower side effects than bismuth-containing quadruple therapy, which were the alternative choice. The diagnosis rate of early GC was low and distinguishing Chinese GC risk population for the further endoscopy screening was important. Efforts have been done to establish prediction models to stratify GC risk in the Chinese GC risk population. We reviewed the current situation of the management of H. pylori infection and prevention and control of GC in China here.

Diagnostic performances of pepsinogens and gastrin-17 for atrophic gastritis and gastric cancer in Mongolian subjects

In Mongolia, gastric cancer morbidity and mortality are high, and more than 80 percent of cases are diagnosed at an advanced stage. This study aimed to evaluate pepsinogens (PGIs) and gastrin-17 (G-17) levels and to determine the diagnostic performances for gastric cancer and chronic atrophic gastritis among Mongolian individuals. We enrolled a total of 120 subjects, including gastric cancer (40), atrophic gastritis (40), and healthy control (40), matched by age (±2) and sex. Pepsinogen I (PGI), Pepsinogen II (PGII), G-17, and H. pylori IgG levels were measured using GastroPanel ELISA kit (Biohit, Helsinki, Finland). Also, PGI to PGII ratio (PGR) was calculated. For atrophic gastritis, when the optimal cut-off value of PGI was ≤75.07 ng/ml, the sensitivity and specificity were 75% and 50%, respectively; when the optimal cut-off value of PGR was ≤6.25, sensitivity and specificity were 85% and 44.7%, respectively. For gastric cancer, when the optimal cut-off value of PGI was ≤35.25 ng/ml, the sensitivity and specificity were 47.2% and 86.8%, respectively; when the optimal cut-off value of PGR was ≤5.27, sensitivity and specificity were 75% and 60.5%, respectively. Combinations of biomarkers with risk factors could improve diagnostic accuracy (AUC for atrophic gastritis 74.8, 95% CI 64.0–85.7, p<0.001; AUC for gastric cancer 75.5, 95% CI 64.2–86.8, p<0.001). PGI, PGR biomarkers combined with the risk of age, family history of gastric cancer, and previous gastric disease could not be an alternative test for upper endoscopy but might be a supportive method which is identifying individuals at medium- and high risk of gastric cancer and precancerous lesions who may need upper endoscopy.

Reevaluation of Gastric Cancer Screening by Levin's Equation

INTRODUCTION

This study aimed to reevaluate the effectiveness of fluoroscopy and endoscopy in reducing gastric cancer mortality at the population level.

METHODS

Crude and age-adjusted mortality rates of gastric cancer and the introduction rates of gastric cancer screening were extracted from the Cancer Registry and Statistics database. The population-attributable risk (PAR) percent of no screening for gastric cancer mortality was calculated using Levin's equation. The PAR of each mortality rate in the no-screening group was estimated as follows: mortality × PAR%. The Jonckheere-Terpstra test for trends and linear regression were performed to compare the PAR of gastric cancer mortality rates among the decades.

RESULTS

The PAR of crude and age-adjusted mortality rates in the no-screening group significantly decreased in the total population ( P for trend <0.001), as well as individually in the male ( P for trend <0.001) and female ( P for trend <0.001) populations. The PAR of the crude mortality rate in the female population significantly decreased in 2000-2009 and 2010-2019, compared with that in 1980-1989. There was no significant difference in the PAR of crude mortality rate in the male population among the decades. The PAR of the age-adjusted mortality rate significantly decreased in 2000-2009 and 2010-2019, compared with that in 1980-1989, in the male and female populations.

DISCUSSION

PAR% and PAR of no screening for gastric cancer mortality could be estimated using Levin's equation, and the effectiveness of the present gastric cancer screenings with fluoroscopy and endoscopy has been decreasing, especially in the female population.

Association of serum pepsinogens and gastrin-17 with Helicobacter pylori infection assessed by urea breath test

Background

Association of gastric atrophy or cancer with levels of serum pepsinogens, gastrin-17 and anti-Helicobacter pylori IgG antibody have been extensively studied. However, the association of serum pepsinogen and gastrin-17 with H. pylori infection has not been studied in a large population.

Aim

To investigate the impact of H. pylori infection on serum levels of pepsinogens and gastrin-17.

Methods

A total of 354, 972 subjects who underwent health check-ups were included. Serum levels of pepsinogens and gastrin-17 were measured using the enzyme-linked immunosorbent assay. H. pylori infection was detected using ¹⁴C-urea breath test (UBT). Multivariable logistic regression analysis was used to investigate the association of serum pepsinogen and gastrin-17 with H. pylori infection.

Results

H. pylori prevalence was 33.18% in this study. The mean levels of pepsinogens and gastrin-17 were higher, while the mean pepsinogen-I/II ratio were lower among H. pylori-positive than -negative subjects. In H. pylori-positive subjects, pepsinogen and gastrin-17 levels correlated positively, whereas the pepsinogen-I/II ratio correlated negatively with UBT values (e.g., the mean serum level of pepsinogen-I in subjects with UBT values in the range of 100-499dpm, 500-1499dpm, and ≥1500dpm was 94.77 ± 38.99, 102.77 ± 43.59, and 111.53 ± 47.47 ng/mL, respectively). Compared with H. pylori-negative subjects, the adjusted odds ratio (aOR) of having pepsinogen-I ≤ 70 ng/mL in the three H. pylori-positive but with different UBT value groups was 0.31 (p<0.001), 0.16 (p<0.001), and 0.08 (p<0.001), respectively; while the aOR of having G-17>5.70 pmol/L was 4.56 (p<0.001), 7.43 (p<0.001), and 7.12 (p<0.001). This suggested that H. pylori-positive subjects with higher UBT values were less likely to have pepsinogen-I ≤70 ng/mL (a serum marker for gastric atrophy), but more likely to have gastrin-17 >5.70 pmol/L (a marker for peptic ulcer).

Conclusions

H. pylori-positive subjects with higher UBT values are unlikely to have gastric atrophy, but may have greater risk of severe gastritis or peptic ulcers. Our study suggests that H. pylori-positive patients with high UBT values may benefit the most from H. pylori eradication.

Prevalence of Helicobacter pylori infection in the general population evaluated by a resident-register-based epidemiological study

BACKGROUND

The current status of Helicobacter pylori infection in Japan has not been investigated. We evaluated the status of H. pylori infection in a Japanese general population using large-scale resident-register-based sampling.

METHODS

All 6069 adults in a rural town and 6000 adults in two urban cities (3000 each), selected by register-based random sampling, were enrolled in our health check-up program. Antibody titers against Helicobacter pylori (cut-off value was 3 U/mL by Eiken E-plate) were evaluated, and subjects with a positive result were encouraged to undergo further examinations.

RESULTS

A total of 1586 subjects participated in serum sampling. The overall prevalence of H. pylori infection was 40.0% (634/1586), and it increased with age both in rural and urban areas. Although the overall positive rate was higher in the rural area (49.4%) than in the urban areas (35.6 and 32.3%), there was no difference in H. pylori status of younger subjects between the two areas. Among 634 patients with a positive titer, 374 (59.0%) underwent further examinations including endoscopic examination, and 180/634 (28.4%) patients received eradication therapy. Gastric neoplasms (three adenocarcinomas and one adenoma) were found in our screening program.

CONCLUSION

We clarified population-based random sampling data of H. pylori infection in a Japanese general population. In younger subjects, a decrease in the prevalence of H. pylori infection was confirmed both in rural and urban areas. This provides basic information for establishing a strategy to reduce gastric cancer deaths.

Gastric Cancer Screening in Japan: A Narrative Review

Gastric cancer is the second leading cause of cancer incidence in Japan, although gastric cancer mortality has decreased over the past few decades. This decrease is attributed to a decline in the prevalence of H. pylori infection. Radiographic examination has long been performed as the only method of gastric screening with evidence of reduction in mortality in the past. The revised 2014 Japanese Guidelines for Gastric Cancer Screening approved gastric endoscopy for use in population-based screening, together with radiography. While endoscopic gastric cancer screening has begun, there are some problems associated with its implementation, including endoscopic capacity, equal access, and cost-effectiveness. As H. pylori infection and atrophic gastritis are well-known risk factors for gastric cancer, a different screening method might be considered, depending on its association with the individual’s background and gastric cancer risk. In this review, we summarize the current status and problems of gastric cancer screening in Japan. We also introduce and discuss the results of gastric cancer screening using H. pylori infection status in Hoki-cho, Tottori prefecture. Further, we review risk stratification as a system for improving gastric cancer screening in the future.

Assessment of Serum Pepsinogens with and without Co-Testing with Gastrin-17 in Gastric Cancer Risk Assessment-Results from the GISTAR Pilot Study

Introduction−−Serum pepsinogen tests for gastric cancer screening have been debated for decades. We assessed the performance of two pepsinogen assays with or without gastrin-17 for the detection of different precancerous lesions alone or as a composite endpoint in a Latvian cohort. Methods−−Within the intervention arm of the GISTAR population-based study, participants with abnormal pepsinogen values by ELISA or latex-agglutination tests, or abnormal gastrin-17 by ELISA and a subset of subjects with all normal biomarker values were referred for upper endoscopy with biopsies. Performance of biomarkers, corrected by verification bias, to detect five composite outcomes based on atrophy, intestinal metaplasia, dysplasia or cancer was explored. Results−−Data from 1045 subjects were analysed, of those 273 with normal biomarker results. Both pepsinogen assays showed high specificity (>93%) but poor sensitivity (range: 18.4−31.1%) that slightly improved when lesions were restricted to corpus location (40.5%) but decreased when dysplasia and prevalent cancer cases were included (23.8%). Adding gastrin-17 detection, sensitivity reached 33−45% while specificity decreased (range: 61.1−62%) and referral rate for upper endoscopy increased to 38.6%. Conclusions−−Low sensitivity of pepsinogen assays is a limiting factor for their use in population-based primary gastric cancer screening, however their high specificity could be useful for triage.

Clinical Benefit and Cost Effectiveness of Risk-Stratified Gastric Cancer Screening Strategies in China: A Modeling Study

BACKGROUND AND OBJECTIVE

A new gastric cancer screening scoring system (NGCS) strategy was recommended for the early gastric cancer (GC) screening process in China. The current study aimed to assess the clinical benefits and the cost effectiveness of the NGCS strategy in GC high-risk areas of China from a societal perspective.

METHODS

A Markov microsimulation model was developed to evaluate 30 alternative screening strategies with varying initiation age, including the NGCS strategy, the modified NGCS strategy, and the endoscopic screening strategy with various screening intervals. The primary outcomes included GC mortality, number of endoscopies, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). Cost estimates were reported in 2021 USD (US$) and both costs and benefits were discounted at 5% annually. Deterministic and probabilistic sensitivity analyses were performed to evaluate model uncertainty.

RESULTS

Screening with the NGCS strategy from age 40 years (40-NGCS) reduced the GC incidence by 86.4%, which provided the greatest benefit across strategies. Compared with all strategies, at a willingness-to pay threshold of US$17,922 per QALY, the 40-NGCS strategy was a leading cost-effective strategy, with an ICER of US$15,668 per QALY. Results were robust in univariate and probabilistic sensitivity analyses. The probability of the 40-NGCS strategy being cost effective was 0.863.

CONCLUSIONS

The 40-NGCS strategy was an effective and cost-effective strategy to reduce GC incidence and mortality in China. The findings provide important evidence for decision makers to formulate and optimize targeted approaches for GC prevention and control policies in China.

Serum Pepsinogen as a Biomarker for Gastric Cancer in the United States: A Nested Case-Control Study Using the PLCO Cancer Screening Trial Data

BACKGROUND

Gastric cancer lacks specific symptoms, resulting in diagnosis at later stages and high mortality. Serum pepsinogen is a biomarker for atrophic gastritis, a gastric cancer precursor, and may be useful to detect persons at increased risk of gastric cancer.

METHODS

The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial was conducted in the United States between 1993 and 2001. ELISA-based pepsinogen tests were conducted on prediagnostic serum samples of 105 PLCO participants who developed gastric cancer and 209 age, sex, and race-matched controls. Pepsinogen positive (PG+) was defined as pepsinogen I ≤ 70 μg/L and pepsinogen I/II ratio ≤3.0. Results of conditional logistic regression models, and sensitivity and specificity, of PG+ for gastric cancer are reported.

RESULTS

Gastric cancer cases were more likely to be PG+ (31.4% vs. 5.5%, P < 0.001) at baseline than controls. Compared to PG-, PG+ was associated with an 8.5-fold increased risk for gastric cancer [95% confidence interval (CI) = 3.8-19.4]. This risk remained significant after adjusting for Helicobacter pylori, family history of gastric cancer, education, smoking, and BMI (aOR, 10.6; 95% CI, 4.3-26.2). In subgroup analysis, PG+ individuals were 11-fold more like to develop non-cardia gastric cancer (OR, 11.1; 95% CI, 4.3-28.8); conversely, they were not significantly more likely to develop cardia gastric cancer (OR, 2.0; 95% CI = 0.3-14.2). PG+ status yielded low sensitivity but high specificity for both noncardia (44.3%; 93.6%) and cardia gastric cancer (5.7%; 97.2%).

CONCLUSIONS

Prediagnostic serum pepsinogen levels from a large, prospective cohort study were associated with risk of gastric cancer, particularly noncardia gastric cancer.

IMPACT

PG status may identify individuals at higher risk of noncardia gastric cancer for targeted screening or interventions. See related commentary by Zhou and Huang, p. 1257.

Catching Up with the World: Pepsinogen Screening for Gastric Cancer in the United States

Gastric cancer remains a deadly cancer with poor outcomes in the United States. There is a need for screening strategies for gastric cancer in the U.S. population. With progressive Helicobacter pylori-mediated inflammation of the gastric mucosa, pepsinogen I levels decrease and the pepsinogen I/II ratio decreases. Pepsinogen test positivity (PG+) has been evaluated as a promising screening test among Asian and European populations; however, its utility in multiethnic U.S. populations is poorly described. In this case-control study nested within the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial, In and colleagues evaluate the discrimination of PG+ in serum collected from individuals prior to the development of gastric cancer. The authors find that PG+ individuals were at nearly 10-fold increased risk for developing gastric cancer, and this effect remained robust after adjusting for Helicobacter pylori status, family history, education, smoking, and obesity. In subgroup analysis, the predictive ability of the test was particularly robust for noncardia gastric cancers, and nonpredictive of cardia gastric cancers. Serum pepsinogen testing holds promise as a noninvasive screening strategy to triage individuals at heightened risk for gastric cancer, and may help to improve early diagnosis in the United States. See related article by In et al., p. 1426.

Identification of Helicobacter pylori-related gastric cancer risk using serological gastritis markers and endoscopic findings: a large-scale retrospective cohort study

Background

Gastric cancer remains a severe public health problem worldwide, particularly in Japan. Recent studies have demonstrated that serum markers are beneficial for risk stratification in gastric cancer development. We aimed to evaluate the usefulness of serum markers either alone or in combination (serum markers plus endoscopy) for effective risk stratification of gastric cancer development.

Methods

We enrolled 22,736 patients aged 20–95 years who underwent blood sampling and endoscopic examination at Hiroshima University Hospital in Japan between 1990 and 2014. The serum pepsinogen (PG) levels and anti-Helicobacter pylori antibody (Hp-Ab) titers were evaluated in each patient. The enrolled patients were matched with the database of the Hiroshima Prefecture Regional Cancer Registry. We processed the medical records and excluded patients with possible confounding factors for PG levels, such as proton pump inhibitor use, prior successful eradication therapy, post-gastrectomy, severe hepatorenal dysfunction, Zollinger–Ellison syndrome, and autoimmune gastritis. Among the remaining 5131 patients, we reviewed records of endoscopic examinations and selected 1507 patients (mean age, 62.5 years; 985 men and 522 women) who underwent endoscopic examination more than three months after blood sampling.

First, based on the ABC method, patients were classified as follows: High PG levels and negative Hp-Ab, group A, high PG levels and positive Hp-Ab, group B, low PG levels and positive Hp-Ab, group C, and low PG levels and negative Hp-Ab, group D. Group A was further classified into two subgroups using endoscopic findings: true A without atrophic gastritis and pseudo A with atrophic gastritis. All patients underwent annual endoscopy follow-up.

Results

Among the 1,507 patients (mean age, 62.5 years; 985 men), 24 were diagnosed with newly developed gastric cancer. No significant difference in cancer development was found between group A (PG negative and Hp-Ab negative) and the other groups. Remarkably, no true A group subjects developed gastric cancer.

Conclusions

The combination of serum markers and endoscopic findings is essential for the risk evaluation of gastric cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02381-z.

Application of a novel scoring system for gastric cancer opportunistic screening in hospital visits

Background

A novel scoring system and screening procedure for gastric cancer (GC) screening was proposed based on the national conditions of China, which state that endoscopy professionals and facilities are relatively limited compared with the large Chinese population.

Methods

A novel scoring system for gastric cancer screening was used to retrospectively analyse the patients who met the screening procedure from April 2017 to December 2019 in our hospital. We divided all of the patients into three groups: low-risk group (0–11 scores), medium-risk group (12–16 scores), and high-risk group (17–23 scores). Statistical analysis was performed on the detection rate of gastric cancer and precursors of gastric cancer among these three groups.

Results

A total of 6701 patients were enrolled in this study, including 4,352(64.95%) in the low-risk group, 1,948 patients (29.07%) in the medium-risk group, and 401 patients (5.98%) in the high-risk group. The total detection rate of gastric cancer was 2.84% (190/6,701), with a 0.94% rate (41/4,352) in the low-risk group, a 5.18% rate (101/1,948) in the medium-risk group, and a 11.97% rate (48/401) in the high-risk group. There were statistically significant differences in the detection rate of gastric cancer among these three groups (all P < 0.05). The detection rate of early gastric cancer was 46.31% (88/190) among all of the detected gastric cancers in this study. In addition, the detection rates of differentiated gastric cancer and precursors of gastric cancer in the medium-risk group and high-risk group were significantly higher than those in the low-risk group. In addition, the area under the curve (AUC) of the receiver operating characteristic curve (ROC) of the novel scoring system in differentiating GC was 0.79.

Conclusion

The screening strategy based on the novel scoring system can significantly improve the efficiency of gastric cancer opportunistic screening in hospital visits. Gastroscopy should be strongly recommended for patients in the medium-risk group and high-risk group, and detailed gastroscopy should be adopted as early as possible to improve the detection rate of early gastric cancer.

Predictive value of nomogram based on Kyoto classification of gastritis to diagnosis of gastric cancer

BACKGROUND AND AIM

It is important to predict the risk of gastric cancer (GC) for endoscopists because early detection of GC determines the selection of the best treatment strategy and the prognosis of patients. The study aimed to evaluate the utility of a predictive nomogram based on the Kyoto classification of gastritis for GC.

METHODS

It was a retrospective study that included 2639 patients who received esophagogastroduodenoscopy and serum pepsinogen (PG) assay from January 2019 to November 2019 at the Endoscopy Center of the Department of Gastroenterology, Wenzhou Central Hospital. Routine biopsy was conducted to determine the benign and malignant lesions pathologically. All cases were randomly divided into the training set (70%) and the validation set (30%) by using the bootstrap method. A nomogram was formulated according to multivariate analysis of the training set. The predictive accuracy and discriminative ability of the nomogram were assessed by concordance index (C-index), area under the curve (AUC) of receiver operating characteristic curve (ROC) as well as calibration curve and were validated by the validation set.

RESULTS

Among all patients enrolled, 102 of 2636 cases showed LGIN, HGIN and gastric cancer pathology results, whereas the rest cases showed benign pathological results. Multivariate analysis indicated that age, sex, PG I/II ratio and Kyoto classification scores were independent predictive variables for GC. The C-index of the nomogram of the training set was 0.79 (95% CI: 0.74 to 0.84) and the AUC of ROC is 0.79. The calibration curve of the nomogram demonstrated an optimal agreement between predicted probability and observed probability of the risk of GC. The C-index was 0.86 (95% CI: 0.79 to 0.94) with a calibration curve of better concurrence in the validation set.

CONCLUSION

The nomogram formulated was proven to be of high predictive value for GC.

Risk factors for gastric cancer in Japan in the 2010s: a large, long-term observational study

BACKGROUND

The numbers of Helicobacter pylori (HP)-infected individuals and deaths due to gastric cancer are decreasing in Japan. We aimed to determine whether the serological test for chronic gastritis (the ABC method) is still useful for gastric cancer risk stratification in the 2010s and to analyze risk factors for developing gastric cancer in Japan.

METHODS

In this prospective study, we monitored 20773 individuals for the incidence of gastric cancer from 2010 to 2019. The relationships between blood sampling results, physical examination, and lifestyle in 2010 and the cumulative incidence of gastric cancer were analyzed.

RESULTS

A total of 19343 participants who met the study criteria were analyzed. Overall, 0.08% of participants in group A (9/11717), 0.63% in group B (28/4452), 2.05% in group C (43/2098), 1.52% in group D (1/66), and 0.30% in group E (3/1010) developed gastric cancer. Cox hazard analysis showed that age ≥ 50 years; groups B, C, and D according to the ABC method; and current smoking habits were independent risk factors for gastric cancer. The hazard ratios (HRs) of the incidence of gastric cancer were 6.7 in group B and 21.7 in groups C and D, while the HRs of group E was 2.8, which was not significantly different from that of group A. The incidence of gastric cancer was not statistically significantly different between those with and without successful HP eradication in groups B, C, and D during follow-up.

CONCLUSIONS

The ABC method was still useful for gastric cancer risk stratification in the 2010s.

Severity of gastric intestinal metaplasia predicts the risk of gastric cancer: a prospective multicentre cohort study (GCEP)

OBJECTIVE

To investigate the incidence of gastric cancer (GC) attributed to gastric intestinal metaplasia (IM), and validate the Operative Link on Gastric Intestinal Metaplasia (OLGIM) for targeted endoscopic surveillance in regions with low-intermediate incidence of GC.

METHODS

A prospective, longitudinal and multicentre study was carried out in Singapore. The study participants comprised 2980 patients undergoing screening gastroscopy with standardised gastric mucosal sampling, from January 2004 and December 2010, with scheduled surveillance endoscopies at year 3 and 5. Participants were also matched against the National Registry of Diseases Office for missed diagnoses of early gastric neoplasia (EGN).

RESULTS

There were 21 participants diagnosed with EGN. IM was a significant risk factor for EGN (adjusted-HR 5.36; 95% CI 1.51 to 19.0; p<0.01). The age-adjusted EGN incidence rates for patients with and without IM were 133.9 and 12.5 per 100 000 person-years. Participants with OLGIM stages III-IV were at greatest risk (adjusted-HR 20.7; 95% CI 5.04 to 85.6; p<0.01). More than half of the EGNs (n=4/7) attributed to baseline OLGIM III-IV developed within 2 years (range: 12.7-44.8 months). Serum trefoil factor 3 distinguishes (Area Under the Receiver Operating Characteristics 0.749) patients with OLGIM III-IV if they are negative for H. pylori. Participants with OLGIM II were also at significant risk of EGN (adjusted-HR 7.34; 95% CI 1.60 to 33.7; p=0.02). A significant smoking history further increases the risk of EGN among patients with OLGIM stages II-IV.

CONCLUSIONS

We suggest a risk-stratified approach and recommend that high-risk patients (OLGIM III-IV) have endoscopic surveillance in 2 years, intermediate-risk patients (OLGIM II) in 5 years.

Serum Pepsinogens Combined with New Biomarkers Testing Using Chemiluminescent Enzyme Immunoassay for Non-Invasive Diagnosis of Atrophic Gastritis: A Prospective, Multicenter Study

Background: Analysis of serum biomarkers for the assessment of atrophic gastritis (AG), a gastric precancerous lesion, is of growing interest for identification of patients at increased risk of gastric cancer. The aim was to analyze the diagnostic performance of serum pepsinogen testing using another method, chemiluminescent enzyme immunoassay (CLEIA), as well as of other new potential biomarkers. Material and Methods: The sera of patients considered at increased risk of gastric cancer and undergoing upper endoscopy collected in our previous prospective, multicenter study were tested for pepsinogen I (PGI) and II (PGII), interleukin-6 (IL-6), human epididymal protein 4 (HE-4), adiponectin, ferritin and Krebs von den Lungen (KL-6) using the CLEIA. The diagnostic performance for the detection of AG was calculated by taking histology as the reference. Results: In total, 356 patients (162 men (46%); mean age 58.6 (±14.2) years), including 152 with AG, were included. For the detection of moderate to severe corpus AG, sensitivity and specificity of the pepsinogen I/II ratio were of 75.0% (95%CI 57.8–87.9) and 92.6% (88.2–95.8), respectively. For the detection of moderate to severe antrum AG, sensitivity of IL-6 was of 72.2% (95%CI 46.5–90.3). Combination of pepsinogen I/II ratio or HE-4 showed a sensitivity of 85.2% (95%CI 72.9–93.4) for the detection of moderate to severe AG at any location. Conclusion: This study shows that PG testing by CLEIA represents an accurate assay for the detection of corpus AG. Additionally, IL-6 and HE-4 may be of interest for the detection of antrum AG. Mini-abstract: Pepsinogens testing by chemiluminescent enzyme immunoassay is accurate for the detection of corpus atrophic gastritis. IL-6 and HE-4 maybe of interest for the detection of antrum atrophic gastritis.

The Association of Trefoil Factors with Gastric Cancer and Premalignant Lesions: A Cross-sectional Population-based Cohort Study

BACKGROUND

A lack of research on the association of trefoil factors (TFFs) with gastric cancer (GC) and premalignant lesions (PMLs) in the general populations is an important obstacle to the application of TFFs for GC screening. We aimed to analyze the association of TFFs with GC and PMLs in a general population.

METHODS

We evaluated 3,986 adults residing in Wuwei, China. We collected baseline characteristics and GC risk factors, including TFFs, endoscopic diagnosis, and pathological information. Three logistic regression models were generated to analyze the association between TFFs and GC, as well as PMLs. Adjusted odds ratio (OR) and 95% confidence intervals (95% CI) were calculated to determine the strength of association.

RESULTS

Compared with pepsinogen (PG) and anti-Helicobacter pylori immunoglobulin G antibody (Hp-IgG), TFFs had significant association with GC and PMLs after adjusting for biomarkers and risk factors (P < 0.05). The ORs [95% CI] for TFF1 (1.67 [1.27-2.20]), TFF2 (2.66 [2.01-3.51]), and TFF3 (1.32 [1.00-1.74]) were larger than the ORs for PGI (0.79 [0.61-1.03]), PGI/II (1.00 [0.76-1.31]) and Hp-IgG (0.99 [0.73-1.35]) in the GC group. In intestinal metaplasia (IM) group, not only the TFF3 serum level was the highest, but also the OR (1.92 [1.64-2.25]) was the highest.

CONCLUSIONS

Trefoil factor were associated with risk of GC and PMLs.

IMPACT

Serum TFFs can improve the screening of high-risk populations for GC.

Who Could Be Blamed in the Case of Discrepant Histology and Serology Results for Helicobacter pylori Detection?

BACKGROUND

Discrepancies between histology and serology results for Helicobacter pylori detection could be caused by a variety of factors, including a biopsy sampling error, expertise of the pathologist, natural loss of infection due to advanced atrophy, or a false-positive serology in the case of a previous infection, since antibodies may be present in blood following recovery from the infection.

AIMS

To identify true H. pylori-positive individuals in discrepant cases by serology and histology using real time polymerase chain reaction (RT-PCR) as a gold standard.

METHODS

Study subjects with discrepant histology and serology results were selected from the GISTAR pilot study data base in Latvia. Subjects having received previous H. pylori eradication therapy or reporting use of proton pump inhibitors, antibacterial medications, or bismuth containing drugs one month prior to upper endoscopy were excluded. We compared the discrepant cases to the corresponding results of RT-PCR performed on gastric biopsies.

RESULTS

In total, 97 individuals with discrepant results were identified: 81 subjects were serology-positive/histology-negative, while 16 were serology-negative/histology-positive. Among the serology-positive/histology-negative cases, 64/81 (79.0%) were false-positives by serology and, for the majority, inflammation was absent in all biopsies, while, in the serology-negative/histology-positive group, only 6.2% were proven false-positives by histology.

CONCLUSIONS

Among this high H. pylori prevalent, middle-aged population, the majority of discrepant cases between serology and histology were due to false positive-serology, rather than false-negative histology. This confirms the available evidence that the choice of treatment should not be based solely on the serological results, but also after excluding previous, self-reported eradication therapy.

The Optimal Cut-off of the Latex Immunoassay (LZ Test) for Helicobacter pylori Infection Based on the Stool Antigen Test and Helicobacter pylori-associated Gastritis

Objective Helicobacter pylori antibody kits using the latex immunoassay (LIA) are widely used in Japan. However, the optimal cut-off of the LIA remains unclear. This study clarified the optimal cut-off of the LIA for assessing the current infection status of patients (currently infected, never infected, spontaneously eradicated) in clinical practice. Methods In total, 482 subjects with no history of H. pylori eradication therapy who underwent a medical examination at our hospital were enrolled. The infection status was ascertained using a stool antigen test, and the endoscopic findings of H. pylori-associated gastritis. H. pylori antibody levels were measured using the LIA. Results In total, 414, 38, and 30 subjects were categorized into the never-infected, currently infected, and spontaneously eradicated groups. The optimal cut-off based on receiver operating characteristic curve analysis was 4 U/mL, whereas the area under the curve, sensitivity, and specificity for differentiating never-infected and currently infected subjects were 0.95, 92.1%, and 94.7%, respectively. When applying the cut-off of 4 U/mL to the judgment of current infection in all subjects, the sensitivity and specificity were 92.1% and 92.6%, respectively. Conclusion Our findings suggest that 4 U/mL was the optimal cut-off for differentiating current infection from no prior infection, and the value may be stable because of the exclusion of subjects with spontaneous eradication. The cut-off may be useful in initial screening for current H. pylori infection.

Analysis of long-term serological and histological changes after eradication of <i>Helicobacter pylori</i>

Stratification of gastric cancer risk by measuring serological biomarkers is useful for screening of gastric cancer. However, this method has problem such as overlooking past infected patients. We aimed to evaluate the association between Helicobacter pylori infection status and serological biomarkers. We divided 5,268 patients according to Helicobacter pylori infection status and past infected patients were divided into 12 groups according to time elapsed since eradication. We analyzed mean serum H. pylori immunoglobulin G antibody, pepsinogen titers, histological and endoscopic atrophy score of each group. Mean H. pylori immunoglobulin G antibody showed a decreasing tendency, there was no significant difference from the uninfected group at 11 years after eradication (p = 0.19). PGI, PGII decreased in short term after eradication. However, both PGI and PGII gradually increased as long-term changes after eradication, became comparable to those in the uninfected group (p = 0.41, p = 0.37, respectively). Histological atrophy improved gradually, became equivalent to uninfected group. Endoscopic atrophy score did not improve for long term after eradication. In conclusion, patients with long term after eradication reach the uninfected condition serologically, histologically. Endoscopic assessment of gastric mucosal atrophy may be useful for accurate assessment of gastric cancer risk.

A non-invasive combined strategy to improve the appropriateness of upper gastrointestinal endoscopy

Background and aim Increasing the appropriateness of upper gastrointestinal endoscopy (UGIE) improves the quality of care while containing costs. The aim of this study was to improve the appropriateness of UGIE through a process involving evaluation of prescriptions and the use of a non-invasive alternative. Materials and methods A senior endoscopist evaluated the appropriateness of all outpatient referrals for UGIE and established the proper timing. Referrals were either accepted and programmed, canceled, or substituted by a non-invasive evaluation of gastric function, determining serum levels of gastrin-17 (G17), Pepsinogen I (PGI) and II (PGII), and antibodies against Helicobacter pylori. Results A total of 5102 requests for UGIE examinations were evaluated; 540 (10.4%) were inappropriate and had been prescribed for: gastroesophageal reflux disease (n=307), surveillance with erroneous timing (n=113), dyspepsia (n=66), other indications (n=20), and absence of written indication (n=34). Gastric function was evaluated in 282/540 patients; findings included normal values in 94 patients without proton-pump inhibitor therapy (PPI) and in 48 on PPI, active H pylori infection in 56, previous H pylori infection in 30, GERD in n=50, and atrophic gastritis in n=4. UGIE was performed in the latter 4 cases.  Within 2 years (range 1-22 months) of the initial refusal, 105/504 patients underwent UGIE, with normal endoscopic findings in 71/105 (67.5%), and with no cases of cancer. Conclusions This strategy, based on a strict control of prescriptions, is effective to increase the appropriateness while containing public health costs. The use of gastric function testing improves patient selection for UGIE endoscopy.

Serum Assay Findings after Successful Helicobacter pylori Eradication

Serum pepsinogen (PG), anti-Helicobacter pylori (H. pylori) immunoglobulin G (IgG), and gastrin-17 (G-17) are plasma biomarkers for gastritis. H. pylori serology titers and PG levels increase during active H. pylori infection; moreover, elevated PG II levels indicate a high risk for diffuse-type gastric cancer in East Asian populations. Serum PG I/II ratios and PG I levels decrease with the progression of gastric corpus atrophy; thus, a combination of serum PG I levels ≤70 ng/mL and a PG I/II ratio ≤3 (serologic atrophy) indicates a high risk of intestinal-type gastric cancer. Serum G-17 is often not used as an indicator in H. pylori-seroprevalent populations because it is usually elevated in subjects with H. pylori infections. When H. pylori is eradicated, most patients show a rapid decrease in serum PG II levels and anti-H. pylori IgG titers within a few months. Seroreversion is required for several months to years after regression of H. pylori. Moreover, seroreversion may not always be achieved in all eradicated cases. The serum PG I/II ratio starts to increase after eradication; therefore, serologic atrophy improves accordingly, unless severe atrophy is present. Thus, some eradicated patients may show normal serum assay findings but have a higher risk for developing gastric cancer than H. pylori-naive subjects. Furthermore, serum PG levels decrease after gastrectomy and increase with the intake of certain drugs (e.g., aspirin or acid suppressants) or in renal failure patients. Due to such wide variations, serum assays are inadequate for the confirmation of H. pylori eradication. It is useful when interpreted with gastroscopy and other H. pylori test findings.