Screening Services

Public Health Wales

Screening for Stomach Cancer:

A report for the National Screening Committee

Dr Sharon Hillier
Specialist Registrar in Public Health
sharon.hillier@nphs.wales.nhs.uk

Dr Hilary Fielder
Director Screening Services
Public Health Wales

November 2009

Introduction
This report reviews screening for stomach (gastric) cancer in the United
Kingdom (UK) population against the UK National Screening Committee
Criteria for appraising the viability, effectiveness and appropriateness of a
screening programme.1
Stomach cancer is a disease with the recognised risk factors of Helicobacter
pylori (H. Pylori) infection, genetic, environmental and nutritional factors. In
1994 H. pylori was classified as a group I carcinogen for stomach cancer by
the International Agency for Research on Cancer.2
Approximately 90% of stomach cancers are adenocarcinomas arising in the
gastric mucosa.3 There is a stepwise progression from chronic inflammation of
the mucosa which can slowly progress through the premalignant stages of
atrophic gastritis, intestinal metaplasia, dysplasia and finally to
adenocarcinoma.
In the UK, although the incidence of stomach cancer is low, presentation is
generally at an advanced stage and therefore treatment options are more
limited and prognosis poorer. Some countries that have a high incidence of
stomach cancer have established national population based screening
programmes and these include Japan (started 1960) and Korea (started
1999).
In 2003 the Health Technology Assessment published a report 4 on the costeffectiveness of screening for H. pylori to reduce mortality and morbidity from
gastric cancer and peptic ulcer disease. With respect to stomach cancer the
conclusions were that there was uncertainty of the effect of eradication of H.
pylori on stomach cancer risk. The National Screening Committee reviewed
the report and did not recommend a national population based screening
programme for stomach cancer. The policy was reviewed in 2006 but no
significant changes were made.

Method
A literature search was performed by an information scientist at the National
Screening Committee to find citations on screening for stomach cancer
published since 2002 (as the evidence on which the current policy was based
was published in 2003). Sources searched were Medline, Embase, the
Cochrane Library and Centre for Reviews and Dissemination databases.
Current work was searched on the metaRegister of Clinical Trial,
ClinicalTrials.gov and the Health Technology Assessment database. The
search strategy is listed in Appendix 1. A total of 19,062 references were
identified and these were scanned by the information scientist for relevance to
screening for stomach cancer and duplication. In total there were 149 citations
plus one ongoing trial from the registers and these were categorised
according to the UK NSC criteria.
Screening for Stomach Cancer

The reviewer read all of the abstracts and obtained the papers in full if they
were in English and the abstract indicated that the paper would inform the
review with respect to the screening criteria. Of the 149 abstracts, 84 papers
were obtained in full, 22 papers were not in the English language and 42 were
sufficient as abstracts and one abstract was a duplicate. One additional paper
detailing a meta-analysis was identified after the literature search was
undertaken.

The Condition
1. The condition should be an important health problem.
The incidence and mortality from stomach cancer are decreasing worldwide
but it remains a major health concern in several developed and developing
countries.5 Stomach cancer is the second commonest cause of cancer deaths
worldwide. In 2002 it accounted for more than 900 000 new cancer cases
diagnosed and 700 000 deaths.6
Areas with a high incidence of stomach cancer are defined as an incidence
rate greater than 20 cases per 100,000 persons per year.7 High incidence
countries are those in eastern Asia, Korea (age-standardised rate in men 69.7
per 100,000); Japan (62.0 per 100,000) and China (41.1 per 100,000)
whereas most of Europe, North America and Africa are low incidence areas. 8
In the UK, there were 5,133 registrations for stomach cancer in males and
2,886 for females during the period of 2004-2006. The European directly agestandardised incidence per 100,000 population was for overall UK 14.0 males
and 5.7 females and the individual nations: England 13.6 males and 5.4
females; Wales 16.2 males and 6.8 females; Scotland 16.1 males and 7.3
females and Northern Ireland 14.3 males and 7.0 females. 9
In the UK, there were 3,464 deaths from stomach cancer in males during the
period 2004-2006 and 2,149 deaths in females. The European directly agestandardised mortality rates per 100,000 population were for overall UK 9.2
males, 4.0 females; England 8.9 males, 3.8 females; Wales 10.9 males, 4.5
females; Scotland 11.2 females, 5.4 males and Northern Ireland 11.0 males,
5.2 females. 9
The five year relative survival rates for stomach cancer from diagnosis in
1995-1999 were 17.2 for Northern Ireland, 16.1 for England, 15.7 for Scotland
and 15.9 for Wales. The rates were similar across the nations in the UK but
they were lower than some of the other countries in Europe for example
Austria had a 30.3% five year survival rate. 10
It is important to note that although the incidence of stomach cancer is
declining, the absolute annual number of new cases will increase due to
increased life expectancy and population expansion. 11

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2. The epidemiology and natural history of the condition, including

development from latent to declared disease, should be adequately
understood and there should be a detectable risk factor, disease marker,
latent period or early symptomatic stage.
Epidemiology
In the UK, stomach cancer incidence increases with age with very few
cancers in those aged 40 years or less. The mean age at diagnosis in Wales
is 70.8 years in males and 75.2 years in females. It is about twice as common
in males than females in the UK.10
Since the 1970s in the UK the age-standardised incidence rate for males has
more than halved, with the rate reported as 31.0 per 100,000 in 1975 and the
trend is similar for females.12
Natural history
Adenocarcinoma of the stomach is divided into two main histological types;
intestinal (or well differentiated) and diffuse. The intestinal type is associated
with gastric atrophy and is potentially identified by stomach cancer screening.
In the intestinal type there is a stepwise progression from chronic
inflammation of the mucosa resulting from H. pylori infection which slowly
progresses through the premalignant stages of atrophic gastritis, intestinal
metaplasia, dysplasia and finally to adenocarcinoma.2, 13
Estimates of progression rates of premaligant lesions are primarily based on
historic cohort studies. Data from these studies suggest that among 100 H.
pylori-positive subjects 50 will develop atrophic gastritis, 40 will develop
intestinal metaplasia, eight will develop dysplasia and one or two will
eventually develop stomach cancer.11 The progression of premalignant gastric
lesions to stomach cancer generally takes decades. It has been reported that
early stage stomach cancer takes about 44 months to progress to advanced
stage.14
Risk factors
Stomach cancer is a multifactorial disease with the recognised risk factors of
H. pylori infection, genetic, environmental and nutritional factors. In 1994 H.
pylori was classified as a group I carcinogen for stomach cancer by the
International Agency for Research on Cancer. Smoked food, preservations
with salt and specific cultural dietary habits may contribute to higher incidence
in certain geographical areas.2
Although H. pylori is a recognised necessary risk factor of stomach cancer,
screening for H. pylori antibodies is problematic as it does not differentiate
between chronic, non-atrophic gastritis and premalignant lesions. Also in
atrophic gastritis H. pylori colonisation can disappear and then the test result
becomes negative.11

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Symptoms
Dyspeptic symptoms are common in patients with early stage stomach cancer
with 60-90% having symptoms.8 However, these symptoms are very common
in the general population with estimates of 40% of the adult population in the
UK annually experiencing symptoms, of whom 5% would consult their
General Practitioner.15
The National Institute for Health and Clinical Excellence (NICE) guidance16 for
investigations for stomach cancer is that routine endoscopic investigation of
patients of any age, presenting with dyspepsia and without alarm signs, is not
necessary.
However, patients aged 55 years and older with unexplained and persistent
recent-onset dyspepsia alone should have an urgent referral for endoscopy.
Urgent specialist referral or endoscopic investigation is also indicated for
patients of any age with dyspepsia when presenting with any of the following:
chronic gastrointestinal bleeding; progressive unintentional weight loss;
progressive difficulty swallowing; persistent vomiting; iron deficiency anaemia;
epigastric mass or suspicious barium meal.
Therefore although the epidemiology of stomach cancer is understood, there
is a lack of suitable risk factor or early symptom that is specific enough to be
used in a screening programme.

3. All the cost-effective primary prevention interventions should have

been implemented as far as practicable.
As epidemiological studies have demonstrated a clear causal link between H.
pylori and stomach cancer, interest has focused on whether H. pylori
eradication can prevent stomach cancer. In the Western European population,
H. pylori infection prevalence is approximately 30-40%.17 Although a
randomised trial published in 2002 conducted in Bristol, UK, exploring
eradication of H. pylori in the general population (male and female aged 20-59
years), found that prevalence of H. pylori infection was as low as 15.5%.18
As stomach cancer has a relatively low incidence and a long natural history, it
is difficult to undertake studies as they have to be very large and participants
followed up for a long time. To overcome these limitations a large number of
interventional studies have evaluated the effect of H. pylori eradication on the
progression of precancerous lesions rather than stomach cancer as the
primary end point.19
A meta analysis 5 published in 2009 of randomised controlled trials that
compared eradication treatment with no treatment in H. pylori positive
patients, assessed stomach cancer or progression of precancerous lesions
during follow up. The pooled analysis of six studies with a total of 6695
participants followed from 410 years reported that the relative risk for
stomach cancer was 0.65 (95% CI 0.43-0.98). The limitations of the analysis
was that all studies were performed in areas of high incidence of stomach

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cancer; only two assessed stomach cancer incidence as their primary end
point and only 2 were double blinded.
The disadvantages of H. pylori eradication have been proposed as: antibiotic
resistance with widespread use of the antibiotics; compliance issues as
patients prescribed the treatment will probably be asymptomatic and may not
complete the prescribed course; there is a lack of information on the
reinfection rate of H. pylori in the UK; and the risk of developing
gastroesophageal diseases may be increased.20,21
Other modifiable risk factors for stomach cancer such as increasing fruit and
vegetables consumption; reducing salt intake and stopping smoking are
recognised as general health primary prevention measures and as such
should be implemented.
4. If the carriers of a mutation are identified as a result of screening the
natural history of people with this status should be understood,
including the psychological implications.
Although there is an understanding that stomach cancer tends to cluster in
families with the risk of stomach cancer increased at least 1.5 times in siblings
or offspring of patients with stomach cancer, it is only hereditary diffuse
stomach cancer that is recognised as an inherited form of stomach cancer.14
Screening for stomach cancer would not identify carriers of a mutation.

The Test
5. There should be a simple, safe, precise and validated screening test.
There have been several tests explored for stomach cancer screening and the
following five are discussed below; H. pylori, pepsionogen, gastrin-17, barium
studies and endoscopy. It is only barium studies and endoscopy that have
been recognised as validated tests for the national based screening
programmes in Japan and Korea.

Helicobacter pylori (H. Pylori)

H. pylori is a recognised necessary risk factor for stomach cancer and there
are validated non-invasive tests available. However, screening for H. pylori
antibodies is problematic as it does not differentiate between chronic, nonatrophic gastritis and precancerous lesions. Also in atrophic gastritis H. pylori
colonisation can disappear and then the test result becomes negative. 11

Pepsinogen
Serum pepsinogen is a serological test that has been used in Japan. Serum
pepsinogen consists of two types: PGI and PGII. A low PGI concentration or a
low PGI/II ratio are indicators of atrophic gastritis. A PGI concentration of less
than 70mg/l and a PGI/II ratio of less than 3.0 are cut offs used for

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identification of patients with atrophic gastritis in Japan. In a pooled analysis

of Japanese studies that assessed about 300,000 people the sensitivity of
serum pepsinogen testing was 77% and the specificity was 73%.14
The combination of H. pylori serology and the measurement of pepsinogen
concentrations may aid in the prediction of stomach cancer development. The
picture is complicated though as in a series of 9,000 people stratified
according to H. pylori antibody status and serum pepsinogen concentrations;
men who were older than 60 years and who had a negative H. pylori serology
had the highest annual stomach cancer incidence of 1.8%. 14
The low stomach cancer incidence in the UK means that the positive
predictive value for serum pepsinogen testing will be low.

Gastrin-17
Gastrin-17 is synthesised in G cells found in the antrum of the stomach. 8 It
has been proposed for the identification of patients with gastric atrophy as
fasting serum gastrin-17 concentration is low in people with high acid
production or atrophy.14 The interpretation of serum concentration is
complicated as the concentration of gastrin-17 increases in patients with
stomach cancer and does not distinguish early gastric cancer from that of
advanced. Although it cannot be used as a single marker for gastric cancer it
may be used in combination with other markers. The combination of
pepsinogen and gastrin levels together with H.pylori antibody status has been
reported as having a sensitivity and specificity of 89% and 93% in being able
to identify and distinguish different types of atrophic gastritis.8

Barium Studies
Photoflurography has been used for stomach cancer screening in Japan since
1960. There is an initial examination (indirect examination) which uses an
eight series of small radiographs. Abnormal examination is followed up with a
more detailed examination (direct examination) with an 11 series of
radiographs.14 Endoscopy is used to analyse any suspicious lesions identified.
The sensitivity and specificity of photofluorography has been reported as
between 70-90% and 80-90% respectively.22
Even in countries with high stomach cancer incidence the detection rate can
be low. To illustrate, in the Kanagawa Health Service (Japan) 770,710
individuals were screened for stomach cancer by barium meal examination
between April 1992 and March 2000. There were 364 (0.047%) asymptomatic
stomach cancers detected, which is a yield of 5 in 10,000.23

Endoscopy
Upper gastrointestinal endoscopies are generally accepted as the gold
standard for the diagnosis of stomach cancer. This technique is increasingly
used for stomach cancer screening in Japan because of its high detections
rate. One study reported the detection of stomach cancer by endoscopy was

Screening for Stomach Cancer

about 2.7 to 4.6 times higher than by direct of indirect radiograph examination
24
.
Despite this promising result direct evidence about the effectiveness,
complications and acceptability of endoscopy among individuals at average
risk of stomach cancer is still not sufficient to justify its use for routine
screening.24 It is an unpleasant procedure that carries the risk of haemorrhage
and perforation with a reported mortality of 0.0008% and a morbidity of
0.432%.25 The technique depends heavily on the skills of the endoscopist 22
and the false negative rate, which as been reported as between 10 and 19%,
is also a limitation.8

6. The distribution of test values in the target population should be

known and a suitable cut-off level defined and agreed.
As the national screening programmes in Japan and Korea are both based on
tests that are clinical judgements and have either a positive or negative result,
they do not have cut-off levels defined. If a screening programme was to be
established in the UK, the test, cut-off levels (if appropriate) and target
population would need to be defined and agreed.
The morphology of lesions to be biopsied should be described and the
histological results which would lead to further healthcare management would
need to be agreed. Screening inevitably finds lesions which have not
previously been seen from patients presenting with clinical symptoms and the
management to ensure best outcomes for these lesions should be researched
at an early stage.

7. The test should be acceptable to the population.

As there is no stomach screening programme in the UK the evidence of
acceptability of the test is gained from the experience in Japan and Korea.
In Japan, the eligible population to be screened is all asymptomatic males and
females aged 40 years and older. According to the Japanese National Survey
the rate of participation in stomach cancer screening in 2004 was only 22%.26
In Korea, screening for stomach cancer started in 1999 as a national
programme and biennial stomach cancer screening is recommended for men
and women aged 40 years and older with either photofluorography or
endoscopy. In 2005 only 20% of the eligible population participated in the
screening programme. Opportunistic screening also occurs and the estimate
in 2006 was that about 19% of men and women aged 40 years and older had
undergone opportunistic screening within the previous 2 years. 24

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8. There should be an agreed policy on the further diagnostic

investigation of individuals with a positive test result and on the choices
available to those individuals.
Endoscopy is the first line investigation in establishing a diagnosis and
biopsies should be taken for histological confirmation.2 If a stomach cancer
screening programme was to be established in the UK then agreed guidelines
on investigations and choices need to be standardised.
9. If the test is for mutations the criteria used to select the subset of
mutations to be covered by screening, if all possible mutations are not
being tested, should be clearly set out.
This is not applicable in stomach cancer screening

The Treatment
10. There should be an effective treatment of intervention for patients
identified through early detection, with evidence of early treatment
leading to better outcomes than late treatment.
In Western countries early disease is accounts for between 10 and 20% of all
stomach cancers detected.8 Early Gastric Cancer (EGC) is a term defined in
Japan for a malignant tumour limited to the mucosa or submucosa
irrespective of the presence of lymph node metastases. In Japan, 5 year
survival rates are reported as over 90% for ECG. In the west 5 year survival
rates are more variable ranging from 68-92%.8 There is some debate about
the definition of EGC with Western pathologists only diagnosing stomach
cancer when there is evidence of invasion.
Treatment is related to stage so all relevant information about tumour spread
must be obtained from staging investigations.2 Newly diagnosed patients
should be assessed by a multidisciplinary team working to agreed protocols
and algothrithms. Dysplasia and early stomach cancer are amenable to
endoscopic treatment, pioneered in Japan where excision of stomach cancer
is achieved by endoscopic mucosal resection.
NICE guidance 27 states that for patients whose stomach cancer is diagnosed
at a stage that is amenable to surgical treatment, the options include open or
laparoscopic gastrectomy. A multicentre case series of 1294 patients with
early gastric cancer treated with laparoscopic gastrectomy reported 5-year
disease-free survival of 99.8% for stage IA disease, 98.7% for stage IB
disease, and 85.7% for stage II disease. In a second case series of 100
patients with advanced disease, 5-year overall and disease-free survival rates
were 59% and 57%, respectively.

Screening for Stomach Cancer

11. There should be agreed evidence based policies covering which

individuals should be offered treatment and the appropriate treatment to
be offered.
As there is no screening programme for stomach cancer in the UK currently
there are no evidence based policies available which detail which individuals
should be offered treatment and the appropriate treatment. Clarification would
be needed for situations such as the necessity of re-evaluation or surveillance
of patients with premalignant gastric lesions.11

12. Clinical management of the condition and patient outcomes should

be optimised in all health care providers prior -to participation in a
screening programme.
The clinical management of stomach cancer would need to be further
standardised and optimised should a screening programme be introduced.

The screening programme

13. There should be evidence from high quality randomised controlled
trials that the screening programme is effective in reducing mortality
and morbidity.
Although randomised controlled trials represent the most reliable method for
evaluating the impact of screening on cancer risk, no such studies are
available in Japan. The introduction of mass screening coincided with a
decline in the incidence of and mortality from stomach cancer in Japan. Four
case control studies from Japan showed a decrease in mortality from stomach
cancer in those who have been screened which ranged from 40-60% and all
results reached statistical significant. Five large prospective studies that
defined death from stomach cancer as an endpoint mostly showed a
protective effective of screening as the relative risk was reduced but the
results were not consistent and some did not reach statistic significance.14
Indeed the impact of screening may be overestimated. To illustrate, a review
of the medical records from 2001 to 2003 of a total of 1226 patients (male and
female age range 26- 95 years) with a diagnosis of early gastric cancer (ECG)
who underwent cancer resection at the National Cancer Centre Hospital in
Tokyo was undertaken.28 The authors reported that most patients with EGC
were detected outside of the mass screening programme. 512 patients were
symptomatic and of these only 5 were examined by the screening programme
and of the 714 who reported no symptoms, 88 were identified by the
screening programme. The proportion of the patients that underwent an
endoscopy initially was approximately 92% of the symptomatic patients and
68% of the asymptomatic patients.
There would need to be evidence from randomised controlled trials that
showed that a stomach cancer screening programme was effective in

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10

reducing mortality and morbidity in the UK population. The target population,

test and screening interval would need to be defined.

14. There should be evidence that the complete screening programme

(test, diagnostic procedures, treatment, intervention) is clinically,
socially and ethically acceptable to health professionals and the public.
No references were identified in the literature search that evidenced the
acceptability of a screening programme for stomach cancer in the UK. To be
acceptable the screening programme needs to follow established national
guidelines.

15. The benefit from screening programme should outweigh the physical
and psychological harm (caused by the test, diagnostic procedures and
treatment).
Overall the potential harms outweigh the potential benefits of a national
stomach cancer screening programme in the UK. The benefits of a
programme would be identifying individuals with early stomach cancer and
therefore to be able to treat the cancer at a curative stage. However, the UK
has a low incidence of stomach cancer and there is a psychological harm to
cause worry in a population whose actual risk of developing stomach cancer
is low; the initial test is a procedure with radiation or endoscopy which is
invasive, there is lack evidence of effectiveness from randomised controlled
trials and the programme is unlikely to be cost effective.

16. The opportunity cost of the screening programme (including testing,

diagnosis and treatment, administration, training and quality assurance)
should be economically balanced in relation to expenditure on medical
care as a whole (i.e. value for money).
There was a lack of information on cost effectiveness of stomach cancer
screening programme in countries with a low incidence of stomach cancer.
Much of the cost effectiveness studies discussed the cost effectiveness of H.
pylori screening.
The programme is unlikely to be value for money as the test would be
expensive as it involves highly skilled practitioners, and the incidence of
stomach cancer is low in the UK and therefore the yield of positive cases
would be very small.

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11

17. There should be a plan for managing and monitoring the screening
programme and an agreed set of quality assurance standards.
There is currently no national screening programme for stomach cancer in the
UK but if it was to be implemented then quality assurance standards would
need to be agreed.

18. Adequate staffing and facilities for testing, diagnosis, treatment and
programme management should be available prior to the
commencement of the screening programme.
As there is currently no national screening programme for stomach cancer in
the UK then adequate staffing and facilities would have to be made available
if a programme was to be established.

19. All other options for managing the condition should have been
considered (e.g. improving treatment, providing other services), to
ensure that no more cost effective intervention could be introduced or
current interventions increase within the resources available.
Dyspeptic symptoms are common in patients with Early Gastric Cancer (EGC)
with 60-90% having symptoms. Screening of symptomatic patients over the
age of 40 year olds in the UK through open access gastroscopy has been
explored with inconsistent results.8 Two studies found that the detection rate
of ECG improved from 126% and in one study the curative resections
increased to 63%. Another 5 year prospective study found no significant
differences in patient referred via open access gastroscopy to those patients
referred to a specialist via the conventional UK pathway. The issue identified
was that there was a risk of diagnostic failure by endoscopy.
20. Evidence-based information, explaining the consequences of
testing, investigation and treatment, should be made available to
potential participants to assist them in making an informed choice.
As there is currently no national screening programme for stomach cancer in
the UK this material would have to be developed if a programme was to be
established.
21. Public pressure for widening the eligibility criteria, for reducing the
screening interval, and for increasing the sensitivity of the testing
process, should be anticipated. Decisions about these parameters
should be scientifically justifiable to the public.
As there is currently no national screening programme for stomach cancer in
the UK and there has not been the research from randomised controlled trials
to evidence the age group, screening interval or sensitivity of the testing
process. If the decision was to introduce a screening programme then the
evidence behind these decisions would need to be available.
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12

22. If screening is for a mutation the programme should be acceptable to

people identified as carriers and to other family members.
This is not applicable to stomach cancer screening.

Implications for policy

This review of the knowledge update on stomach cancer screening concludes
that the current policy on stomach cancer screening should be maintained
and that a national screening programme for stomach cancer in the UK is not
recommended.
Overall, the potential harms outweigh the potential benefits of a national
stomach cancer screening programme. The benefits of a programme would
be identifying individuals with early stomach cancer and be able to treat the
cancer at a curative stage. However, the UK has a low incidence of stomach
cancer and there is a psychological harm to cause worry in a population
whose actual risk of developing stomach cancer is low; the initial test is a
procedure with radiation or endoscopy which is invasive, there is lack of
evidence of effectiveness from randomised controlled trials and the
programme is unlikely to be cost effective.

Further work
The five year relative survival rates for stomach cancer in the UK are lower
that some of the other countries in Europe and investigations why this is the
case is needed.
Currently in the UK, stomach cancer is identified by opportunist screening of
symptomatic patients. Patients presenting with symptoms and have
recognised risk factors are investigated by upper gastrointestinal endoscopy.
It is recognised that endoscopy is dependent on the skills of the endoscopist
and there is a risk of diagnostic failure. To ensure that this pathway is as high
quality as possible then training and standardisation is required and outcomes
audited. It is also important to demonstrate compliance with NICE guidelines
in the identification of patients who need to be referred for endoscopy.

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gastrointestinal series. Cancer Epidemiology, Biomarkers & Prevention

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Appendix 1
Knowledge update on screening for stomach cancer
August 2009
BACKGROUND: A literature search was performed to find citations on
screening for stomach cancer published since the National Screening
Committees consideration of the topic in 2006. Since the evidence, Health
Technology Assessment by Roderick et al, on which the current policy is
based was published in 2003 (see full details below), the search was
performed from 2002 onwards.
SOURCES SEARCHED: Medline, Embase, the Cochrane Library, Centre for
Reviews and Dissemination (CRD) databases. A simple search of the
metaRegister of Clinical Trials, ClinicalTrials.gov and the HTA database for
work that is currently going on but not yet published, was also performed.
DATES OF SEARCH: January 2002 to 4 July 2009
SEARCH STRATEGY: Medline Ovid
The strategy was designed to be as broad as possible to ensure nothing
related to stomach cancer screening was missed. As a result many hits that
were not relevant were also retrieved.
1. exp Stomach Neoplasms/
2. (stomach adj4 cancer).tw.
3. (stomach adj4 neoplasm$).tw.
4. (stomach adj4 (tumor$ or tumour$)).tw.
5. (stomach adj4 neoplasia).tw.
6. (gastric adj4 cancer).tw.
7. (gastric adj4 neoplasm$).tw.
8. (gastric adj4 (tumor$ or tumour$)).tw.
9. (gastric adj4 neoplasia).tw.
10. exp Helicobacter pylori/
11. "h. pylori".tw.
12. helicobacter pylori.tw.
13. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12
14. screen$3.tw.
15. detect$3.tw.
16. (test or tests or testing).tw.
17. exp Enzyme-Linked Immunosorbent Assay/
18. enzyme linked immunosorbent assay.tw.
19. ELISA.tw.
20. Mass Screening/
21. "predictive value of tests"/
22. "sensitivity and specificity"/
23. Hematologic tests/
24. haematologic$2 tests.tw.

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25. Diagnostic tests, routine/

26. Serologic Tests/
27. serologic$ test$.tw.
28. exp early diagnosis/
29. 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26
or 27
or 28
30. 13 and 29
This was then limited by year (2002 to July 2009).

RESULTS: The above strategy retrieved 8741 citations from Medline. A

similarsearch was conducted in Embase, the Cochrane Library, CRD
databases. Database Number of references: Medline 8741; Embase 9582;
Cochrane 597; CRD databases 142. Total 19062
There was some duplication of references between different database
searches.The titles and abstracts of these citations were scanned for
relevance to screening for stomach cancer, and 149 citations, plus one
ongoing trial from the registers, were deemed to be relevant. These citations
were classified into the categories below according to the UK NSC criteria.
There will inevitably be some overlap of the categories within these citations.
Citations
Systematic reviews and meta-analyses 3
Other reviews 52
The condition 14
The test 33
The treatment 12
The screening programme 36

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