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==Primary prevention==
==Primary prevention==


=== Environmental changes ===
=== Lifestyle modifications ===
* Dietary modification is an important approach to control gastric cancer. There is a link between physical inactivity and [[obesity]] to many types of cancer.  
* [[Dietary]] modification is an important approach to control gastric cancer. There is a link between [[physical inactivity]] and [[obesity]] to many types of [[cancer]].  
* Diets with low consumption of red meat, high in fruits and vegetables may have a protective effect against many cancers.  
* [[Diet (nutrition)|Diet]] with low consumption of red meat, high in fruits and vegetables may have a protective effect against many [[cancers]].  
* The World Health Assembly adopted the WHO Global Strategy on Diet, Physical Activity, and Health, in May 2004 to reduce deaths and diseases.
* The World Health Assembly adopted the WHO Global Strategy on Diet, Physical Activity, and Health, in May 2004 to reduce deaths and diseases.


=== H.pylori eradication ===
=== H.pylori eradication ===
*The incidence of metachronous gastric cancer following the [[Endoscopy|endoscopic resection]] of a gastric neoplasm was reduced by the eradication of [[Helicobacter pylori|H. pylori]] infection.  
*The [[incidence]] of metachronous gastric cancer following the [[Endoscopy|endoscopic resection]] of a gastric neoplasm is known to be reduced by the eradication of [[Helicobacter pylori|H. pylori]] [[infection]].  


'''Recommended first-line therapies for H pylori infection''':
'''Recommended first-line therapies for H pylori infection''':
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|-
|-
|Sequential
|Sequential
|[[Proton pump inhibitor|PPI]] (standard dose) + Amoxicillin (1gm)
|[[Proton pump inhibitor|PPI]] (standard dose) + [[Amoxicillin]] (1gm)
[[Proton pump inhibitor|PPI]], Clarithromycin (500mg) + Nitroimidazole (500mg)
[[Proton pump inhibitor|PPI]], [[Clarithromycin]] (500mg) + [[Nitroimidazole]] (500mg)
|BID
|BID


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|-
|-
|Hybrid  
|Hybrid  
|[[Proton pump inhibitor|PPI]] (standard) + Amoxicillin (1gm)
|[[Proton pump inhibitor|PPI]] (standard) + [[Amoxicillin]] (1gm)
PPI, Amoxicillin, Clarithromycin (500mg), Nitroimidazole (500mg)
PPI, [[Amoxicillin]], [[Clarithromycin]] (500mg), [[Nitroimidazole]] (500mg)
|BID
|BID
BID
BID
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! colspan="5" |Salvage therapies for Helicobacter pylori infection
! colspan="5" |Salvage therapies for Helicobacter pylori infection
|-
|-
|Regimen
|'''Regimen'''
|Drugs(doses)
|'''Drugs(doses)'''
|Dosing frequency  
|'''Dosing frequency'''
|Duration(days)
|'''Duration(days)'''
|FDA approval
|'''FDA approval'''
|-
|-
|[[Bismuth]] quadruple  
|[[Bismuth]] quadruple  

Revision as of 14:53, 22 December 2017


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Parminder Dhingra, M.D. [2] Mohammed Abdelwahed M.D[3]

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Overview

Effective measures for the primary prevention of stomach cancer include smoking cessation, eradication of Helicobacter pylori infection, and having a balanced diet rich in fruits and vegetables. In areas of low gastric cancer incidence, screening for gastric cancer with upper endoscopy should be reserved for specific high-risk subgroups. Individuals at increased risk for gastric cancer include; gastric adenomas, pernicious anemia, gastric intestinal metaplasia, familial adenomatous polyposis, Lynch syndrome, Peutz-Jeghers syndrome, Juvenile polyposis syndrome.

Primary prevention

Lifestyle modifications

  • Dietary modification is an important approach to control gastric cancer. There is a link between physical inactivity and obesity to many types of cancer.
  • Diet with low consumption of red meat, high in fruits and vegetables may have a protective effect against many cancers.
  • The World Health Assembly adopted the WHO Global Strategy on Diet, Physical Activity, and Health, in May 2004 to reduce deaths and diseases.

H.pylori eradication

Recommended first-line therapies for H pylori infection:

Regimen Drug dose Dosing frequency Duration(days) FDA approval
Clarithromycin triple PPI (standard or double dose)

Clarithromycin (500mg)

Amoxicillin (1gm) or Metronidazole (500mg TID)

BID 14 days YES
Bismuth Quadruple PPI (standard dose)

Bismuth subcitrate (120-300mg)or Subsalicylate (300mg)

Tetracyclin (500mg)

Metronidazole (250-500mg)

BID

QID

QID

TID to QID (500mg)

10-14 days NO
Concomitant PPI (standard dose)

Clarithromycin (500mg)

Amoxicillin (1gm)

Nitroimidazole (500mg)c

BID 10 -14 days NO
Sequential PPI (standard dose) + Amoxicillin (1gm)

PPI, Clarithromycin (500mg) + Nitroimidazole (500mg)

BID

BID

5-7 days

5-7 days

NO
Hybrid PPI (standard) + Amoxicillin (1gm)

PPI, Amoxicillin, Clarithromycin (500mg), Nitroimidazole (500mg)

BID

BID

7 days

7 days

NO
Levofloxacin triple PPI (standard dose)

Levofloxacin (500mg)

Amoxicillin (1gm)

BID

QID

BID

10-14 days NO
Levofloxacin sequential PPI (standard or double dose) + Amoxicillin (1 gm)

PPI, Amoxicillin, Levofloxacin (500mg QD), Nitroimidazole (500mg)

BID

BID

5-7 days NO
LOAD Levofloxacin (250mg)

PPI (double dose)

Nitazoxanide (500mg)c

Doxycycline (100mg)

QD

QD

BID

QD

7-10 days NO
: Several PPI, Clarithromycin, and Amoxicillin combinations have achieved FDA approval, PPI, Clarithromycin, Metronidazole are not an FDA approved treatment regimen.

‡: PPI, Bismuth, Tetracycline, and metronidazole prescribed separately are not an FDA approved treatment regimen.

  • BID, twice daily; FDA, Food and Drug Administration; PPI, proton pump inhibitor; TID, three times daily; QD, once daily; QID, four times daily.

c: Metronidazole or Tinidazole[1]

After the failure of first-line therapy, such patients should be considered for referral for salvage treatment.

Salvage therapies for Helicobacter pylori infection
Regimen Drugs(doses) Dosing frequency Duration(days) FDA approval
Bismuth quadruple BID

QID

QID

TID or QID

14 NO
Levofloxacin triple BID

QD

BID

14 NO
Concomitant BID

BID

BID

BID or TID

10-14 NO
Rifabutin triple BID

QD

BID

10 NO
High-dose dual TID or QID

TID or QID

14 NO
  • Whenever H. pylori infection is identified and treated, testing to prove eradication should be performed using:
  • A urea breath test
  • Fecal antigen test
  • Biopsy-based testing at least 4 weeks after the completion of antibiotic therapy and after PPI therapy has been withheld for 1–2 weeks.

Screening

In countries with a high incidence of gastric cancer such as east Asia countries, universal screening is recommended. [17-19]

In Japan, population-based screening for gastric cancer is recommended for individuals older than 50 years with conventional double-contrast barium radiograph with photofluorography every year or upper endoscopy every two to three years [20,33,34].

Screening interval is recommended to be every two years but may be widened to a three-year rather than a two-year interval without significant effect [38-40].  

Hereditary cancer prevention

Screening

In areas of low gastric cancer incidence, screening for gastric cancer with upper endoscopy should be reserved for specific high-risk subgroups

Individuals at increased risk for gastric cancer include those with the following:

Prevention

  •  Asymptomatic patients with a family history of HDGC and CDH1 mutations have a high probability of developing signet ring cell adenocarcinoma of the stomach. Prophylactic total gastrectomy is recommended for patients with family history of HDGC and CDH1 mutations.[2]
  • For patients with a CDH1 mutation but who are not from an HDGC family, we recommend individualized evaluation at an experienced center before prophylactic total gastrectomy is offered.[3]
  • Prophylactic gastrectomy is often advised between age 20 and 30.
  • Some suggest timing total gastrectomy in CDH1 mutation carriers at an age that is five years younger than the youngest family member who developed gastric cancer.[4]
  • Older patients are less likely to benefit from a prophylactic gastrectomy than younger patients because of a shorter life-expectancy and a higher perioperative risk.
  • patients who are older than 75 years should not undergo such a procedure, as their mortality from the procedure outweighs their mortality from gastric cancer.
  • Decisions should be individualized based upon their comorbidities and the age of gastric cancer onset in their respective kindred.[5]

Gatric polyps

  • Polypectomy should be performed for all known neoplastic polyps and for all polyps ≥1 cm in diameter, as biopsies alone cannot exclude foci of high-grade dysplasia or early gastric cancer.
  • In patients with multiple polyps, the largest polyp should be excised and representative biopsies obtained from the remaining polyps.

Hyperplastic polyps

Juvenile polyposis syndrome

Lynch syndrome

  • Endometrial cancer prior to age 50 years
  • First-degree relative of those with known MMR/EPCAM gene mutation
  • Individuals with >5 percent chance of an MMR gene mutation

References

  1. "www.nature.com" (PDF).
  2. Keller G, Vogelsang H, Becker I, Hutter J, Ott K, Candidus S; et al. (1999). "Diffuse type gastric and lobular breast carcinoma in a familial gastric cancer patient with an E-cadherin germline mutation". Am J Pathol. 155 (2): 337–42. doi:10.1016/S0002-9440(10)65129-2. PMC 1866861. PMID 10433926.
  3. Pharoah PD, Guilford P, Caldas C, International Gastric Cancer Linkage Consortium (2001). "Incidence of gastric cancer and breast cancer in CDH1 (E-cadherin) mutation carriers from hereditary diffuse gastric cancer families". Gastroenterology. 121 (6): 1348–53. PMID 11729114.
  4. Norton JA, Ham CM, Van Dam J, Jeffrey RB, Longacre TA, Huntsman DG; et al. (2007). "CDH1 truncating mutations in the E-cadherin gene: an indication for total gastrectomy to treat hereditary diffuse gastric cancer". Ann Surg. 245 (6): 873–9. doi:10.1097/01.sla.0000254370.29893.e4. PMC 1876967. PMID 17522512.
  5. Chun YS, Lindor NM, Smyrk TC, Petersen BT, Burgart LJ, Guilford PJ; et al. (2001). "Germline E-cadherin gene mutations: is prophylactic total gastrectomy indicated?". Cancer. 92 (1): 181–7. PMID 11443625.

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