Gastric cancer secondary prevention in dyspeptic patients

BACKGROUND: In dyspeptic patients without alarm symptoms, the “Test-and-Treat” (TT) strategy aims to alleviate symptoms and prevent adverse outcomes. An alternative workup expands the TT-strategy by incorporating esophagogastroduodenoscopy (Test-Treat-and-Scope [TT-S]). OBJECTIVE: This prospective cross-sectional study provides evidence-based insights into the clinical workup of dyspepsia by applying the TT and TT-S options. DESIGN: In a consecutive cohort of 2171 dyspeptic patients without alarm symptoms, H. pylori (Hp) status was assessed by 13C-Urea Breath Test, Rapid urease test, and histology. Histology profiling was based on six biopsies and included atrophy staging (OLGA-system). RESULTS: Among Hp-positive and Hp-negative patients, the prevalence of mucosal atrophy was 22.2% and 1.3% (p < 0.001), respectively. In the study population, 92.5% did not exhibit atrophic disease (OLGA stage 0). Among Hp-positive patients, mucosal atrophy occurred in 142/640 subjects. Nine in 640 (1.4%) Hp-positive patients presented advanced atrophy (OLGA-stages III-IV), considered at high-risk for gastric cancer. The overall prevalence of high-risk OLGA stages (III-IV) was below 1.5% (all Hp-positive). The mean age of patients with OLGA stages III-IV was 15 years older than that of non-atrophic patients (p < 0.0001). In all atrophic OLGA-stages, Hp-positive subjects dominated over the Hp-negative (test-for-trend; p < 0.0001). None of the Hp-negative subjects showed extensive atrophy (OLGA-stages III-IV). CONCLUSION: In the considered epidemiological context, advanced gastric atrophy (OLGA-stages III-IV), consistently recognized as at risk of cancer development, only occurred in Hp-positive patients over 55 years. These results support the priority of the TT-S-strategy in Hp-positive patients older than 55, even in the absence of alarm symptoms.