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Notes: Economic models have suggested that population Helicobacter pylori screening and treatment may be a cost-effective method of reducing mortality from gastric cancer. These models are conservative as they do not consider that the programme may reduce health service peptic ulcer and other dyspepsia costs. We have evaluated the economic impact of population H. pylori screening and treatment over 2 years in a randomized controlled trial and have incorporated the results into an economic model exploring the impact of H. pylori eradication on peptic ulcer disease and gastric cancer.〈section xml:id="abs1-2"〉〈title type="main"〉Methods:Subjects between the ages of 40 and 49 years were randomly invited to attend their local primary care centre. H. pylori status was evaluated by 13C-urea breath test and infected individuals were randomized to receive omeprazole, 20 mg b.d., clarithromycin, 250 mg b.d., and tinidazole, 500 mg b.d., for 7 days or identical placebos. Economic data on health service costs for dyspepsia were obtained from a primary care note review for the 2 years following randomization. These data were incorporated into a Markov model comparing population H. pylori screening and treatment with no intervention.〈section xml:id="abs1-3"〉〈title type="main"〉Results:A total of 2329 of 8407 subjects were H. pylori positive: 1161 were randomized to receive eradication therapy and 1163 to receive placebo. The cost difference favoured the intervention group 2 years after randomization, but this did not reach statistical significance (£11.42 per subject cost saving; 95% confidence interval, £30.04 to – £7.19; P=0.23). Analysis by gender suggested a statistically significant dyspepsia cost saving in men (£27.17 per subject; 95% confidence interval, £50.01 to £4.32; P=0.02), with no benefit in women (– £4.46 per subject; 95% confidence interval, – £33.85 to £24.93). Modelling of these data suggested that population H. pylori screening and treatment for 1 000 000 45-year-olds would save over £6 000 000 and 1300 years of life. The programme would cost £14 200 per life year saved if the health service dyspepsia cost savings were the lower limit of the 95% confidence intervals and H. pylori eradication had only a 10% efficacy in reducing mortality from distal gastric cancer and peptic ulcer disease.〈section xml:id="abs1-4"〉〈title type="main"〉Conclusions:Modelling suggests that population H. pylori screening and treatment are likely to be cost-effective and could be the first cost-neutral screening programme. This provides a further mandate for clinical trials to evaluate the efficacy of population H. pylori screening and treatment in preventing mortality from gastric cancer and peptic ulcer disease.

Notes: Background: Evidence for the effectiveness of antacids, histamine-2 receptor antagonists, bismuth salts, sucralfate and prokinetic therapy in non-ulcer dyspepsia is conflicting.Aim: To conduct a systematic review evaluating these therapies in non-ulcer dyspepsia.Methods: Electronic searches were performed using the Cochrane Controlled Trials Register, Medline, EMBASE, Cinahl and SIGLE until September 2002. Dyspepsia outcomes were dichotomized into cured/improved vs. same/worse.Results: Prokinetics [14 trials, 1053 patients; relative risk reduction (RRR), 48%; 95% confidence interval (95% CI), 27–63%] and histamine-2 receptor antagonists (11 trials, 2164 patients; RRR, 22%; 95% CI, 7–35%) were significantly more effective than placebo. Bismuth salts (RRR, 40%; 95% CI, − 3% to 65%) were superior to placebo, but this was of marginal statistical significance. Antacids and sucralfate were not statistically significantly superior to placebo. A funnel plot suggested that the prokinetic and histamine-2 receptor antagonist results could be due to publication bias.Conclusions: The meta-analyses suggest that histamine-2 receptor antagonists and prokinetics are superior to placebo. These data are difficult to interpret, however, as funnel plot asymmetry suggests that the magnitude of the effect could be due to publication bias or other heterogeneity-related issues.

Notes: This article reviews the epidemiology of cancers arising in the distal oesophagus and proximal stomach, sometimes collectively termed oesophago-gastric junctional adenocarcinomas. The several complexities involved in defining this group of cancers are considered and the reported increasing trends in incidence are reviewed, together with the descriptive epidemiology. The rates of these cancers are increasing, but not as dramatically as sometimes reported. They are also more common in white males than in other ethnic groups or in females. Although several aetiological risk factors have been reported, the two most consistent are an elevated body mass index (obesity) and a history of gastro-oesophageal reflux disease. Reflux is also associated with Barrett's oesophagus, an important and increasingly diagnosed premalignant lesion. The rate of progression from Barrett's oesophagus to cancer is controversial, as is the cost–benefit balance of routine endoscopic surveillance of such patients. The development of molecular biomarkers to identify Barrett's oesophagus patients with high rates of malignant transformation would represent a significant advance.

Notes: Helicobacter pylori infection is causally related to gastric cancer, a malignancy associated with high morbidity and poor prognosis, and to peptic ulcer disease, a disease with high morbidity and modest mortality. Theoretically, H. pylori eradication is the most practical means of preventing gastric cancer and peptic ulcer disease. From a public policy perspective, the current evidence is insufficient to assess accurately the magnitude of the benefits of a universal ‘search and treat’ approach. Nonetheless, it is possible to identify high-risk patients for whom testing for the presence of H. pylori infection, with the intention-to-treat infected individuals is currently indicated. This list includes patients with ulcers or dyspepsia, first-degree relatives of patients with peptic ulcer or gastric cancer, gastric cancer patients after potentially curative resection of their gastric cancer, patients in whom long-term acid antisecretory therapy or long-term nonsteroidal anti-inflammatory drug therapy (including low-dose aspirin) is planned, and finally those who desire testing. Population screening among asymptomatic individuals with a high risk of gastric cancer, such as Korean- and Japanese-Americans, appears logical, but from a public health perspective should be done as a component of controlled intervention studies. There are no known H. pylori infections without risk of a symptomatic outcome, therefore screening represents a rational strategy for cancer prevention. Adoption of such a policy will require carefully balancing the costs of the programme with its benefits.