ACG unveils gastric premalignancy guidelines aligned with colon, esophagus surveillance
Key takeaways:
- H. pylori eradication is strongly encouraged for patients with gastric premalignant conditions.
- High-quality endoscopic evaluation of the stomach is recommended to identify gastric premalignant conditions.
The ACG has released its first guidance for gastric premalignant conditions, such as atrophic gastritis, gastric intestinal metaplasia and dysplasia, in sync with surveillance recommendations established for the colon and esophagus.
Although the United States is considered to have low rates of gastric cancer incidence, “specific U.S. populations, such as immigrants from high-gastric cancer incidence countries and certain non-white populations, have substantially higher gastric cancer incidence rates, exceeding those for esophageal cancer and, in some cases, approaching those for colorectal cancer,” Douglas R. Morgan, MD, MPH, AGAF, FACG, director of the division of gastroenterology and hepatology at The University of Alabama at Birmingham, and colleagues wrote in The American Journal of Gastroenterology.
“There is a growing body of evidence demonstrating that the burden of gastric cancer in high-risk populations is sufficiently high to justify prevention and early detection interventions,” the authors added. “There is also evidence from U.S. populations that Helicobacter pylori treatment is associated with reduced gastric cancer incidence.”
To develop a clinical practice guideline for gastric premalignant conditions more in line with surveillance recommendations for esophageal and colorectal precancerous conditions, Morgan and colleagues evaluated a series of clinically relevant questions, developed by experts in gastric premalignancy and gastric cancer.
Using Grading of Recommendations, Assessment, Development and Evaluation methodology, Morgan and colleagues evaluated options for patients with gastric premalignant conditions and analyzed population-intervention-comparison-outcome questions, from which 22 recommendations were generated. They also created 21 key concepts, in the absence of sufficient evidence or if the topic was not amenable to GRADE methodology.
Highlights from the guidance, which provides “a paradigm shift in U.S. clinical practice,” include:
- ACG refrained from recommending indiscriminate endoscopy screening for patients at high risk for gastric cancer or gastric premalignancy based on immigration status, race or ethnicity, due to “insufficient direct evidence from U.S. populations.”
- ACG strongly recommends H. pylori eradication in patients with gastric premalignant conditions to curb development of gastric cancer, as well as in patients with resected early gastric cancer to reduce risk for progression to metachronous early gastric cancer.
- ACG strongly recommends that patients with gastric premalignant conditions receive high-quality endoscopic evaluation of the stomach, including adequate mucosal visualization with cleansing and insufflation, visual station mapping, photodocumentation of anatomical landmarks and any irregularities, as well as adequate gastric evaluation time.
- ACG strongly recommends that patients who are eligible for endoscopic resection of dysplasia be referred to a high-volume center with suitable expertise for diagnosis and resection of gastric neoplasia.
- For patients with confirmed complete resection of dysplasia, the ACG strongly recommends that surveillance exams are performed by experienced endoscopists using high-definition white light endoscopy and image-enhanced endoscopy, with biopsies conducted according to systematic biopsy protocol.
- ACG strongly recommends that patients with autoimmune gastritis should be evaluated for H. pylori infection with non-serological testing, and prescribed eradication treatment if found to be positive.
“It is hoped that these initiatives will change the clinical paradigm to establish surveillance practices for higher-risk gastric premalignant conditions to finally align with surveillance norms in the colon and esophagus,” Morgan told Healio. “The guidelines are also expected to drive research, as U.S. data have been lacking despite robust international data — essentially, it’s a work in progress.”
Perspective
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Gastric cancer is the fourth most common cause of cancer-related death worldwide. Its variable effect on different demographics complicates our clinical understanding of this condition.
Nonetheless, given its prevalence, the ability to risk-stratify, evaluate and surveil those at risk for gastric premalignant and malignant conditions is critical. This makes ACG's first clinical guideline for this issue all the more relevant.
My key takeaways from the guideline are:
- Identify individuals at high risk for premalignant gastric conditions and perform an endoscopy. This includes people with a family history of gastric cancer, those with hereditary syndromes, foreign-born individuals from high-risk regions and Americans with high-risk backgrounds.
- How an endoscopy is performed is important. High-quality endoscopy should include a systematic approach including biopsies, high-definition white light endoscopy, and adequate insufflation and visualization. This takes time and the endoscopist should anticipate this.
- Monitor those with premalignant conditions. ACG's new guideline offers easy-to-understand and tangible surveillance strategies.
- H. pylori testing and eradication remain important, as always. An infection-association malignancy, gastric cancer or a premalignant gastric condition can be cured by identifying and treating H. pylori infection.
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