Is gastric cancer becoming a rare disease? A global assessment of predicted incidence trends to 2035.

OBJECTIVES: The incidence of gastric cancer continues to decrease globally, approaching levels that in some populations could define it as a rare disease. To explore this on a wider scale, we predict its future burden in 34 countries with long-standing population-based data. METHODS: Data on gastric cancer incidence by year of diagnosis, sex and age were extracted for 92 cancer registries in 34 countries included in Cancer Incidence in Five Continents Plus. Numbers of new cases and age-standardised incidence rates (ASR per 100 000) were predicted up to 2035 by fitting and extrapolating age-period-cohort models. RESULTS: Overall gastric cancer incidence rates are predicted to continue falling in the future in the majority of countries, including high-incidence countries such as Japan (ASR 36 in 2010 vs ASR 30 in 2035) but also low-incidence countries such as Australia (ASR 5.1 in 2010 vs ASR 4.6 in 2035). A total of 16 countries are predicted to fall below the rare disease threshold (defined as 6 per 100 000 person-years) by 2035, while the number of newly diagnosed cases remains high and is predicted to continue growing. In contrast, incidence increases were seen in younger age groups (below age 50 years) in both low-incidence and high-incidence populations. CONCLUSIONS: While gastric cancer is predicted to become a rare disease in a growing number of countries, incidence levels remain high in some regions, and increasing risks have been observed in younger generations. The predicted growing number of new cases highlights that gastric cancer remains a major challenge to public health on a global scale.

Long-term Realism and Cost-effectiveness: Primary Prevention in Combatting Cancer and Associated Inequalities Worldwide.

The global figure of 14 million new cancer cases in 2012 is projected to rise to almost 22 million by 2030, with the burden in low- and middle-income countries (LMICs) shifting from 59% to 65% of all cancer cases worldwide over this time. While the overheads of cancer care are set to rapidly increase in all countries worldwide irrespective of income, the limited resources to treat and manage the growing number of cancer patients in LMICs threaten national economic development. Current data collated in the recent second edition of The Cancer Atlas by the American Cancer Society and International Agency for Research on Cancer show that a substantial proportion of cancers are preventable and that prevention is cost-effective. Therefore, cancer control strategies within countries must prioritize primary and secondary prevention, alongside cancer management and palliative care and integrate these measures into existing health care plans. There are many examples of the effectiveness of prevention in terms of declining cancer rates and major risk factors, including an 80% decrease in liver cancer incidence rates among children and young adults following universal infant hepatitis B vaccination in Taiwan and a 46% reduction in smoking prevalence in Brazil after the implementation of a more aggressive tobacco control program beginning in 1989. Prevention can bring rich dividends in net savings but actions must be promoted and implemented. The successful approaches to combatting certain infectious diseases provide a model for implementing cancer prevention, particularly in LMICs, via the utilization of existing infrastructures for multiple purposes.

Gastric cancer survival and affiliation to health insurance in a middle-income setting.

OBJECTIVE: To investigate whether health insurance affiliation and socioeconomic deprivation is associated with overall cause survival from gastric cancer in a middle-income country. METHODS: All patients resident in the Bucaramanga metropolitan area (Colombia) diagnosed with gastric cancer between 2003 and 2009 (n=1039), identified in the population-based cancer registry, were followed for vital status until 31/12/2013. Kaplan-Meier models provided crude survival estimates by health insurance regime (HIR) and social stratum (SS). Multivariate Cox-proportional hazard models adjusting HIR and SS for sex, age and tumor grade, were performed. RESULTS: Overall 1 and 5 year survival proportions were 32.4% and 11.0%, respectively, varying from 49.3% and 15.8% for patients affiliated to the most generous HIR to 12.9% and 5.3% for unaffiliated patients, and from 41.4% and 20.7% for patients in the highest SS, versus 27.1% and 7.4% for the lowest SS. The multivariate analyses showed type of HIR as well as SS to remain independently associated with survival, with an 11% improvement in survival for each increase in SS subgroup (HR 0.89 (95% CI 0.83; 0.96), and with worse survival in the subsidized (least generous) HIR and unaffiliated patients compared to the contributory HIR (HR subsidized 1.20 (95% CI 1.00; 1.43) and HR not affiliated 2.03 (95% CI 1.48; 2.78)). Of the non-affiliated patients, 60% had died at the time of diagnosis, versus 4-14% of affiliated patients (p<0.0005). CONCLUSIONS: Despite the 'universal' health insurance system, large socioeconomic differences in gastric cancer survival exist in Colombia. Both social stratum and access to effective diagnostic and curative care strongly influence survival.

Trends in inequalities in premature cancer mortality by educational level in Colombia, 1998-2007.

BACKGROUND: There is a paucity of studies on socioeconomic inequalities in cancer mortality in developing countries. We examined trends in inequalities in cancer mortality by educational attainment in Colombia during a period of epidemiological transition and rapid expansion of health insurance coverage. METHODS: Population mortality data (1998-2007) were linked to census data to obtain age-standardised cancer mortality rates by educational attainment at ages 25-64 years for stomach, cervical, prostate, lung, colorectal, breast and other cancers. We used Poisson regression to model mortality by educational attainment and estimated the contribution of specific cancers to the slope index of inequality in cancer mortality. RESULTS: We observed large educational inequalities in cancer mortality, particularly for cancer of the cervix (rate ratio (RR) primary vs tertiary groups=5.75, contributing 51% of cancer inequalities), stomach (RR=2.56 for males, contributing 49% of total cancer inequalities and RR=1.98 for females, contributing 14% to total cancer inequalities) and lung (RR=1.64 for males contributing 17% of total cancer inequalities and 1.32 for females contributing 5% to total cancer inequalities). Total cancer mortality rates declined faster among those with higher education, with the exception of mortality from cervical cancer, which declined more rapidly in the lower educational groups. CONCLUSIONS: There are large socioeconomic inequalities in preventable cancer mortality in Colombia, which underscore the need for intensifying prevention efforts. Reduction of cervical cancer can be achieved through reducing human papilloma virus infection, early detection and improved access to treatment of preneoplastic lesions. Reinforcing antitobacco measures may be particularly important to curb inequalities in cancer mortality.

The burden of stomach cancer in indigenous populations: a systematic review and global assessment.

OBJECTIVE: Stomach cancer is a leading cause of cancer death, especially in developing countries. Incidence has been associated with poverty and is also reported to disproportionately affect indigenous peoples, many of whom live in poor socioeconomic circumstances and experience lower standards of health. In this comprehensive assessment, we explore the burden of stomach cancer among indigenous peoples globally. DESIGN: The literature was searched systematically for studies on stomach cancer incidence, mortality and survival in indigenous populations, including Indigenous Australians, Maori in New Zealand, indigenous peoples from the circumpolar region, native Americans and Alaska natives in the USA, and the Mapuche peoples in Chile. Data from the New Zealand Health Information Service and the Surveillance Epidemiology and End Results (SEER) Program were used to estimate trends in incidence. RESULTS: Elevated rates of stomach cancer incidence and mortality were found in almost all indigenous peoples relative to corresponding non-indigenous populations in the same regions or countries. This was particularly evident among Inuit residing in the circumpolar region (standardised incidence ratios (SIR) males: 3.9, females: 3.6) and in Maori (SIR males: 2.2, females: 3.2). Increasing trends in incidence were found for some groups. CONCLUSIONS: We found a higher burden of stomach cancer in indigenous populations globally, and rising incidence in some indigenous groups, in stark contrast to the decreasing global trends. This is of major public health concern requiring close surveillance and further research of potential risk factors. Given evidence that improving nutrition and housing sanitation, and Helicobacter pylori eradication programmes could reduce stomach cancer rates, policies which address these initiatives could reduce inequalities in stomach cancer burden for indigenous peoples.

Global burden of cancer in 2008: a systematic analysis of disability-adjusted life-years in 12 world regions.

BACKGROUND: Country comparisons that consider the effect of fatal and non-fatal disease outcomes are needed for health-care planning. We calculated disability-adjusted life-years (DALYs) to estimate the global burden of cancer in 2008. METHODS: We used population-based data, mostly from cancer registries, for incidence, mortality, life expectancy, disease duration, and age at onset and death, alongside proportions of patients who were treated and living with sequelae or regarded as cured, to calculate years of life lost (YLLs) and years lived with disability (YLDs). We used YLLs and YLDs to derive DALYs for 27 sites of cancers in 184 countries in 12 world regions. Estimates were grouped into four categories based on a country's human development index (HDI). We applied zero discounting and uniform age weighting, and age-standardised rates to enable cross-country and regional comparisons. FINDINGS: Worldwide, an estimated 169·3 million years of healthy life were lost because of cancer in 2008. Colorectal, lung, breast, and prostate cancers were the main contributors to total DALYs in most world regions and caused 18-50% of the total cancer burden. We estimated an additional burden of 25% from infection-related cancers (liver, stomach, and cervical) in sub-Saharan Africa, and 27% in eastern Asia. We noted substantial global differences in the cancer profile of DALYs by country and region; however, YLLs were the most important component of DALYs in all countries and for all cancers, and contributed to more than 90% of the total burden. Nonetheless, low-resource settings had consistently higher YLLs (as a proportion of total DALYs) than did high-resource settings. INTERPRETATION: Age-adjusted DALYs lost from cancer are substantial, irrespective of world region. The consistently larger proportions of YLLs in low HDI than in high HDI countries indicate substantial inequalities in prognosis after diagnosis, related to degree of human development. Therefore, radical improvement in cancer care is needed in low-resource countries. FUNDING: Dutch Scientific Society, Erasmus University Rotterdam, and International Agency for research on Cancer.

Global cancer transitions according to the Human Development Index (2008-2030): a population-based study.

BACKGROUND: Cancer is set to become a major cause of morbidity and mortality in the coming decades in every region of the world. We aimed to assess the changing patterns of cancer according to varying levels of human development. METHODS: We used four levels (low, medium, high, and very high) of the Human Development Index (HDI), a composite indicator of life expectancy, education, and gross domestic product per head, to highlight cancer-specific patterns in 2008 (on the basis of GLOBOCAN estimates) and trends 1988-2002 (on the basis of the series in Cancer Incidence in Five Continents), and to produce future burden scenario for 2030 according to projected demographic changes alone and trends-based changes for selected cancer sites. FINDINGS: In the highest HDI regions in 2008, cancers of the female breast, lung, colorectum, and prostate accounted for half the overall cancer burden, whereas in medium HDI regions, cancers of the oesophagus, stomach, and liver were also common, and together these seven cancers comprised 62% of the total cancer burden in medium to very high HDI areas. In low HDI regions, cervical cancer was more common than both breast cancer and liver cancer. Nine different cancers were the most commonly diagnosed in men across 184 countries, with cancers of the prostate, lung, and liver being the most common. Breast and cervical cancers were the most common in women. In medium HDI and high HDI settings, decreases in cervical and stomach cancer incidence seem to be offset by increases in the incidence of cancers of the female breast, prostate, and colorectum. If the cancer-specific and sex-specific trends estimated in this study continue, we predict an increase in the incidence of all-cancer cases from 12·7 million new cases in 2008 to 22·2 million by 2030. INTERPRETATION: Our findings suggest that rapid societal and economic transition in many countries means that any reductions in infection-related cancers are offset by an increasing number of new cases that are more associated with reproductive, dietary, and hormonal factors. Targeted interventions can lead to a decrease in the projected increases in cancer burden through effective primary prevention strategies, alongside the implementation of vaccination, early detection, and effective treatment programmes. FUNDING: None.

Cancer burden in Africa and opportunities for prevention.

Cancer is an emerging public health problem in Africa. About 715,000 new cancer cases and 542,000 cancer deaths occurred in 2008 on the continent, with these numbers expected to double in the next 20 years simply because of the aging and growth of the population. Furthermore, cancers such as lung, female breast, and prostate cancers are diagnosed at much higher frequencies than in the past because of changes in lifestyle factors and detection practices associated with urbanization and economic development. Breast cancer in women and prostate cancer in men have now become the most commonly diagnosed cancers in many Sub-Saharan African countries, replacing cervical and liver cancers. In most African countries, cancer control programs and the provision of early detection and treatment services are limited despite this increasing burden. This paper reviews the current patterns of cancer in Africa and the opportunities for reducing the burden through the application of resource level interventions, including implementation of vaccinations for liver and cervical cancers, tobacco control policies for smoking-related cancers, and low-tech early detection methods for cervical cancer, as well as pain relief at the palliative stage of cancer.

Primary health and supportive care needs of long-term cancer survivors: a questionnaire survey.

PURPOSE: There are 1.2 million long-term cancer survivors in the United Kingdom. Existing research on the health and supportive care needs of these survivors is sparse and inconclusive. This study investigated health status, psychological morbidity, and supportive care needs in long-term cancer survivors in the United Kingdom. METHODS: Five to 16 years after diagnosis, 1,275 eligible survivors of breast, colorectal, and prostate cancers were approached to participate in a questionnaire survey. The questionnaire explored health status (European Quality of Life-5 Dimensions), psychological morbidity (Hospital Anxiety and Depression Scale), and supportive care needs (Cancer Survivors' Unmet Needs Measure). Data were analyzed by type of cancer and time since diagnosis. Logistic regression was used to identify predictors of unmet supportive care needs. RESULTS: The response rate was 51.7% (659 survivors). Overall health status and levels of psychological morbidity were consistent with population norms. At least one unmet supportive care need was reported by 47.4% of survivors, but overall numbers of unmet needs were low (mean, 2.8; standard deviation, 4.8). The most frequently endorsed unmet need was for help to manage concerns about cancer recurrence. Trait anxiety (P < .001), nondischarged status (P < .01), dissatisfaction with discharge (P < .01), and receipt of hormonal therapy (P < .01) were predictive of unmet supportive care needs. CONCLUSION: The findings suggest a majority of long-term breast, colorectal, and prostate cancer survivors who have no signs of recurrence report good health and do not have psychological morbidity or large numbers of unmet supportive care needs. A minority of long-term survivors may benefit from ongoing support. The identification and support of those long-term survivors with ongoing needs is a key challenge for health care professionals.

Multilevel latent class casemix modelling: a novel approach to accommodate patient casemix.

BACKGROUND: Using routinely collected patient data we explore the utility of multilevel latent class (MLLC) models to adjust for patient casemix and rank Trust performance. We contrast this with ranks derived from Trust standardised mortality ratios (SMRs). METHODS: Patients with colorectal cancer diagnosed between 1998 and 2004 and resident in Northern and Yorkshire regions were identified from the cancer registry database (n = 24,640). Patient age, sex, stage-at-diagnosis (Dukes), and Trust of diagnosis/treatment were extracted. Socioeconomic background was derived using the Townsend Index. Outcome was survival at 3 years after diagnosis. MLLC-modelled and SMR-generated Trust ranks were compared. RESULTS: Patients were assigned to two classes of similar size: one with reasonable prognosis (63.0% died within 3 years), and one with better prognosis (39.3% died within 3 years). In patient class one, all patients diagnosed at stage B or C died within 3 years; in patient class two, all patients diagnosed at stage A, B or C survived. Trusts were assigned two classes with 51.3% and 53.2% of patients respectively dying within 3 years. Differences in the ranked Trust performance between the MLLC model and SMRs were all within estimated 95% CIs. CONCLUSIONS: A novel approach to casemix adjustment is illustrated, ranking Trust performance whilst facilitating the evaluation of factors associated with the patient journey (e.g. treatments) and factors associated with the processes of healthcare delivery (e.g. delays). Further research can demonstrate the value of modelling patient pathways and evaluating healthcare processes across provider institutions.

Geographical variation in cancer survival in England, 1991-2006: an analysis by Cancer Network.

BACKGROUND: Reducing geographical inequalities in cancer survival in England was a key aim of the Calman-Hine Report (1995) and the NHS Cancer Plan (2000). This study assesses whether geographical inequalities changed following these policy developments by analysing the trend in 1-year relative survival in the 28 cancer networks of England. METHODS: Population-based age-standardised relative survival at 1 year is estimated for 1.4 million patients diagnosed with cancer of the oesophagus, stomach, colon, lung, breast (women) or cervix in England during 1991-2006 and followed up to 2007. Regional and deprivation-specific life tables are built to adjust survival estimates for differences in background mortality. Analysis is divided into three calendar periods: 1991-5, 1996-2000 and 2001-6. Funnel plots are used to assess geographical variation in survival over time. RESULTS: One-year relative survival improved for all cancers except cervical cancer. There was a wide geographical variation in survival with generally lower estimates in northern England. This north-south divide became less marked over time, although the overall number of cancer networks that were lower outliers compared with the England value remained stable. Breast cancer was the only cancer for which there was a marked reduction in geographical inequality in survival over time. CONCLUSION: Policy changes over the past two decades coincided with improved relative survival, without an increase in geographical variation. The north-south divide in relative survival became less pronounced over time but geographical inequalities persist. The reduction in geographical inequality in breast cancer survival may be followed by a similar trend for other cancers, provided government recommendations are implemented similarly.

Latent class modelling of the association between socioeconomic background and breast cancer survival status at 5 years incorporating stage of disease.

BACKGROUND: Stage of disease and socioeconomic background (SEB) are often used to 'explain' differences in breast cancer outcomes. There are challenges for all types of analysis (eg, survival analysis, logistic regression), including missing data, measurement error and the 'reversal paradox'. This study investigates the association between SEB and survival status within 5 years of breast cancer diagnosis using (1) logistic regression with and without adjustment for stage and (2) logistic latent class analysis (LCA) excluding stage as a covariate but with and without stage as a latent class predictor. METHODS: Women diagnosed with invasive breast cancer between 1998 and 2000 in one UK region were identified (n=11 781). Multilevel logistic regression was performed using standard regression and LCA. Models included SEB (2001 Townsend Index), age and stage ('missing' stage (8.0%) modelled as a separate category). The association of SEB with stage was also assessed. RESULTS: Using standard regression, there was a substantial association between SEB and death within 5 years, with and without adjustment for stage. Using LCA, patients were assigned to a large good prognosis group and a small poor prognosis group. The association between SEB and survival was substantive in both classes for the model without stage, but only in the larger class for the model with stage. Increasing deprivation was associated with more advanced stage at diagnosis. CONCLUSIONS: LCA categorises patients into prognostic groups according to patient and tumour characteristics, providing an alternative strategy to the usual statistical adjustment for stage.

Population-based cancer survival trends in England and Wales up to 2007: an assessment of the NHS cancer plan for England.

BACKGROUND: The National Health Service (NHS) cancer plan for England was published in 2000, with the aim of improving the survival of patients with cancer. By contrast, a formal cancer strategy was not implemented in Wales until late 2006. National data on cancer patient survival in England and Wales up to 2007 thus offer the opportunity for a first formal assessment of the cancer plan in England, by comparing survival trends in England with those in Wales before, during, and after the implementation of the plan. METHODS: We analysed population-based survival in 2.2 million adults diagnosed with one of 21 common cancers in England and Wales during 1996-2006 and followed up to Dec 31, 2007. We defined three calendar periods: 1996-2000 (before the cancer plan), 2001-03 (initialisation), and 2004-06 (implementation). We estimated year-on-year trends in 1-year relative survival for patients diagnosed during each period, and changes in those trends between successive periods in England and separately in Wales. Changes between successive periods in mean survival up to 5 years after diagnosis were analysed by country and by government office region of England. Life tables for single year of age, sex, calendar year, deprivation category, and government office region were used to control for background mortality in all analyses. FINDINGS: 1-year survival in England and Wales improved for most cancers in men and women diagnosed during 1996-2006 and followed until 2007, although not all trends were significant. Annual trends were generally higher in Wales than in England during 1996-2000 and 2001-03, but higher in England than in Wales during 2004-06. 1-year survival for patients diagnosed in 2006 was over 60% for 12 of 17 cancers in men and 13 of 18 cancers in women. Differences in 3-year survival trends between England and Wales were less marked than the differences in 1-year survival. North-South differences in survival trends for the four most common cancers were not striking, but the North West region and Wales showed the smallest improvements during 2001-03 and 2004-06. INTERPRETATION: The findings indicate slightly faster improvement in 1-year survival in England than in Wales during 2004-06, whereas the opposite was true during 2001-03. This reversal of survival trends in 2001-03 and 2004-06 between England and Wales is much less obvious for 3-year survival. These different patterns of survival suggest some beneficial effect of the NHS cancer plan for England, although the data do not so far provide a definitive assessment of the effectiveness of the plan.

A community screening program for Helicobacter pylori saves money: 10-year follow-up of a randomized controlled trial.

BACKGROUND & AIMS: Population screening and treatment of Helicobacter pylori has been advocated as a means of reducing mortality from gastric cancer, as well as dyspepsia and dyspepsia-related resource use. Previous programs have failed to demonstrate a significant effect on mortality or resource use, but follow-up was only for 1 or 2 years. We aimed to determine the effect of screening for H pylori on dyspepsia and dyspepsia-related resource use over 10 years. METHODS: H pylori-positive individuals, aged 40-49 years, enrolled in a community screening program, randomized to eradication therapy or placebo in 1994, were sent a validated dyspepsia questionnaire by mail 10 years later, and primary care records were reexamined. Consultation, referral, prescribing, and investigation data related to dyspepsia were extracted. United Kingdom costs were applied to derive total cost per person (1 pound = 1.8 dollars). RESULTS: Of 2324 original participants, 1864 (80%) were traced and contacted. Of these, 1086 (47%) responded, and 919 (40%) agreed to a review of their primary care records. There was a 10-year mean saving in total dyspepsia-related costs of 117 dollars per person (95% confidence interval [CI] = 11 dollars-220 dollars, P = .03) with eradication therapy. Those symptomatic at baseline showed a nonsignificant trend toward resolution of symptoms at 10 years with eradication therapy (relative risk of remaining symptomatic, 0.89; 95% CI: 0.77-1.03). CONCLUSIONS: There were significant reductions in total dyspepsia-related health care costs. The savings made were greater than the initial cost of H pylori screening and treatment.

Ethnicity, gender, and socioeconomic status as risk factors for esophagitis and Barrett's esophagus.

Barrett's esophagus is thought to be a disease occurring predominantly in White Caucasian males of higher socioeconomic status. There are no published studies simultaneously examining risk of Barrett's esophagus according to ethnicity, gender, and socioeconomic status within a single data set. The authors conducted a retrospective case-control analysis within a cross-sectional study to determine risk of Barrett's esophagus in relation to sociodemographic variables in a large United Kingdom population. All patients undergoing upper gastrointestinal endoscopy at two clinical centers between January 2000 and January 2003 were evaluated. Data on ethnicity, age, gender, socioeconomic status, and the presence of Barrett's esophagus and esophagitis at endoscopy were collected. A total of 20,310 patients were analyzed. Barrett's esophagus was more common in White Caucasians (401/14,095 (2.8%)) than in South Asians (16/5,190 (0.3%)) (adjusted odds ratio (OR)=6.03, 95% confidence interval (CI): 3.56, 10.22), as was esophagitis (2,500/14,095 (17.7%) vs. 557/5,190 (10.7%); adjusted OR=1.76, 95% CI: 1.57, 1.97). Patients with Barrett's esophagus were also more likely to be male (adjusted OR=2.70, 95% CI: 2.18, 3.35) and of higher socioeconomic status (adjusted OR=1.58, 95% CI: 1.16, 2.15 (top tertile vs. bottom tertile)). White Caucasian ethnicity, male gender, and higher socioeconomic status are independent risk factors for Barrett's esophagus.

The efficacy of proton pump inhibitors in nonulcer dyspepsia: a systematic review and economic analysis.

BACKGROUND AND AIMS: The evidence that proton pump inhibitor (PPI) therapy affects symptoms of nonulcer dyspepsia is conflicting. We conducted a systematic review to evaluate whether PPI therapy had any effect in nonulcer dyspepsia and constructed a health economic model to assess the cost-effectiveness of this approach. 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 versus same/worse. Results were incorporated into a Markov model comparing health service costs and benefits of PPI with antacid therapy over 1 year. RESULTS: Eight trials were identified that compared PPI therapy with placebo in 3293 patients. The relative risk of remaining dyspeptic with PPI therapy versus placebo was .86 (95% confidence interval, .78-.95; P = .003, random-effects model) with a number needed to treat of 9 (95% confidence interval, 5-25). There was statistically significant heterogeneity between trials (heterogeneity chi(2) = 30.05; df = 7; P < .001). The PPI strategy would cost an extra US dollar 278/month free from dyspepsia if the drug cost US dollar 90/month. If a generic price of US dollar 19.99 is used, then a PPI strategy costs an extra US dollar 57/month free from dyspepsia. A third-party payer would be 95% certain that PPI therapy would be cost-effective, provided they were willing to pay US dollar 94/month free from dyspepsia. CONCLUSIONS: PPI therapy may be a cost-effective therapy in nonulcer dyspepsia, provided generic prices are used.

Eradication therapy in Helicobacter pylori positive peptic ulcer disease: systematic review and economic analysis.

BACKGROUND AND AIM: We conducted a systematic review and economic analysis to ascertain the efficacy of eradication therapy in the treatment of H. pylori positive peptic ulcer disease. METHODS: Comprehensive search of electronic databases, bibliographies of retrieved articles, contact with pharmaceutical companies, and experts in the field to identify published and unpublished literature from 1966 to the present. The data were incorporated into a Monte Carlo simulation Markov model that incorporated all the uncertainty in the estimates to evaluate cost-effectiveness. RESULTS: Fifty-two trials were included in the final metaanalysis. In duodenal ulcer healing, H. pylori eradication therapy was superior to ulcer healing drug (relative risk (RR) of ulcer persisting = 0.66; 95% confidence interval (CI) = 0.58 to 0.76) and no treatment (RR = 0.37; 95% CI 0.26 to 0.53). In gastric ulcer healing, H. pylori eradication therapy was not statistically superior to ulcer healing drug (RR = 1.32; 95% CI = 0.92 to 1.90). In preventing duodenal ulcer recurrence, H. pylori eradication therapy was not statistically superior to maintenance therapy with ulcer healing drug (RR of ulcer recurring = 0.73; 95% CI = 0.42 to 1.25), but was superior to no treatment (RR = 0.19; 95% CI = 0.15 to 0.26). In preventing gastric ulcer recurrence, H. pylori eradication was superior to no treatment (RR = 0.31; 95% CI 0.19 to 0.48). The Markov model suggested H. pylori eradication is cost-effective for duodenal ulcer over 1 year and gastric ulcer over 2 years with over 95% confidence despite the uncertainty in the data. CONCLUSIONS: H. pylori eradication therapy reduces the recurrence of peptic ulcer disease and is cost-effective.