Bridging the gap in gastric cancer diagnosis
Dyspepsia affects between 20-40 % of the population, with GPs in the UK commonly seeing patients with various symptoms relating to the upper gastrointestinal (GI) tract. These patients are well managed at the primary care level, but there can be a gap in the patient pathway for refractory cases or those presenting with something potentially more sinister. This blog discusses the current limitations in managing patients with GI problems, and a potential solution to help streamline the screening process for gastric cancer.
The clinical puzzle
Chronic or recurrent GI problems can signal something more serious, such as gastric atrophy (GA) or gastric intestinal metaplasia (GIM) – both precursors to cancer – which are frequently initiated by Helicobacter pylori infection. The British Society of Gastroenterology (BSG) recently updated its guidelines, which clearly state that the key to early cancer detection is to non-invasively detect pre-cancerous conditions, such as GA and GIM, before endoscopy.
However, in current practice there is an ambiguous interface between primary and secondary care in patients presenting with GI problems. Patients often stay in primary care too long, and are referred at a later, less curable stage. Conversely, they are referred too soon, resulting in a low diagnostic yield with the majority of gastroscopies identifying no pathology. This is worrying to gastroenterologists – who feel they are missing disease cases – and adds to the ever-increasing burden on endoscopy resources, which has amassed a considerable backlog of referrals in the past year due to the COVID-19 pandemic.
These patients need to be investigated but hover in the vast chasm between primary and secondary care. A potential solution is to accurately screen patients with gastric symptoms, or within at-risk groups, in primary care – before referral – to more closely identify those who really need a gastroscopy. Public Health England guidance currently recommends a stool antigen test or urea breath test to identify H. pylori infection. Crucially, however, these tests fail to show GA caused by long term H. pylori infection or autoimmune disease – a significant risk factor for gastric cancer, with 18 % of atrophic cases progressing to cancer within 10 years.1 It is therefore imperative to identify these high-risk patients as early as possible.
Bridging the gap in the patient pathway
GastroPanel® is a blood test panel indicated for dyspeptic patients presenting with stomach complaints that offers the solution needed at this interface in care. It enables GPs to confidently identify patients who can be managed symptomatically or otherwise should be referred to a specialist for gastroscopy. This non-invasive option gives detailed information about the health and functionality of the stomach, as well as H. pylori status, by detecting and quantifying four stomach-specific biomarkers:
- pepsinogen I;
- pepsinogen II;
- H. pylori IgG antibodies.
The results are then fed into a sophisticated algorithm to produce a detailed report with a written interpretation, which GPs can easily understand in primary care. This can help to improve the management of each patient appropriately, and reassures GPs by ruling out the presence of pre-cancerous conditions of the stomach.
The appropriate implementation of GastroPanel still needs to be considered in context to ensure the best use of resources. Widespread population screening is not recommended, but preferably an accepted cohort needs to be established – e.g. dyspeptic patients, >50 years of age with a history of smoking and query H. pylori – to help accurately identify patients at risk of developing gastric cancer. Then, once the criteria have been refined, selectively screening higher risk patients in primary care will benefit patients and the healthcare system alike. Only those who need a gastroscopy will be identified and referred, potentially increasing the diagnostic yield, detecting more cancers at an earlier, more curable stage, and reducing both the cost and volume burden on healthcare resources.
To find out more about BIOHIT’s GastroPanel, visit: www.biohithealthcare.co.uk/gastropanel.
Banks M, Graham D, Jansen M, et al. British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma. Gut 2019;0:1–31.
Public Health England (2014). Test and treat for Helicobacter pylori (HP) in dyspepsia. Quick reference guide for primary care: For consultation and local adaptation. Available at: https://www.bsg.org.uk/clinical-resource/test-and-treat-for-helicobacter-pylori-hp-in-dyspepsia/ (Accessed: 30/07/2021).
Bornschein J, Pritchard DM. Myths and misconceptions in the management of Helicobacter pylori infection. Frontline Gastroenterology 2021;0:1–9.
Whiting JL, Sigurdsson A, Rowlands DC, et al. The long term results of endoscopic surveillance of premalignant gastric lesions. Gut. 2002 Mar;50(3):378-81.
Pimentel-Nunes P, Libânio D, Marcos-Pinto R, et al. Management of precancerous conditions and lesions in the stomach (MAPS II): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED) guideline update 2019. Endoscopy. 2019; 51: 365–388.