Stomach (Gastric) Cancer Prevention (PDQ®)–Health Professional Version

Overview

Note: Separate PDQ summaries on Stomach (Gastric) Cancer Screening,Gastric Cancer Treatment, and Levels of Evidence for Cancer Screening and Prevention Studies are also available.

Who Is at Risk?

People at elevated risk for gastric cancer include elderly patients with atrophic gastritis or pernicious anemia, patients with sporadic gastric adenomas,[1] familial adenomatous polyposis,[2] or hereditary nonpolyposis colon cancer,[3] and immigrant ethnic populations from countries with high rates of gastric carcinoma.[4,5] Workers in the rubber and coal industries are also at increased risk.[6]

Risk factors for gastric cancer include the presence of precursor conditions such as chronic atrophic gastritis and intestinal metaplasia, pernicious anemia, and gastric adenomatous polyps. Genetic factors include a family history of gastric cancer, Li Fraumeni syndrome, and type A blood type.[6] Environmental factors include low consumption of fruits and vegetables; consumption of salted, smoked, or poorly preserved foods; cigarette smoking; and radiation exposure.[6-8]

There is consistent evidence that Helicobacter pylori infection, also known as H. pyloriinfection, of the stomach is strongly associated with both the initiation and promotion of carcinoma of the gastric body and antrum and of gastric lymphoma.[9-11] The International Agency for Research on Cancer classifies H. pylori infection as a cause of noncardia gastric carcinoma and gastric low-grade B-cell mucosa-associated lymphoid tissue or MALT lymphoma (i.e., a Group 1 human carcinogen).[12,13] Gastric cancer has been observed to be more common among individuals who use proton pump inhibitors (PPIs), relative to nonusers, after apparent successful H. Pylori eradication therapy,[14] but confounding and detection bias cannot be ruled out as explanations.

Compared with the general population, people with duodenal ulcer disease may have a lower risk of gastric cancer.[15]

Interventions for Reduction of Stomach (Gastric) Cancer Risk

Smoking cessation

Based on solid evidence, smoking is associated with an increased risk of stomach cancer.[16-18] The 2004 Surgeon General’s report identifies cigarette smoking as a cause of stomach cancer, with an average relative risk (RR) in former smokers of 1.2 and in current smokers of 1.6.[19] Compared with persistent smokers, the risk of stomach cancer decreases among former smokers with time since cessation. This pattern of observations makes it reasonable to infer that cigarette smoking prevention or cessation would result in a decreased risk of gastric cancer.

Magnitude of Effect: A systematic review and meta-analysis showed a 60% increase in gastric cancer in male smokers and a 20% increase in gastric cancer in female smokers compared with nonsmokers.[16]

Study Design: Evidence obtained from case-control and cohort studies.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.

H. Pylori infection eradication

Based on solid evidence, H. pylori infection is associated with an increased risk of gastric cancer. A meta-analysis of seven randomized studies, all conducted in areas of high-risk gastric cancer and all but one conducted in Asia, suggests that treatment of H. pylori may reduce gastric cancer risk (from 1.7% to 1.1%; RR = 0.65; 95% confidence interval, 0.43–0.98).[20] Only two studies assessed gastric cancer incidence as the primary study outcome, and two different studies were double blinded. It is unclear how generalizable the results may be to the North American population.

In the initial report from a clinical trial, 3,365 randomized subjects were followed in an intention-to-treat analysis; it was shown that short-term treatment with amoxicillin and omeprazole reduced the incidence of gastric cancer by 39% during a period of 15 years following randomization, with similar but not statistically significant reductions for gastric cancer mortality.[21]

Magnitude of Effect: Risk of cancer may be reduced; effect on cancer mortality is not known.

Study Design: Randomized controlled trials of H. pylori eradication.
Internal Validity: Good.
Consistency: Good.
External Validity: Good.

Interventions With Inadequate Evidence as to Whether They Reduce the Risk of Stomach (Gastric) Cancer

Diet

Based on fair evidence, excessive salt intake and deficient dietary consumption of fresh fruits and vegetables are associated with an increased risk of gastric cancer. Dietary intake of vitamin C contained in vegetables, fruits, and other foods of plant origin is associated with a reduced risk of gastric cancer. Diets high in whole-grain cereals, carotenoids, allium compounds, and green tea are also associated with a reduced risk of this cancer. However, it is uncertain if changing one's diet to include more vegetables, fruits, and whole grains would reduce the risk of gastric cancer.

Magnitude of Effect: Small, difficult to determine.

Study Design: Cohort or case-control studies.
Internal Validity: Good.
Consistency: Small number of studies.
External Validity: Fair (populations vary greatly in their underlying nutritional status).

References

MING SC, GOLDMAN H: Gastric polyps: a histogenetic classification and its relation to carcinoma. Cancer 18: 721-6, 1965. [PUBMED Abstract]
Utsunomiya J, Maki T, Iwama T, et al.: Gastric lesion of familial polyposis coli. Cancer 34 (3): 745-54, 1974. [PUBMED Abstract]
Aarnio M, Salovaara R, Aaltonen LA, et al.: Features of gastric cancer in hereditary non-polyposis colorectal cancer syndrome. Int J Cancer 74 (5): 551-5, 1997. [PUBMED Abstract]
Kurtz RC, Sherlock P: The diagnosis of gastric cancer. Semin Oncol 12 (1): 11-8, 1985. [PUBMED Abstract]
Boeing H: Epidemiological research in stomach cancer: progress over the last ten years. J Cancer Res Clin Oncol 117 (2): 133-43, 1991. [PUBMED Abstract]
Pisters PWT, Kelsen DP, Tepper JE: Cancer of the stomach. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds.: Cancer: Principles and Practice of Oncology. Vols. 1 & 2. 8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2008, pp 1043-1079.
Crew KD, Neugut AI: Epidemiology of gastric cancer. World J Gastroenterol 12 (3): 354-62, 2006. [PUBMED Abstract]
Leung WK, Wu MS, Kakugawa Y, et al.: Screening for gastric cancer in Asia: current evidence and practice. Lancet Oncol 9 (3): 279-87, 2008. [PUBMED Abstract]
Parsonnet J, Hansen S, Rodriguez L, et al.: Helicobacter pylori infection and gastric lymphoma. N Engl J Med 330 (18): 1267-71, 1994. [PUBMED Abstract]
Ando T, Goto Y, Maeda O, et al.: Causal role of Helicobacter pylori infection in gastric cancer. World J Gastroenterol 12 (2): 181-6, 2006. [PUBMED Abstract]
Aromaa A, Kosunen TU, Knekt P, et al.: Circulating anti-Helicobacter pylori immunoglobulin A antibodies and low serum pepsinogen I level are associated with increased risk of gastric cancer. Am J Epidemiol 144 (2): 142-9, 1996. [PUBMED Abstract]
IARC Working Group on the Evaluation of Carcinogenic Risks to Humans: A review of human carcinogens--Part B: biological agents. Volume 100. Lyon, France: IARC Press, 2011.
Bouvard V, Baan R, Straif K, et al.: A review of human carcinogens--Part B: biological agents. Lancet Oncol 10 (4): 321-2, 2009. [PUBMED Abstract]
Cheung KS, Chan EW, Wong AYS, et al.: Long-term proton pump inhibitors and risk of gastric cancer development after treatment for Helicobacter pylori: a population-based study. Gut 67 (1): 28-35, 2018. [PUBMED Abstract]
Hansson LE, Nyrén O, Hsing AW, et al.: The risk of stomach cancer in patients with gastric or duodenal ulcer disease. N Engl J Med 335 (4): 242-9, 1996. [PUBMED Abstract]
Ladeiras-Lopes R, Pereira AK, Nogueira A, et al.: Smoking and gastric cancer: systematic review and meta-analysis of cohort studies. Cancer Causes Control 19 (7): 689-701, 2008. [PUBMED Abstract]
González CA, Pera G, Agudo A, et al.: Smoking and the risk of gastric cancer in the European Prospective Investigation Into Cancer and Nutrition (EPIC). Int J Cancer 107 (4): 629-34, 2003. [PUBMED Abstract]
La Torre G, Chiaradia G, Gianfagna F, et al.: Smoking status and gastric cancer risk: an updated meta-analysis of case-control studies published in the past ten years. Tumori 95 (1): 13-22, 2009 Jan-Feb. [PUBMED Abstract]
The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, Ga: U.S. Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Also available online. Last accessed August 13, 2018.
Fuccio L, Zagari RM, Eusebi LH, et al.: Meta-analysis: can Helicobacter pylori eradication treatment reduce the risk for gastric cancer? Ann Intern Med 151 (2): 121-8, 2009. [PUBMED Abstract]
Ma JL, Zhang L, Brown LM, et al.: Fifteen-year effects of Helicobacter pylori, garlic, and vitamin treatments on gastric cancer incidence and mortality. J Natl Cancer Inst 104 (6): 488-92, 2012. [PUBMED Abstract]