Screening for Upper Gastrointestinal Malignancies in the United States-Which Immigrant Groups Should Be Considered High-Risk?

Helicobacter pylori and Human Immunodeficiency Virus Co-Infection: Potential Implications for Future Gastric Cancer Risk

Objective: Helicobacter pylori and human immunodeficiency virus (HIV) are both pandemic infections with variable geographic prevalence rates. H. pylori–HIV co-infection at the regional and sub-regional levels with a perspective on gastric cancer incidence is discussed. Design: Based on PRISMA guidelines, national data for H. pylori, HIV, and H. pylori–HIV co-infection were collected for the general population through December 2019. Joint temporal and geographical data for H. pylori and HIV infections in 48 countries were available and used to generate H. pylori–HIV co-infection estimates by cross-sectional analysis. These data were compared with gastric carcinoma statistics for the same countries. Results: The estimated global prevalence rate of H. pylori–HIV co-infection was 1.7 per 1000 people, representing 12.6 million people. Prevalence according to region was, in decreasing order, sub-Saharan Africa 21.9‰, Eastern Europe/Central Asia 4.3‰, Latin America/Caribbean 2.0 ‰, North America/Western/Southern/Northern Europe 1.1‰, Asia/Pacific 0.8‰, and North Africa/Middle East 0.1 ‰. The incidence and mortality rates for gastric carcinoma were higher in East/Pacific Asia, Southern/Andean Latin America, and Eastern Europe regions, and the incidence appeared to be 1.8-fold greater in H. pylori–HIV-infected people in East Asia. Conclusions: The population at risk of H. pylori–HIV co-infection is estimated to be 12.6 million people (2015 reference year). The heterogeneity of H. pylori–HIV co-infection across regions and sub-regions does not show a clear association with gastric carcinoma. Other methodological approaches with analytical studies (cohort, case–control) are required to measure the potential effect of H. pylori infection and its treatment on the incidence of gastric carcinoma in the large HIV–H. pylori-positive cohort.

Predicting Gastric Intestinal Metaplasia in a High-Risk Population

INTRODUCTION

Gastric intestinal metaplasia (GIM) is a precancerous lesion. It has a low prevalence rate in the United States. However, GIM is more common among non-White and immigrant populations. Harlem Hospital serves a community that includes predominantly African Americans, Hispanics, and immigrants from West Africa and Spanish-speaking Caribbean countries. This study aims to define the factors predicting GIM in this high-risk group as well as help define screening strategies for vulnerable populations.

METHODS

A total of 1351 patients who underwent endoscopic gastroduodenoscopy (EGD) and biopsy in 2018 and 2019 for any indication at Harlem Hospital were included in this study. Gastric biopsy specimens taken during the procedure were assessed for GIM by histopathology. Baseline demographics were collected, including age, sex, and ethnicity. Other information collected included risk factors for GIM such as Helicobacter pylori infection, smoking status, and the use of alcohol. Descriptive analysis was done and the Wilcoxon rank sum test and chi-squared test were used to test for associations. Multiple logistic regressions were used to assess the odds of independent factors associated with increased risk of GIM.

RESULTS

Of the 1351 patients reviewed, 106 had GIM for a prevalence of 8.0% (CI: 6.7%-9.6%, p < 0.001). Univariate analysis revealed older patients, males, history of smoking, alcohol, and H. pylori infection were significantly associated with GIM. Using multiple logistic regressions and adjusting for underlying risk factors, smoking (OR: 1.61, 95% CI: 1.00-2.570) and H. pylori infection (OR: 3.35, 95% CI: 2.18-5.15) continued to be significantly associated with increased risk of GIM; however, alcohol use was not significant after adjusting for other risk factors (OR: 1.10, 95% CI: 0.68-1.78). Hispanic risk for GIM was slightly higher than African Americans (OR: 1.17, 95% CI: 0.74-1.83). The predicted marginal effect of age on the odds of GIM was significant from age 40 and increased exponentially at age 50. By age 70, the odds of GIM were as high as 11% (95% CI: 8.3-13.6).

CONCLUSION

The prevalence of GIM in our population is significantly higher compared to reported cases in the United States. Age, male gender, H. pylori infection, and smoking significantly increase the risk of GIM. Given the high prevalence of GIM in our population, early endoscopic screening would play an important role in evaluating dyspepsia to diagnose GIM with or without H. pylori infection. We propose screening all at-risk ethnicities from age 40 years with EGD according to the Sydney System biopsy protocol. We believe this will ultimately decrease the incidence of gastric cancer death in these vulnerable populations of color.

Cancer Screening in Refugees and Immigrants: A Global Perspective

Clinicians in the United States are trained to screen for cancer based on patient age, gender, family history, and environmental risk factors such as smoking. These cancers generally include, breast, cervical, colon, lung, and prostate cancers. We know that refugees and other immigrants to the United States experience dramatic disparities in cancer screening. Additionally, many immigrants experience elevated risks from infection-attributable cancers due to their country or region of origin. U.S.- based clinicians may not routinely consider these unique risk factors. Although this article focuses on refugees, it is also intended to guide clinicians caring for other foreign-born immigrant groups living in the United States (hereafter referred to as "immigrants"). The document contains two sections: 1) special considerations for U.S. Preventive Services Task Force guidelines cancer screening recommendations in immigrants and 2) cancer risks and screening recommendation unique to certain immigrant groups. Disparities in cancer screening and prevalence are often greater for specific immigrant groups than for broader racial or ethnic groups (e.g., Black, Asian, Hispanic) into which they may fit. Disaggregation of data by language or country of origin is useful to identify such disparities and to design intervention opportunities within specific communities that are culturally distinct and/or who have different environmental exposures. Unique cancer risks and disparities in screening support a nuanced approach to cancer screening for immigrant and refugee populations, which is the focus of this narrative review.

A Summary of the 2020 Gastric Cancer Summit at Stanford University

There exists no coherent national strategy for the early detection or prevention of gastric cancer in the United States (US), even among identified high-risk groups such as Asian Americans, African Americans, Hispanic Americans, and Alaska Native/American Indian peoples. As a result, patients with gastric cancer in the US are diagnosed at later stages and demonstrate worse overall survival compared to nations of East Asia with established screening programs (Table 1). The under-recognition of gastric cancer risk within minority communities is a significant unaddressed healthcare disparity.