Why internists should care about Helicobacter pylori: recapitulating gastric cancer prevention.

Infection with Helicobacter pylori (H. pylori) is a leading but also modifiable cause of gastric cancer. However, evidence indicates that the goal of a primary prevention of gastric cancer is still far from being achieved. Main obstacles derive from inadequate screening and management of H. pylori infection but also from other external risk factors, responsible for about a quarter of future cases of gastric cancer. The need for population-based H. pylori screen-and-treat programs remains not fully addressed, mainly due to concerns about cost, to underpowered screening efficacy of policies only targeting symptomatic people, to the lack of screen-and-treat approach performed early. Further concerns derive from persisting gaps between guideline-recommended H. pylori management and real-world patterns, leading to inappropriate therapies and increased antimicrobial resistance. A critical role is also played by unhealthy lifestyle and by environmental factors other than H. pylori. In fact, critical external factors increasing the risk of gastric cancer originate from the contamination of environmental matrices and of the food chain with toxic chemicals of anthropogenic origin. An effective strategy for the primary prevention of gastric cancer should therefore consider a full implementation of population-based screen-and-treat programs, but also educational strategies oriented to correct unhealthy habits, and rules and policies oriented to decrease the involuntary exposure to toxic chemicals. In the absence of this comprehensive approach and urgent and efficient prevention policies, local health systems should be prepared to manage the high cost deriving from the growing burden of a preventable (but not prevented) disease, as is gastric cancer. Maximal efforts should also be oriented to ensure a correct application of the available guidelines for the management of H. pylori infection. This goal should lead to an accurate selection of the best treatment regimen, but also to antibiotic stewardship, and to constant monitoring of outcomes and epidemiologic data, to improve quality and equity of care. Internist as well urge to master such topics which involve present and future key public health issues.