454 GASTROINTESTINAL ENDOSCOPY VOLUME 54, NO. 4, 2001 Incidence of gastroesophageal malignancy in patients with dyspepsia in Hong Kong: implications for screening strategies Joseph Jao Yiu Sung, MD, PhD, Wei Cheong Lao, MD, Mun Sing Lai, MD,Ting Ho Li, MD, Francis Ka Leung Chan, MD, Justin Chi Yuen Wu, MD, Vincent King Sun Leung, MD,Yiu Wing Luk, MD, Nelson Nam Shing Kung, MD, Jessica Yuet Ling Ching, BN,Wel Keung Leung, MD, James Lau, MD, Sydney J.Y. Chung, MD Hong Kong Background: A “test-and-treat” strategy for H pylori infection has been recommended in Europe and North America as safe and cost-effective for management of patients with dyspepsia. The pri- mary aim of this study was to determine the frequency of gastroesophageal cancer in 2 groups of patients with dyspepsia: those 45 years of age or younger without “alarm” symptoms (low-risk group) and patients over 45 years of age or any patient with “alarm” symptoms (high-risk group). A secondary aim was to determine the frequency of gastric cancer among patients in the low-risk group with or without a positive serology for H pylori. Methods: Patients with persistent dyspepsia were recruited from 4 regional hospitals in Hong Kong. Those in the low-risk group were evaluated for H pylori by using a whole blood serology test; they underwent endoscopy within 1 week. Those in the high-risk group and those taking non- steroidal anti-inflammatory drugs (NSAIDs) underwent endoscopy promptly. Alarm symptoms were as follows: weight loss (10 or more pounds over 8 weeks), recurrent vomiting, dysphagia, bleeding, or anemia. Results: Of 2627 patients enrolled, 1017 were in the low-risk group and 1610 in the high-risk group. Twenty-three patients (0.9%) had gastroesophageal cancers (20 gastric, 3 esophageal). Four patients with cancer (17.4%) were in the low-risk group (3 gastric, 1 esophageal); all except the patient with esophageal cancer had a positive serology test. In the high-risk group, 19 patients had cancer (17 gastric, 2 esophageal). Conclusion: Gastric cancer is relatively frequent among young patients with dyspepsia who have no alarm features in Hong Kong. This finding raise concerns as to the safety of the “test-and-treat” strategy for the management of patients with dyspepsia in Asia. (Gastrointest Endosc 2001;54:454-8.) The management of dyspepsia, a problem that con- stitutes 2% to 5% of consultations with primary care physicians, is a major issue in clinical practice. 1 Unfortunately, optimal management remains contro- versial. The confusion arises from the poor correlation between symptoms and an underlying condition. 2 Endoscopy is the investigation of choice, but in most patients no serious disease is present. The demand for endoscopy continues to increase and waiting lists can often be unreasonably long. To cope with the increasing workload and contain costs, restrictions on the use of endoscopy seem inevitable. H pylori infection is associated with most cases of peptic ulcer and gastric cancer. Two studies from Europe have shown that H pylori serology before endoscopy in patients less than 45 years of age iden- tifies most cases of peptic ulcer and thereby elimi- nates the need for a large number of endoscopies. 3,4 The prospective screening study of Patel et al. 5 found that treating seropositive patients without endoscopy, the so-called “test-and-treat” strategy, reduces drug usage and the number of endoscopic procedures without disadvantaging patients. Based on these studies, European and American authori- ties have recommended “test-and-treat” for H pylori as a safe and cost effective management strategy for patients with dyspepsia. 6-8 This “test-and-treat” strategy has raised serious concerns in the Far East because gastric cancer is still one of the most common malignancies in this region. The incidence has been reported as 5 to 80 cases per 100,000 population, varying among different Asian countries and ethnic groups. 9 The Asia-Pacific Consensus Conference has cautiously recommended Received January 5, 2001. Accepted June 28, 2001. From the Prince of Wales Hospital, Chinese University of Hong Kong, Pamela Voude Eastern Hospital, Alice Ho Nethersole Hospital, and United Christian Hospital, Hong Kong. Reprint requests: Joseph JY Sung MD, PhD, Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, NT, Hong Kong. Copyright © 2001 by the American Society for Gastrointestinal Endoscopy 0016-5107/2001/$35.00 + 0 37/1/118254 doi:10.1067/mge.2001.118254