In the medical student world, though critical and diagnostic thinking are highly emphasized, rote pattern recognition is just as important. During our internal medicine rotation and board exam studying common scenarios are pounded into our brains. Young African American woman with difficulty breathing? Sarcoidosis. Diabetic with an unhealing ulcer? Osteomyeolitis. The list goes on and on. The Asian claim to fame? The Japanese man who eats lots of preserved foods. He has gastric cancer.
Earlier this year I did a rotation at Asian Health Services (AHS) in Oakland, CA. AHS is a non-profit primary care healthcare system that provides services to low-income, linguistically-isolated Asian Americans in Alameda County. Part of my time there was spent reviewing the current research on screening for H. pyolori, gastric cancer, and Asian Americans. I could only find one study that actually studied gastric cancer in Asian Americans. It was an epidemiological study that found that rates of gastric cancer in Japanese families decrease in each subsequent generation after immigration. One other study used Japanese Americans as a subset for analysis. It was a cost-effectiveness analysis and they simply took data on white men in the United States and multiplied their risk by four. I'm not sure that counts.
It's not surprising that though gastric cancer in Asians is common enough to warrant a board's question, there's been little research done on it in the United States. Asian American's are nearly invisible when it comes to health research. The US Department of Health and Human Service's Healthy People, in their 2010 Asian Americans/Pacific Islanders: Defining a Baseline, reported that only 0.1% of published medical research articles even mention API populations. This, in combination with the model minority myth, only perpetuates and contributes to the false notion that the API population does not suffer from any health inequities. Despite this having been recognized for years, little has changed in medical research and issues in data collection and analysis still remain.
Unfortunately, we've only known about H. pylori since 1984 and the amount of research that has been done, especially related to gastric cancer, is still in its early stages. While we have data to suggest that a screening program would be helpful, there isn't enough data to flush out what the exact details should be. In order for a screening program to be effective, one has to target the proper population at the right time with the right test. We just don't have the answers to those questions to create a formal screening program.
Ultimately we concluded that high-risk patients (immigrants from China, Korea, or Japan; men; smokers; and positive family history) be screened for H. pylori based on clinical judgment with the understanding that the evidence suggests that it should be done no later than 40 years old. Additionally, though serum pepsinogen was recognized as a promising screening tool for gastric mucosal changes, there was also not enough evidence to recommend a formal screening program. Asymptomatic high-risk patients should be screened based on clinical judgment. The evidence and epidemiology suggest that this should be done between the ages of 40 and 50 years old.
For a more comprehensive review of the data and an analysis of a key research study, the document I put together for my presentation can be found here.