Helicobacter pylori-naïve gastric cancer (HPNGC), rather than H. pylori-associated gastric cancer, has been increasingly detected in recent years. HPNGC was previously uncommon as it usually occurs in patients with hereditary gastric cancer or gastric adenocarcinoma of the fundic gland type.^2,3 Since the incidence of H. pylori infection has been decreasing, even in areas where gastric cancer is prevalent, HPNGC occurrence should be considered during endoscopic evaluation.

Ishibashi et al.⁴ surveyed the number of HPNGC cases detected annually and used a questionnaire to obtain data regarding HPNGC awareness, diagnostic proactiveness, and interest in HPNGC from 712 Japanese endoscopists. Higher HPNGC detection was independently associated with board certification and high awareness and interest scores. In particular, the endoscopists who attended conferences to collect information on HPNGC had a higher level of awareness. Therefore, this report concluded that awareness of the disease and education of endoscopists could improve the detection of HPNGC. This study also showed that the number of years of endoscopic experience was not directly associated with HPNGC detection, consistent with a previous study.⁵ This indicates the importance of education in improving EGD quality. Since HPNGC is not widely recognized, educational programs should be a prerequisite for high-quality EGD in patients after H. pylori eradication.

The development of measurable components for EGD is crucial. The authors considered the associated factors, board certification, and high awareness and interest scores to be quality indicators for diagnosing HPNGC. However, these two indicators cannot be quantified. Without quantifying quality, there is no way to identify good clinical practice. Furthermore, there was no chance to learn how good clinical practice was provided, resulting in the quality not being upgraded. Therefore, additional quantifiable quality indicators must be developed.

The authors discussed the role of the Endoscopy Society, a Japanese professional organization. Obtaining certification from this society is essential as the endoscopic specialist system operated by this society universally ensures the quality and competency of endoscopists without creating regional disparities. In addition to education, expert committees or endoscopy organizations should play a central role in defining what needs to be characterized for quality measurement and creating tools to collect quality-related factors effectively. Professional organizations should also persuade members to join quality improvement programs, exploit tools to facilitate provider engagement and promote provider training on data-supporting quality metrics.

It has been reported that using antispasmodic and sedative agents, photo documentation, systemic reporting, and sufficient observation times are essential to increase the detection rate of gastric cancer.¹ A qualified training program and endoscopist attention should be maintained for high-quality EGD.