Can Gastric Cancer Be Prevented? Who Is at High Risk and What Should They Do?

Gastric cancerremains one of the leading causes of preventable cancer deaths worldwide.

According to 2022 data, approximately 967 thousand new cases of gastric cancer were diagnosed worldwide, and 660 thousand people died from the disease. These figures show that gastric cancer remains a major global health threat.

Main Causes of Gastric Cancer

Gastric cancer is a complex disease arising from environmental and genetic factors. Major risk factors include:

• Helicobacter pylori (H. pylori) infection: May promote cancer development by causing chronic inflammation of the gastric mucosa.

• Excessive consumption of salty and processed foods: Foods containing nitrites and nitrates may contribute to the formation of carcinogenic compounds.

• Smoking: Tobacco products contain chemicals that increase gastric cancer risk.

• Family history and genetic predisposition: Gastric cancer in first-degree relatives increases individual risk.

• Chronic gastritis and atrophic gastritis: Prolonged inflammation of the gastric mucosa may predispose to cancer.

• Obesity and physical inactivity: Metabolic changes and hormonal imbalances may increase cancer risk.

Why Is There No Routine Gastric Cancer Screening Program?

There is no standard gastric cancer screening program for the general population. Several reasons account for this:

• Low Incidence: Incidence is low in some countries, reducing the cost-effectiveness of large-scale screening.

• Limitations of Screening Tests: Current methods, such as endoscopy, are invasive and difficult to apply across the population.

• Insufficient Evidence: Evidence that screening reduces death rates in the general population is insufficient.

However, targeted screening and surveillance are recommended for high-risk individuals, such as those with H. pylori infection or a family history.

Cancers With Routine Screening Programs

Effective screening tests exist for certain cancers and are important for early diagnosis and reduced mortality:

• Breast Cancer: Mammographic screening is recommended for women aged 40 and older.

• Cervical Cancer: Pap smears and HPV tests are performed regularly in women aged 21 and older.

• Colorectal Cancer: Colonoscopy and stool tests are recommended from age 45.

• Lung Cancer: Low-dose computed tomography (LDCT) screening is recommended for high-risk individuals.

These programs improve treatment success by detecting disease at an early stage.

Who Is at High Risk of Gastric Cancer?

Gastric cancer generally has a low incidence in the general population , so universal screening is not recommended. However, risk is substantially higher in certain groups , for whom targeted screening and surveillance are recommended.

1. People Positive for Helicobacter pylori (H. pylori)

• H. pylori infection substantially increases gastric cancer risk by promoting chronic gastritis, atrophic gastritis and intestinal metaplasia.

• Long-standing infection is considered particularly high risk.

2. People With a First-Degree Family History

• A history of gastric cancer in a first-degree relative, such as a parent or sibling, increases individual risk approximately 2-3-fold.

3. Immigrants From Endemic Regions

• People from Japan, South Korea, China, Central and South America, and Eastern Europe — countries with a high incidence of gastric cancer— remain at risk even after moving to lower-risk destinations such as the US and Europe.

• This elevated risk is particularly evident in first-generation immigrants .

4. People With Premalignant Gastric Lesions

• Chronic atrophic gastritis

• Gastric intestinal metaplasia (GIM) — particularly the incomplete type of metaplasia

• Gastric dysplasia — low or high grade
  These lesions are directly involved in the development of gastric adenocarcinoma.

5. People With Genetic and Hereditary Cancer Syndromes

• Hereditary Diffuse Gastric Cancer (HDGC) — CDH1 gene mutation carriers

• Lynch Syndrome (HNPCC) — mutations in DNA repair genes

• Peutz-Jeghers Syndrome, Juvenile Polyposis Syndrome, FAP (Adenomatous Polyposis Coli) and similar polyposis syndromes may also increase gastric cancer risk.

6. People With Gastric Polyps (Particularly the Adenomatoid Type)

• Adenomatous gastric polyps in particular carry a risk of dysplasia and carcinoma.

7. People With Previous Gastric Surgery

• Particularly after partial gastrectomy , cancer risk increases in the remaining stomach, especially >15 years after surgery.

New Screening Guidance for High-Risk Individuals

In high-risk individuals, timely endoscopic screening and surveillanceplay a critical role in early diagnosis and prevention. In 2025, the American Gastroenterological Association (AGA) reflected the latest scientific developments by publishing an updated clinical practice guideline , offering physicians clear and practical guidance.

This article reviews gastric cancer screening and surveillance protocols, risk factors and current clinical approaches in light of the new AGA guidance.

AGA, ACG and ASGE Join Forces

The AGA's guideline, published in February 2025 in Gastroenterology , was prepared in alignment with two other important documents from the American College of Gastroenterology (ACG) and the American Society for Gastrointestinal Endoscopy (ASGE):

• ACG clinical guideline on the diagnosis and management of gastric premalignant conditions (2025)

• Quality indicators for upper GI endoscopy (joint ACG-ASGE publication)

Simultaneous publication of these three documents enables gastric screening and surveillance strategies to enter clinical practice, as they have for colon and esophageal cancer.

Who Should Benefit From Gastric Cancer Screening?

The AGA defines high-risk groups in the US as follows:

• From countries with a high incidence of gastric cancer, first-generation immigrants

• People with a family history of gastric cancer in a first-degree relative

• Carriers of hereditary gastrointestinal polyposis syndromes or hereditary cancer syndromes

• Certain ethnic and racial groups, particularly people of Asian, Latin American and Eastern European ancestry

Endoscopy: The Gold Standard for Gastric Cancer Screening

According to the AGA, the most appropriate screening and surveillance method for high-risk individuals is upper GI endoscopy with advanced endoscopic imaging systems. This enables:

• Direct examination of the mucosa

• Detection of high-risk lesions (atrophy, intestinal metaplasia, dysplasia)

• Biopsy sampling for histological staging

High-definition white-light endoscopy, image-enhancement technologies, gastric mucosal cleaning protocols and adequate insufflation are recommended. Systematic biopsy protocols and photographic documentation should also be included.

Addressing Helicobacter pylori: Primary Prevention

One of the main risk factors for gastric cancer is Helicobacter pylori infection, whose eradication plays a key role in primary prevention. The AGA recommends:

• In high-risk individuals, H. pylori infection should be screened for opportunistically

• Among family members of people who test positive, testing should also be recommended

• Eradication therapy should be an integral part of endoscopic screening

Gastric Biopsy: When and How?

In people with suspected atrophy and/or gastric intestinal metaplasia (GIM) , at least 5 biopsies are recommended. Sampling sites:

• Antrum/incisura angularis

• Corpus (gastric body)

Pathologists are advised to include the following in biopsy reports:

• H. pylori presence/absence

• Atrophy or metaplasia severity

• Histological GIM subtype (complete/incomplete)

Assessment by a gastrointestinal pathologist experienced in dysplasia is important. People with visible or nonvisible dysplasia should be evaluated at a center specializing in gastric neoplasia .

Dysplasia and Early Cancer: Endoscopic Resection

If high-grade dysplasia or early gastric cancer is detected, the aims are:

• En bloc tumor removal with R0 resection

• Accurate pathological staging and potentially curative treatment

If these patients have H. pylori infection, eradication should begin promptly, but must not delay endoscopic procedures.

Surveillance Intervals: How Often Should Endoscopy Be Performed?

• In people without atrophy, GIM or neoplasia, screening frequency should be determined by individual risk and preferences .

• In the presence of severe atrophy, multifocal or incomplete GIM , and additional risk factors such as a family history: endoscopic surveillance every 3 years is recommended.

• Surveillance should also continue after endoscopic resection for dysplasia or early gastric cancer.

Gastric Carcinoids Larger Than 2 cm: Time for Surgery

Type 1 gastric carcinoids are generally slow-growing and benign. However:

• Lesions smaller than 1 cm are generally monitored only

• Lesions of 1-2 cm may be removed endoscopically

• Those larger than 2 cm should be removed surgically because of metastatic risk

Who Should and Should Not Be Screened?

The guideline recommends an individualized approach:

• In people suitable for endoscopic or surgical intervention, screening and surveillance should be performed

• In those with limited life expectancy or severe comorbidities, screening should be stopped

In addition, to address health inequalities, tobacco use, a diet high in salt or food additives and lack of health-care access are highlighted as modifiable risk factors that should also be addressed.

Conclusion: A New Era in Screening Policy

This updated guidance offers a practical framework not only for gastric cancer prevention but also for the diagnosis and management of gastric polyps .

Gastric polyps are generally asymptomatic and discovered incidentally. However, appropriate sampling, accurate classification and a clear understanding of risk factors are essential for proper management.