Stomach cancer screening

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahad Hasan, M.D.[2] Parminder Dhingra, M.D. [3] Mohammed Abdelwahed M.D[4]

Overview

Gastric cancer screening aims to detect adenocarcinoma at an early, curable stage and to identify gastric premalignant conditions along the Correa cascade: atrophic gastritis (AG), gastric intestinal metaplasia (GIM), and dysplasia.[1]

How a population is screened depends on how common gastric cancer is in that region:

  • High-incidence regions: endoscopic screening every 2–3 years is suggested.
  • Low-incidence regions: general-population screening is not recommended.[2]
  • United States: screening endoscopy is considered only for defined high-risk groups.[3]

Upper endoscopy (EGD) is the preferred screening test.[3] In the Korean national program, EGD was associated with lower gastric cancer mortality, whereas the upper GI series (UGIS) was not.[4]

The only randomized trial reported so far found a non-significant reduction in non-cardia gastric cancer mortality with endoscopic screening.[5]

Screening Recommendations

Gastric cancer screening recommendations by setting
Setting / source Recommendation
South Korea (national program) EGD or UGIS every 2 years from age 40 years.[4][6]
Japan (national program) Barium radiography or endoscopy from age 50 years.[7][8]
Biennial endoscopic screening was added to the national program in 2016.[9]
ESGE/EHMSG/ESP (MAPS III, 2025) Endoscopic screening is suggested according to regional risk, measured as the age-standardized rate (ASR) per 100,000 person-years:
  • High-risk regions (ASR >20): every 2–3 years.
  • Intermediate-risk regions (ASR 10–20): every 5 years, only if cost-effectiveness is proven.
  • Low-risk regions (ASR <10): no screening.

Screening or surveillance should not be started, or should be stopped, in asymptomatic individuals older than 80 years.[2]

AGA Clinical Practice Update (2025, US) Consider endoscopic screening in defined high-risk groups (see below), guided by a personalized risk assessment.[3]
ACG guideline on gastric premalignant conditions (2025, US) * Recommends against routine endoscopic screening of the general population.
  • Evidence was judged insufficient to recommend for or against screening in US high-risk populations.
  • Recommends against noninvasive biomarkers for screening or surveillance.[1]

Low-Incidence Regions (United States)

Per the 2025 AGA update, the following groups should be considered for gastric cancer screening:[3]

  • First-generation immigrants from high-incidence regions, and possibly other non-White racial and ethnic groups.
    • US gastric cancer incidence is 2- to 13-fold higher in non-White individuals.[1]
  • Individuals with gastric cancer in a first-degree relative.
  • Individuals with certain hereditary GI polyposis or hereditary cancer syndromes.

Practical points (AGA 2025):[3]

  • Decide on screening and surveillance through a personalized assessment of gastric cancer risk.
  • If the index EGD in a high-risk individual shows no atrophy, GIM, or neoplasia, base further screening on that individual's risk factors and preferences.
    • Consider ongoing screening when there is a family history of gastric cancer or multiple risk factors.
  • Screen, or continue surveillance, only in individuals fit for endoscopic or surgical treatment.

Lynch syndrome: NCCN recommends EGD surveillance starting between ages 30 and 40 years, repeated every 2–4 years and preferably combined with colonoscopy. This applies to carriers of pathogenic variants in MLH1, MSH2, EPCAM, and MSH6; surveillance should be considered in PMS2 carriers.[10]

Screening Tests

Upper Endoscopy

  • EGD is the best test for screening or surveillance in individuals at increased risk.[3]
  • Korean program data: sensitivity was 69.0% for endoscopy versus 36.7% for UGIS. Specificity was 96.0% and 96.1%, respectively.[6]
  • Japanese registry-linked data for localized gastric cancer (endoscopy n = 61,658; radiography n = 73,653):[7]
    • Sensitivity: 83.4% for endoscopy versus 65.3% for radiography
    • Specificity: 99.0% versus 88.7%
    • Positive predictive value: 27.4% versus 2.2%
  • Quality requirements:[1][2]
    • Adequate mucosal cleansing and insufflation
    • Image-enhanced (virtual chromo-) endoscopy
    • Systematic examination with photodocumentation, and adequate inspection time
    • Systematic biopsies: at least 2 from the antrum/incisura and 2 from the corpus, placed in separate, labeled containers

Contrast Radiography

  • Barium radiography has lower sensitivity, specificity, and positive predictive value than endoscopy at every clinical stage.[7]
  • Mortality evidence:
    • In a nested case-control study within the Korean program, the odds ratio for gastric cancer death was 0.53 (95% CI 0.51–0.56) for EGD and 0.98 (95% CI 0.95–1.01) for UGIS.[4]
    • A bias-corrected meta-analysis found a significant per-protocol mortality reduction for endoscopy (RR 0.52) but not for radiography (RR 0.80; 95% credible interval 0.60–1.06).[11]
  • Radiography remains an accepted modality in the Japanese national program.[7]

Noninvasive Tests

  • ACG recommends against noninvasive biomarkers for screening or surveillance of gastric cancer or gastric premalignant conditions (conditional recommendation, very low quality of evidence).[1]

Harms and Limitations

  • Missed cancers: about 10% of patients with upper GI cancer had an EGD within the 3 years before diagnosis that did not find the cancer.
    • Most of these earlier endoscopies were abnormal, which points to gaps in endoscopy quality.[12]
  • Overdiagnosis: screening increases detection of carcinoma in situ (HR 2.31 with endoscopic screening).[9]
  • Healthy-screenee bias: this may inflate the benefit estimates from observational studies.[9]
  • Selection bias in the trial: open-label cluster recruitment in the ESECC trial produced baseline imbalances between groups.[5]

Surveillance After Index Screening

Surveillance after screening endoscopy
Finding Suggested approach
No atrophy, GIM, or neoplasia Individualize based on risk factors and preferences. Consider ongoing screening when there is a family history or multiple risk factors.[3]
Severe AG and/or multifocal or incomplete GIM, especially with other risk factors (e.g., family history) Surveillance EGD, typically every 3 years.
Shorter intervals may suit those with multiple risk factors or severe metaplastic change.[3][1]
GIM in general AGA 2020 recommends against routine surveillance for all patients with GIM.
Patients at higher risk may reasonably choose surveillance.
Patients with a family history of gastric cancer may reasonably choose a repeat EGD within 1 year for risk stratification.
Pooled 10-year incidence of gastric cancer in GIM is about 1.6%.[13]
Successfully resected dysplasia or early cancer Ongoing endoscopic surveillance.[3]
New diagnosis of pernicious anemia AGA: endoscopy if none was done recently.[14]
ASGE: endoscopy within 6 months of diagnosis.[15]

Role of Helicobacter pylori Testing

Details are covered in the primary prevention microchapter.

  • H. pylori eradication reduces gastric cancer risk at all ages. The greatest reduction occurs before premalignant conditions develop.[16]
  • 2025 meta-analysis of RCTs:[17]
    • Gastric cancer incidence: RR 0.64 in healthy infected individuals; RR 0.52 after endoscopic resection.
    • Gastric cancer mortality: RR 0.78.
  • Earlier meta-analysis: the number needed to treat was 72 to prevent one gastric cancer and 135 to prevent one gastric cancer death.[18]
  • Consider H. pylori testing in individuals at increased gastric cancer risk.[3]
  • Offer eradication to all infected adults.[16]
  • Confirm eradication at least 4 weeks after therapy using a urea breath test, stool antigen, or biopsy-based test.[19]
  • In patients with gastric premalignant conditions, ACG recommends both H. pylori test, treat, and confirm, and endoscopic surveillance when the patient is high risk. Eradication does not replace surveillance.[1]

Guideline Disagreement and Evidence Gaps

  • Limited randomized evidence: the only RCT is underpowered, and it was conducted in a region that is not high-risk for gastric cancer.[5]
  • US screening in high-risk groups: AGA supports considering screening EGD in high-risk groups,[3] whereas ACG found the evidence insufficient to make a recommendation.[1]
  • Program-level benefit: the benefit seen in national programs appears to track with endoscopy-based programs rather than radiography-based ones.[20]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Morgan DR, Corral JE, Li D, Montgomery EA, Riquelme A, Kim JJ, Sauer B, Shah SC (2025). "ACG Clinical Guideline: Diagnosis and Management of Gastric Premalignant Conditions". Am J Gastroenterol. 120 (4): 709–737. doi:10.14309/ajg.0000000000003350. PMID 40072510 Check |pmid= value (help).
  2. ↑ 2.0 2.1 2.2 Dinis-Ribeiro M, Libânio D, Uchima H, Spaander MCW, Bornschein J, Matysiak-Budnik T, Tziatzios G, Santos-Antunes J, Areia M, Chapelle N, Esposito G, Fernandez-Esparrach G, Kunovsky L, Garrido M, Tacheci I, Link A, Marcos P, Marcos-Pinto R, Moreira L, Pereira AC, Pimentel-Nunes P, Romanczyk M, Fontes F, Hassan C, Bisschops R, Feakins R, Schulz C, Triantafyllou K, Carneiro F, Kuipers EJ (2025). "Management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG) and European Society of Pathology (ESP) Guideline update 2025". Endoscopy. 57 (5): 504–554. doi:10.1055/a-2529-5025. PMID 40112834 Check |pmid= value (help).
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 Shah SC, Wang AY, Wallace MB, Hwang JH (2025). "AGA Clinical Practice Update on Screening and Surveillance in Individuals at Increased Risk for Gastric Cancer in the United States: Expert Review". Gastroenterology. 168 (2): 405–416.e1. doi:10.1053/j.gastro.2024.11.001. PMID 39718517 Check |pmid= value (help).
  4. ↑ 4.0 4.1 4.2 Jun JK, Choi KS, Lee HY, Suh M, Park B, Song SH, Jung KW, Lee CW, Choi IJ, Park EC, Lee D (2017). "Effectiveness of the Korean National Cancer Screening Program in Reducing Gastric Cancer Mortality". Gastroenterology. 152 (6): 1319–1328.e7. doi:10.1053/j.gastro.2017.01.029. PMID 28147224.
  5. ↑ 5.0 5.1 5.2 Liu M, Yang W, Guo C, Liu Z, Li F, Liu A, Yang H, Shen L, Wu Q, Duan L, Wang H, Tian H, Shi C, Pan Y, Liu Y, Liu F, Cai H, He Z, Ke Y (2026). "Effect of endoscopic screening for non-cardia gastric cancer: a 12-year report of a population-based randomized trial". BMC Med. 24: 529. doi:10.1186/s12916-026-05043-z. PMID 42410417 Check |pmid= value (help).
  6. ↑ 6.0 6.1 Choi KS, Jun JK, Park EC, Park S, Jung KW, Han MA, Choi IJ, Lee HY (2012). "Performance of different gastric cancer screening methods in Korea: a population-based study". PLoS One. 7 (11): e50041. doi:10.1371/journal.pone.0050041. PMID 23209638.
  7. ↑ 7.0 7.1 7.2 7.3 Chei CL, Nakamura S, Watanabe K, Saito H, Isshiki S, Tamura S, Narimatsu H (2026). "Sensitivity and specificity of endoscopic and radiographic screening for localized gastric cancer in a real-world, population-based setting". Gastric Cancer. doi:10.1007/s10120-026-01797-w.
  8. ↑ Hamashima C (2018). "Update version of the Japanese Guidelines for Gastric Cancer Screening". Jpn J Clin Oncol. 48 (7): 673–683. doi:10.1093/jjco/hyy077. PMID 29889263.
  9. ↑ 9.0 9.1 9.2 Narii N, Sobue T, Zha L, Kitamura T, Iwasaki M, Inoue M, Yamaji T, Tsugane S, Sawada N (2022). "Effectiveness of endoscopic screening for gastric cancer: The Japan Public Health Center-based Prospective Study". Cancer Sci. 113 (11): 3922–3931. doi:10.1111/cas.15545. PMID 36002149 Check |pmid= value (help).
  10. ↑ Farha N, Kumar S, Katona BW, Hüneburg R, Lynch PM, Gupta S, Burke CA (2023). "The Approach to Performance of Quality Upper Endoscopy in Lynch Syndrome (QUELS): An International Expert Statement". J Clin Gastroenterol. 57 (1).
  11. ↑ Hibino M, Hamashima C, Iwata M, Terasawa T (2023). "Radiographic and endoscopic screening to reduce gastric cancer mortality: a systematic review and meta-analysis". Lancet Reg Health West Pac. 35: 100741. doi:10.1016/j.lanwpc.2023.100741. PMID 37424675 Check |pmid= value (help).
  12. ↑ Alexandre L, Tsilegeridis-Legeris T, Lam S (2022). "Clinical and Endoscopic Characteristics Associated With Post-Endoscopy Upper Gastrointestinal Cancers: A Systematic Review and Meta-analysis". Gastroenterology. 162 (4): 1123–1135. doi:10.1053/j.gastro.2021.12.270.
  13. ↑ Gupta S, Li D, El Serag HB, Davitkov P, Altayar O, Sultan S, Falck-Ytter Y, Mustafa RA (2020). "AGA Clinical Practice Guidelines on Management of Gastric Intestinal Metaplasia". Gastroenterology. 158 (3): 693–702. doi:10.1053/j.gastro.2019.12.003. PMID 31816298.
  14. ↑ Shah SC, Piazuelo MB, Kuipers EJ, Li D (2021). "AGA Clinical Practice Update on the Diagnosis and Management of Atrophic Gastritis: Expert Review". Gastroenterology. 161 (4): 1325–1332.e7. doi:10.1053/j.gastro.2021.06.078. PMID 34454714 Check |pmid= value (help).
  15. ↑ Evans JA, Chandrasekhara V, Chathadi KV, Decker GA, Early DS, Fisher DA, Foley K, Hwang JH, Jue TL, Lightdale JR, Pasha SF, Sharaf R, Shergill AK, Cash BD, DeWitt JM (2015). "The role of endoscopy in the management of premalignant and malignant conditions of the stomach". Gastrointest Endosc. 82 (1): 1–8. doi:10.1016/j.gie.2015.03.1967. PMID 25935705.
  16. ↑ 16.0 16.1 Liou JM; et al. (2025). "Screening and eradication of Helicobacter pylori for gastric cancer prevention: Taipei Global Consensus II". Gut. 74 (11): 1767–1791. doi:10.1136/gutjnl-2025-336027. PMID 40912906 Check |pmid= value (help).
  17. ↑ Ford AC, Yuan Y, Park JY, Forman D, Moayyedi P (2025). "Eradication Therapy to Prevent Gastric Cancer in Helicobacter pylori-Positive Individuals: Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies". Gastroenterology. 169 (2): 261–276. doi:10.1053/j.gastro.2024.12.033. PMID 39824392 Check |pmid= value (help).
  18. ↑ Ford AC, Yuan Y, Moayyedi P (2020). "Helicobacter pylori eradication therapy to prevent gastric cancer: systematic review and meta-analysis". Gut. 69 (12): 2113–2121. doi:10.1136/gutjnl-2020-320839. PMID 32205420 Check |pmid= value (help).
  19. ↑ Chey WD, Howden CW, Moss SF, Morgan DR, Greer KB, Grover S, Shah SC (2024). "ACG Clinical Guideline: Treatment of Helicobacter pylori Infection". Am J Gastroenterol. 119 (9): 1730–1753. doi:10.14309/ajg.0000000000002968. PMID 39626064 Check |pmid= value (help).
  20. ↑ Invalid <ref> tag; no text was provided for refs named Sun2024

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