Optimising endoscopic yield in gastric cancer detection

Most patients referred for upper GI endoscopy do not have significant pathologies, yet some patients with early gastric cancer are still being missed. A simple blood test could help to identify patients who may be at increased risk of premalignant conditions before endoscopy. At BSG LIVE’26, Andreas Hadjinicolaou, Consultant Gastroenterologist at Addenbrooke’s Hospital and Lecturer in Gastroenterology and Endoscopy at the University of Cambridge, discussed research showing how gastric serum biomarkers detected with GastroPanel® can be used to identify premalignant stomach changes. In this blog, we outline his conclusions and share how biomarker testing could be used to optimise endoscopic yields in gastric cancer detection.

The importance of early gastric cancer detection

Gastric cancer has a very poor five-year survival rate of approximately 20 per cent,¹ largely due to late diagnoses. However, when the disease is identified at stage I, the five-year survival rate increases dramatically to 65 per cent,¹ highlighting the life-saving potential of earlier detection.

Fortunately, gastric cancer does not develop overnight. It typically progresses through a well-defined sequence of precancerous conditions – chronic gastritis, atrophic gastritis, intestinal metaplasia and dysplasia – creating a valuable window of opportunity to detect disease before it becomes malignant. Identifying these premalignant changes is important not only for reducing the risk of gastric cancer, but also because conditions such as gastric atrophy are associated with a range of other serious health complications, including:

• Pernicious anaemia secondary to vitamin B12 deficiency
• Iron deficiency
• Trace element deficiency, such as zinc, magnesium and calcium
• Gastric neuroendocrine tumours (NETs), which can metastasise as a result of increased gastrin levels

Competing problems in gastric atrophy diagnosis

Early identification of premalignant gastric conditions is essential, as it allows patients to enter monitoring or treatment before the disease progresses to gastric cancer. Endoscopy is the gold standard for diagnosis, but this presents several challenges that make early detection difficult in routine clinical practice.

High volumes of routine upper GI endoscopies place significant pressure on clinical time and resources, especially as yields are very low. The PROSPERO study estimated that only 15 per cent of patients referred for upper GI endoscopy had clinically significant pathological findings,² suggesting that around 85 per cent of patients could potentially avoid, or safely delay, an invasive investigation through better risk stratification. Similar findings were reported by the National Endoscopy Database, which showed that around 75 per cent of endoscopies are performed in patients with a pre-test cancer risk of less than one per cent.³ This data highlights a clear opportunity to improve the efficiency of endoscopy services by identifying low-risk patients before referral, reducing unnecessary procedures and allowing endoscopy capacity to be focused on those most likely to benefit.

At the same time, increasing service pressures may be affecting the quality of endoscopic examinations themselves. In England, approximately 8.5 per cent of upper gastrointestinal cancers are diagnosed after a previous endoscopy failed to detect the disease – known as post-endoscopy upper gastrointestinal cancer (PEUGIC).⁴ These represent missed opportunities for earlier diagnosis, when treatment is more likely to be successful. As endoscopists face growing workload and time pressures, maintaining the consistent high quality of examinations becomes more challenging.

The following real-world scenarios illustrate both parts of the problem.

Case 1: low-yield, difficult procedure

• A 26-year-old patient presented with abdominal pain and bloating
• They were previously diagnosed with IBS and fibromyalgia
• Upper GI endoscopy proved extremely difficult due to severe anxiety. Sedation was ineffective, the patient repeatedly retched and required constant reassurance

Endoscopy was normal, CLO test was negative. Could this difficult procedure have been avoided?

Case 2: missed gastric cancer

• A 66-year-old female presented with abdominal pain, nausea and early satiety
• Her visit took place at the end of a busy day
• She was diagnosed with gastritis following endoscopy, so neither biopsies nor enhanced imaging were used

The patient returned two years later with ongoing symptoms, anorexia, weight loss and now advanced gastric cancer. Earlier identification may have enabled diagnosis at a more treatable stage.

The CyGIM study at Addenbrooke’s Hospital and the University of Cambridge is exploring this approach, evaluating biomarkers for detecting premalignant stomach changes using GastroPanel and capsule sponge technology. Unpublished findings demonstrate a strong correlation between GastroPanel’s pepsinogen I/II ratio and the Operative Link on Gastritis Assessment (OLGA) staging system, which is used to estimate gastric cancer risk. No patients with low-risk OLGA stages 0-I had a positive pepsinogen ratio, while all patients with high-risk stages III-IV tested positive, demonstrating excellent discrimination between clinically-relevant and non-significant gastric atrophy. These findings align with BSG guidance, which states that serum pepsinogen I and the pepsinogen I/II ratio – alone or in combination with H. pylori serology and gastrin-17 – can identify individuals with extensive atrophic gastritis.5

A more targeted approach to gastric cancer diagnosis

The question around serum gastric biomarkers is no longer simply whether they can detect gastric atrophy; this is already well understood in literature. Instead, the focus should be on how they can improve clinical pathways. The use of biomarker testing and targeted referrals has the potential to reduce the number of low-risk, low-yield endoscopy procedures, helping to move pathways from symptom-driven to risk-informed triage for better service provision and more streamlined patient care. GastroPanel can also support endoscopists in performing a more targeted examination and taking appropriate biopsies where indicated. This has the potential to improve the detection of atrophic gastritis, reduce missed cases and enable more confident identification of patients at risk of developing gastric cancer.

References

1. Cancer Research UK. (2026). Survival for stomach cancer. Accessed 10th of July 2026. https://www.cancerresearchuk.org/about-cancer/stomach-cancer/survival
2. Hadjinicolaou, A. V., et al. (2025). O76 Prevalence of premalignant upper GI conditions and associated risk factors in upper GI endoscopy population: data from the PROSPERO study.
3. Beaton, D. R., et al. (2024). Diagnostic yield from symptomatic gastroscopy in the UK: British Society of Gastroenterology analysis using data from the National Endoscopy Database. Gut, 73(9), 1421-1430.
4. Kamran, U., et al (2025). The variation in post-endoscopy upper gastrointestinal cancer rates among endoscopy providers in England and associated factors: a population-based study. Endoscopy, 57(01), 17-28.
5. Banks, M., et al. (2019). British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma. Gut, 68(9), 1545-1575.