Using gastric cancer risk to prioritise patients for endoscopy

Population-wide gastric cancer screening programmes exist in some countries, particularly in East Asia, where incidence is high. However, low incidence rates in the UK and other European countries mean such screening programmes are difficult to justify due to the high cost of testing. Despite its relatively low incidence in the UK, gastric cancer is still one of the deadliest malignancies; the age-standardised five-year survival rate is only 23 per cent.¹ Poor outcomes are driven by late diagnosis and a lack of early identification of risk factors, with studies estimating that over half of gastric cancer cases are preventable. Although large scale population-wide screening is unlikely to work effectively in the UK and Europe, identifying predefined high-risk groups using a combination of biomarkers and other risk factors as selection criteria may offer a practical and cost-effective alternative. Several peer-reviewed studies have recently been published that support this approach.

What do we know about gastric cancer risk?

Atrophic gastritis (AG) is a key precursor of gastric cancer, sitting in the middle of the Correra’s cascade, which describes the progression of the condition. The cascade begins with chronic gastritis, most commonly caused by Helicobacter pylori infection or an autoimmune condition, before transitioning to gastric atrophy and developing into cancer.

A systematic review, published in late 2024, assessed the risk of gastric adenocarcinoma – a common form of gastric cancer – developing from AG.² The review examined 18 studies, representing over 25,000 patients across the globe. Across all the studies, participants were followed for just over 220,000 person-years. During this time, 372 cases of gastric cancer were found, equating to an incidence of approximately 1.7 gastric cancers per 1,000 person-years globally. The standardised incidence ratio (SIR) was 15.1, indicating that patients with AG developed gastric cancer around 15 times more frequently than would be expected in the general population. This increase was similar in both Western (SIR 14.8) and Eastern (SIR 17.4) populations, despite the differences in overall prevalence between the groups. Together, this means that, although gastric cancer is less common in Western countries, atrophy remains a powerful indicator of markedly elevated clinical risk, making AG a clinically meaningful marker for risk stratification.

Are high-risk patients being missed in routine endoscopy?

AG and gastric intestinal metaplasia are important precancerous lesions, meaning it is essential to identify them during routine upper GI endoscopy. However, their true prevalence in routine symptomatic patients is poorly defined.

The PROSPERO study was conducted to define the prevalence of premalignant upper GI conditions in a standard endoscopy referral across 11 NHS trusts.³ The study recruited symptomatic patients referred for upper GI endoscopy who had no previous diagnosis of premalignant disease. Standardised endoscopies with systematic biopsies were compared with visual inspection and historical histological results obtained without systematic biopsy. Among the 745 patients taking part in the study, 13.6 per cent had premalignant upper GI pathology – including Barrett’s oesophagus (5.9 per cent) and AG/gastric intestinal metaplasia (7.5 per cent) – while 1.5 per cent of patients were diagnosed with upper GI cancer. Only a quarter of patients with AG/gastric intestinal metaplasia were identified endoscopically, highlighting the importance of systematic biopsy. Systematic biopsy was also better than historical histology approaches, demonstrated by an increase in diagnosis from 1.2 per cent in the historical cohort to 7.5 per cent when using the study’s systematic biopsy procedure.

Upper GI endoscopy with systematic biopsy places significant pressure on clinical time and resources, yet over 85 per cent of patients referred for this procedure have no significant pathological findings. This low diagnostic yield suggests that better risk stratification would allow invasive investigation to be avoided, freeing up capacity for more urgent cases, as well as providing answers for patients sooner. Crucially, this approach could also free up endoscopy capacity for patients indicated to be at high risk of premalignant disease to be seen more quickly.

A recent study from Finland examined how closely GastroPanel agreed with endoscopy and histology in routine gastroscopy referrals.⁴ Over 500 patients underwent GastroPanel serological testing alongside oseophagogastrodudenoscopy (OGD) and systematic gastric biopsies, with histology serving as the reference standard. The study found excellent agreement between GastroPanel and histology, while the visual endoscopy only moderately agreed with serological and histological results.

These findings add further support to previous evidence that GastroPanel has a very high negative predictive value for clinically significant AG.⁵ Although endoscopy with histology remains the gold standard approach, these results demonstrate a potential role for GastroPanel as a triage test to identify patients unlikely to benefit from invasive investigation.

Is population screening economically realistic?

Risk stratification of patients prior to endoscopy is likely to be the most cost-effective alternative to establishing a population-wide screening programme in low prevalence areas. A recent Irish study performed modelling to test if different widespread gastric cancer screening strategies were cost effective.⁶ The study compared five-yearly OGD, a non-invasive screening approach combining serological H. pylori antibody testing with pepsinogen levels, and serological testing combined with a urea breath test and H. pylori eradication.

The study found that widespread population screening was not cost effective, as none of the approaches met Ireland’s willingness-to-pay threshold of €45,000 per quality-adjusted life year (QALY). Routine endoscopy was rarely economically competitive, while the biomarker-based approaches were more cost-effective, but still failed to meet this threshold. The study concluded that, although widespread screening is not cost effective, serological testing combined with the urea breath test and H. pylori eradication targeted towards higher-risk groups could make point-of-care screening more viable.

Targeted point-of-care screening for high-risk populations

While population-wide gastric cancer screening is unlikely to be practical or cost-effective in the UK and most of Europe, there is an increasingly body of evidence supporting a more targeted approach. Recent research shows that AG is a strong predictor of gastric cancer risk, premalignant gastric lesions are more common than previously recognised, and that many are missed during routine endoscopy without systematic biopsy. Validated serological biomarker panels such as GastroPanel offer a non-invasive way of determining if patients are low or high risk, helping to prioritise those most likely to benefit from costlier, gold-standard examinations.

Endoscopy services in the UK are balancing rising demand with limited capacity, meaning that risk-based stratification has the potential to improve early detection while making more efficient use of clinical resources. Although biomarker-based approaches cannot replace endoscopy, they are likely to play an increasingly critical role as a part of wider pathway changes, supporting clinical decision making at the point of care.

Learn more about how GastroPanel can reduce pressure on endoscopy services.

References

1. NHS England. Cancer Survival in England, cancers diagnosed 2015 to 2019, followed up to 2020. . https://digital.nhs.uk/data-and-information/publications/statistical/cancer-survival-in-england/cancers-diagnosed-2015-to-2019-followed-up-to-2020 (2020).
2. Burke, E., Harkins, P. & Arumugasamy, M. Incidence of Gastric Adenocarcinoma in Those With Gastric Atrophy: A Systematic Review. Cureus https://doi.org/10.7759/cureus.71768 (2024) doi:10.7759/cureus.71768.
3. Hadjinicolaou, A. V et al. O76 Prevalence of premalignant upper GI conditions and associated risk factors in upper GI endoscopy population: data from the PROSPERO study. in Oral Presentations A50.2-A51 (BMJ Publishing Group Ltd and British Society of Gastroenterology, 2025). doi:10.1136/gutjnl-2025-BSG.75.
4. Koivurova, O. P. et al. Uniformity Between Serological Biomarker Test, Esophago‐gastro‐duodenoscopy and Biopsy Histology in Triage of Upper Abdominal Symptoms in Gastroscopy Referral Patients. Anticancer Res. 45, 5491–5501 (2025).
5. Papadia, C. et al. Can GastroPanel be used as a triage tool to select patients with advanced atrophic gastritis for gastroscopy? A prospective clinical validation study. BMJ Open Gastroenterol. 12, e001559 (2025).
6. Burke, E., Harkins, P. & Arumugasamy, M. SRS201-Gastric Cancer Screening: Cost-Effectiveness of Endoscopy and Point-of-Care Testing in Ireland. https://academic.oup.com/bjs/article/113/Supplement_2/znag018.188/8551237.