The American College of Gastroenterology has published its first-ever guidelines on the diagnosis and management of gastric premalignant conditions, addressing a significant gap in clinical practice for conditions that can progress to gastric adenocarcinoma.

Published in The American Journal of Gastroenterology, the guidelines provided evidence-based recommendations for endoscopic surveillance among high-risk patients; the performance of high-quality endoscopy for diagnosis; histologic assessment criteria; and treatment strategies for gastric atrophy, gastrointestinal metaplasia (GIM), dysplasia, and certain gastric epithelial polyps.

The guidelines emphasized that gastric cancer in the United States represents a critical health disparity, with incidence rates two- to 13-fold greater in non-White individuals, particularly early-generation immigrants from high-incidence regions.

"Gastric cancer (GC) in the [United States] represents an important cancer disparity because incidence rates are ... particularly [higher among] early-generation immigrants from regions of high GC incidence," the guideline authors stressed. "The U.S. 5-year survival rate for GC is 36%, which falls short of global standards and is driven by the fact that only a small percentage of GC in the [United States] is diagnosed in the early, curable stage," they added.

The guidelines contained 22 formal recommendations across seven domains:

GC screening (two recommendations):

• Against routine screening with upper endoscopy for GC and gastric premalignant conditions (GPMC) in the general U.S. population (very low quality of evidence, conditional recommendation).
• No recommendation on opportunistic screening for GC and GPMC with upper endoscopy in high-risk individuals as a result of insufficient direct evidence from U.S. populations (insufficient evidence, no recommendation).

GPMC Noninvasive Diagnosis (one recommendation):

• Against the use of noninvasive biomarkers for GPMC or GC screening or surveillance (very low quality of evidence, conditional recommendation).

GPMC Endoscopic Diagnosis (two recommendations):

• High-quality endoscopic evaluation of the stomach to identify GPMC, including adequate mucosal visualization with cleansing and insufflation, visual station mapping, photodocumentation, and adequate gastric evaluation time (low quality of evidence, strong recommendation).
• Use of high-definition white light endoscopy (HDWLE) and image-enhanced endoscopy (IEE) for gastric examination (low quality of evidence, conditional recommendation).

GPMC Histologic Diagnosis (three recommendations):

• Systematic gastric sampling according to the updated Sydney biopsy protocol, with separate containers for antrum/incisura and corpus (low quality of evidence, conditional recommendation).
• Reporting the histologic subtype of GIM (incomplete, complete, and mixed) for risk stratification (low quality of evidence, conditional recommendation).
• Reporting the anatomic extent and severity of GIM for risk stratification (very low quality of evidence, conditional recommendation).

GPMC Surveillance (three recommendations):

• Endoscopic surveillance at 3-year intervals for high-risk patients with GIM, including those with incomplete GIM, corpus-extension, family history of GC, foreign-born status from high-incidence regions, or high-risk race/ethnicity (very low quality of evidence, conditional recommendation).
• Endoscopic surveillance at 3-year intervals for severe GIM or atrophic gastritis (very low quality of evidence, conditional recommendation).
• Against endoscopic surveillance for low-risk GIM or atrophy (very low quality of evidence, conditional recommendation).

Endoscopic Management of Dysplastic GPMC (four recommendations):

• Endoscopic resection for dysplasia with visible margins in clinically appropriate patients (low quality of evidence, conditional recommendation).
• Repeat endoscopic evaluation with HDWLE and IEE by an experienced endoscopist for dysplasia without visible margins (low quality of evidence, conditional recommendation).
• Referral to high-volume centers with appropriate expertise for endoscopic resection of dysplasia, particularly endoscopic submucosal dissection (low quality of evidence, strong recommendation).
• Endoscopic surveillance after confirmed complete resection of dysplasia, performed by an experienced endoscopist using HDWLE and IEE with systematic and targeted biopsies (low quality of evidence, strong recommendation).

GPMC Nonendoscopic Management (two recommendations):

• Testing for Helicobacter pylori (and eradication if positive) in patients with GPMC and resected early GC (moderate quality of evidence, strong recommendation).
• Against the use of aspirin, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, or antioxidants for GC chemoprevention in patients with GPMC (very low quality of evidence, conditional recommendation).

Special Topics: Autoimmune Gastritis and Gastric Epithelial Polyps (five recommendations):

• H pylori testing using nonserologic methods, eradication treatment if positive, and confirmation of eradication in patients with autoimmune gastritis (low quality of evidence, strong recommendation).
• Individualized surveillance may be considered for autoimmune gastritis because of an increased risk of type 1 neuroendocrine tumors and possible GC risk (low quality of evidence, conditional recommendation).
• Endoscopic resection of all gastric adenomas, regardless of size, with surgical referral if endoscopic resection not feasible (low quality of evidence, conditional recommendation).
• No recommendation on endoscopic resection of hyperplastic polyps greater than 10 mm (insufficient evidence, no recommendation).
• Systematic gastric biopsies of surrounding flat mucosa in patients with gastric epithelial polyps (excluding fundic gland polyps) as a result of high prevalence of GPMC, H pylori, and autoimmune gastritis (very low quality of evidence, conditional recommendation).

The guidelines acknowledged limitations in the current evidence base, particularly from U.S. populations. The guideline authors noted: "Extensive high-quality data from U.S. populations regarding GPMC management are lacking, but continue to accrue, and the quality of evidence for the recommendations presented herein should be interpreted with this dynamic context in mind."

The panel outlined a broad research agenda that included high-quality prospective studies on opportunistic screening, refinement of risk stratification, development of biomarkers, implementation of training programs, and evaluation of intervention impacts on GC outcomes in the United States.

These guidelines represented a significant shift in U.S. clinical practice for gastric premalignant conditions. Their implementation aims to address the marked GC disparity affecting minority and immigrant populations by reducing cancer incidence, increasing detection of early-stage disease, and improving 5-year survival rates.

For clinicians, the guidelines may provide concrete targets for training and quality initiatives in the endoscopic management of GPMC, with potential to significantly improve outcomes for high-risk patients.

Conflict of interest disclosures can be found in the guidelines.