Is surveillance endoscopy recommended for individuals with a second-degree relative with gastric cancer?

Surveillance Endoscopy for Second-Degree Relatives with Gastric Cancer

Surveillance endoscopy is not routinely recommended for individuals who only have a second-degree relative with gastric cancer, unless additional risk factors are present. 1

Risk Stratification for Gastric Cancer Surveillance

The British Society of Gastroenterology guidelines and other major gastroenterology societies focus surveillance recommendations primarily on:

1. First-degree relatives with gastric cancer (not second-degree)
2. Presence of premalignant conditions (extensive gastric atrophy or intestinal metaplasia)
3. Hereditary cancer syndromes with specific genetic mutations

When to Consider Surveillance for Second-Degree Relatives

While having only a second-degree relative with gastric cancer is not sufficient to warrant routine surveillance, endoscopic screening may be considered if additional risk factors are present:

• Multiple risk factors including:
  • H. pylori infection (current or past)
  • Early-generation immigrant from high-incidence regions (Eastern Europe, Andean Latin America, East Asia)
  • Non-white racial/ethnic groups from high-incidence regions
  • Age ≥45 years 1

Evidence-Based Approach

The British Society of Gastroenterology guidelines specifically recommend:

• Surveillance endoscopy every 3 years for patients with extensive gastric atrophy or intestinal metaplasia affecting both antrum and body 1
• No surveillance for those with limited gastric atrophy/intestinal metaplasia (antrum only) unless additional risk factors like strong family history or persistent H. pylori infection 1

For individuals with hereditary cancer syndromes:

• Specific surveillance protocols exist for conditions like Hereditary Diffuse Gastric Cancer (HDGC) with CDH1 mutations 1
• Familial Intestinal Gastric Cancer (FIGC) has less robust recommendations but may warrant consideration in families with clustering of intestinal-type gastric cancer 1

Practical Algorithm for Second-Degree Relatives

1. Assess additional risk factors:

   • H. pylori status (test and eradicate if positive)
   • Geographic origin/ethnicity (high vs. low risk regions)
   • Personal history of premalignant gastric conditions

2. If no additional risk factors: Routine surveillance not recommended

3. If additional risk factors present:

   • Consider baseline endoscopy at age 45 or 10 years before the youngest affected relative's diagnosis 2
   • If baseline endoscopy normal: No routine surveillance needed
   • If premalignant conditions found: Follow standard surveillance protocols based on findings

Important Considerations

• H. pylori eradication is the most important preventive strategy for those with family history of gastric cancer 3
• The synergistic effect of H. pylori infection and family history significantly increases gastric cancer risk 2
• Early H. pylori eradication (ideally in 20s-30s) may prevent progression to intestinal metaplasia 3

Common Pitfalls to Avoid

• Over-surveillance: Performing unnecessary endoscopies in low-risk individuals wastes resources and exposes patients to procedural risks
• Under-surveillance: Missing high-risk individuals who have multiple risk factors beyond just a second-degree relative
• Neglecting H. pylori testing: All individuals with family history of gastric cancer should be tested and treated for H. pylori infection

In summary, having only a second-degree relative with gastric cancer is not sufficient to warrant routine endoscopic surveillance, but should prompt assessment for additional risk factors that might justify screening.