Screening Recommendations for Family History of Gastric Cancer
For individuals with a family history of gastric cancer, endoscopic screening should be initiated 10 years before the age of onset in the affected relative or by age 40 at the latest, with surveillance intervals determined by specific risk factors and endoscopic findings.
Risk Stratification for Gastric Cancer Screening
Hereditary Diffuse Gastric Cancer (HDGC)
CDH1 genetic testing is recommended for individuals meeting any of the following criteria 1:
- Two or more documented cases of gastric cancer in first/second-degree relatives, with at least one confirmed diffuse gastric cancer
- Personal history of diffuse gastric cancer before age 40
- Personal or family history of diffuse gastric cancer and lobular breast cancer, with one diagnosed before age 50
For confirmed CDH1 mutation carriers 1:
- Annual endoscopic surveillance for those under age 20
- Prophylactic total gastrectomy recommended between ages 20-30
- For those declining gastrectomy: annual endoscopic surveillance with minimum 30 random biopsies
Non-Hereditary Family History
First-degree relatives with gastric cancer 1:
First-generation immigrants from high-incidence regions 1:
- Begin screening at age 45
- Screening interval determined by findings
Endoscopic Screening Protocol
High-Quality Endoscopic Examination
- Technical requirements 1:
- High-definition white-light endoscopy with image enhancement
- Adequate gastric mucosal cleansing and insufflation
- Systematic biopsy protocol for mucosal staging
Biopsy Protocol
- For suspected gastric atrophy/intestinal metaplasia 1:
- Minimum 5 total biopsies following updated Sydney System
- Separate labeling of samples from antrum/incisura and corpus
- Additional biopsies of any suspicious areas
Risk Reduction Strategies
H. pylori Management
- All individuals with family history of gastric cancer should be tested for H. pylori 1, 3
- Eradication therapy should be initiated when H. pylori is detected, ideally by age 20 before precancerous lesions develop 3
- Consider testing adult household members of H. pylori-positive individuals 1
Surveillance After Initial Screening
If no atrophy, intestinal metaplasia, or neoplasia is found 1:
- Continue screening if multiple risk factors or family history exists
- Optimal interval not well defined but generally every 2-3 years
If precancerous lesions are found 1:
- Follow surveillance intervals based on histologic staging
- Document presence/absence of H. pylori, severity of atrophy/metaplasia
Special Considerations
Age-Based Recommendations
- For individuals with affected parent diagnosed before age 50 2:
- Begin screening approximately 10 years earlier than average
- Those with affected fathers develop gastric cancer approximately 10.4 years earlier than those without family history
- Those with affected mothers develop gastric cancer approximately 9.5 years earlier
Common Pitfalls to Avoid
- Inadequate endoscopic technique: Ensure proper mucosal visualization and systematic biopsy protocol
- Failure to test for H. pylori: Essential component of risk reduction
- Overlooking specific family history details: Age of onset in affected relatives significantly impacts screening initiation
- Insufficient biopsies: Random sampling may miss focal lesions; minimum 30 biopsies recommended for HDGC surveillance
Conclusion
Family history of gastric cancer significantly increases risk, with specific patterns depending on relationship to affected relatives and age of onset. Endoscopic screening with appropriate biopsy protocols remains the gold standard for early detection, with timing based on specific risk factors and family history patterns.