Surveillance for Gastric Intestinal Metaplasia to Prevent Gastric Cancer
Your patient qualifies for endoscopic surveillance every 3 years to monitor for progression to dysplasia and gastric adenocarcinoma, though the decision should involve shared decision-making given the borderline risk profile. 1, 2
What Is Being Monitored
The surveillance is specifically monitoring for:
- Progression to dysplasia (low-grade or high-grade) 1, 2
- Development of gastric adenocarcinoma (early detection when curable) 1, 3
- Staging of the extent of preneoplastic conditions 1, 2
The purpose is early cancer detection to reduce gastric cancer mortality and morbidity, as the 5-year survival rate for gastric cancer in the US is only 36%, primarily because most cases are diagnosed at advanced stages. 3
Risk Stratification for Your Patient
Your patient has intermediate-risk features that warrant consideration for surveillance:
Risk Factors Present:
- Second-degree family history of gastric cancer (4.5-fold increased risk if first-degree, lower but still elevated for second-degree) 1
- Prior H. pylori infection (the primary driver of GIM development) 4, 5
- Focal intestinal metaplasia at the incisura (a concerning location) 1
Factors That Would Clearly Mandate Surveillance:
- First-degree (not second-degree) family history of gastric cancer 1, 2
- Corpus-extended GIM (involving both antrum/incisura AND body) 1
- OLGIM stages III/IV 1, 2
- Incomplete (colonic-type) intestinal metaplasia 1, 2
- Persistent/refractory H. pylori infection 1, 2
Important Caveat:
The guidelines distinguish between first-degree and second-degree family history. First-degree relatives (parents, siblings, children) with gastric cancer clearly warrant surveillance, while second-degree relatives (grandparents, aunts, uncles) represent a lower but still elevated risk. 1 The AGA recommends shared decision-making for patients with second-degree family history. 1
Surveillance Protocol If Elected
Interval: Every 3 years with high-quality endoscopy 1, 2, 5
Technique:
- High-definition endoscopy with at least 7 minutes of careful mucosal inspection 6, 5
- Chromoendoscopy (virtual or dye-based) to guide biopsies 5
- Systematic biopsies from at least two topographic sites (antrum and corpus), labeled in separate vials 5
- At least 6-8 biopsies using standard-sized forceps 7
- Any visible lesions should be biopsied separately 1, 5
Critical Next Steps
H. pylori eradication confirmation is essential even though current biopsies are negative, as this is the only proven intervention to reduce gastric cancer risk (moderate quality evidence). 2, 3 Prior infection history means eradication should be confirmed with non-invasive testing (urea breath test or stool antigen) if not already done. 2, 5
Common Pitfalls to Avoid
- Do not assume the baseline endoscopy adequately staged the extent of GIM - the location at the incisura alone doesn't tell you if corpus involvement exists 2
- Consider repeat endoscopy within 1 year for complete risk stratification if the initial endoscopy did not include systematic mapping biopsies from antrum and corpus 1, 2
- Do not perform routine short-interval surveillance (less than 3 years) unless high-grade dysplasia or visible lesions are found 1
- Ensure pathology reports specify complete vs incomplete intestinal metaplasia as this affects risk stratification (3.3-fold increased risk for incomplete type) 1
Shared Decision-Making Considerations
The annual progression rate from GIM to gastric cancer is approximately 0.16% per year, which is lower than Barrett's esophagus progression to esophageal adenocarcinoma (0.33% per year), yet surveillance is commonly recommended for Barrett's. 1 The 5-year cumulative gastric cancer risk is approximately 1.1% for patients with GIM. 1
Patients who place high value on early cancer detection and low value on the risks/costs of surveillance endoscopy may reasonably elect for surveillance, while those with opposite preferences may decline. 1