From age 45, get screening gastroscopy if you live in an area with high stomach or esophageal cancer rates, have a family history, or test positive for H. pylori

Standard gastroscopy costs a few hundred yuan; sedation adds another few hundred, with prices varying locally. You must fast beforehand, and the visit takes about half a day. If you choose sedation, someone must accompany you. The uncomfortable part is the few minutes when the tube passes through your throat.

China's National Health Commission defined high-risk groups in its 2024 protocols as people aged at least 45 who meet any of the following criteria. First, living in a county with high stomach or esophageal cancer incidence: an age-standardized rate above 20 per 100000 for stomach cancer or above 15 per 100000 for esophageal cancer. Second, a parent, child, or sibling with the relevant cancer. Third, a positive H. pylori test, which applies only to stomach cancer. Fourth, smoking, heavy drinking, a high-salt diet, or frequent pickled foods; for esophageal cancer, frequent very hot foods or drinks are also included. Fifth, a history of conditions such as atrophic gastritis, gastric ulcers, gastric polyps, Barrett's esophagus, or reflux esophagitis. Screening is generally for ages 45–74, with gastroscopy preferred, normally once every 5 years. The 2022 national guideline explicitly does not recommend stomach cancer screening outside high-risk groups. A study in 6 high-incidence areas of China followed about 637500 people aged 40–69. Compared with people not invited, those who underwent one gastroscopy had about 57% lower upper gastrointestinal cancer mortality (RR 0.43, 95% CI 0.40–0.47). Upper gastrointestinal cancer incidence was about 23% lower (RR 0.77). Only 33.53% of those invited actually underwent the examination. Counting everyone invited, mortality was about 31% lower (RR 0.69, 95% CI 0.66–0.72). Another study in villages with high esophageal cancer incidence used nonrandomized groups and 10 years of follow-up. Cumulative esophageal squamous cell carcinoma mortality was 3.35% in the screening group and 5.05% in the control group. In South Korea's national screening program, people who underwent gastroscopy had an odds ratio for gastric-cancer death of 0.53 (OR 0.53; 95% CI 0.51–0.56). This is a rare outcome, so the odds ratio is close to relative risk, corresponding to about 47% lower risk. No difference was detected with barium examinations (OR 0.98). More frequent gastroscopy was associated with lower risk. Pooling 10 Asian studies, people who underwent gastroscopy had about 40% lower stomach cancer mortality (RR 0.60, 95% CI 0.49–0.73), without a detectable change in stomach cancer incidence. A village-randomized trial in northern China enrolled 33800 people aged 45–69 and followed them for 9 years. Assignment to screening was associated with about 18% lower esophageal cancer mortality (HR 0.82, 95% CI 0.53–1.26), still within statistical uncertainty. Incidence was about 19% lower (HR 0.81, 95% CI 0.60–1.09), also not significant. A 2023 meta-analysis adjusted for the bias that people who seek screening are already healthier. Among those actually undergoing gastroscopy, stomach cancer mortality was about 48% lower (RR 0.52, confidence interval 0.39–0.79). Across the whole screening program, the estimate was only RR 0.94 (confidence interval 0.71–1.28), with no detectable effect. (China / South Korea / Asia)

国家卫生健康委办公厅 (2024). 关于印发食管癌筛查与早诊早治方案（2024年版）和胃癌筛查与早诊早治方案（2024年版）的通知（国卫办医急函〔2024〕200号）. https://www.nhc.gov.cn/wjw/c100378/202406/7008ffe1c77d4457ac73361be75760c7.shtml（附件全文转载：广东省疾病预防控制中心 https://cdcp.gd.gov.cn/jkjy/jkzt/mxfcrxjbfz/content/mpost_4444507.html）；赫捷, 陈万青, 李兆申, 等 (2022). 中国胃癌筛查与早诊早治指南（2022，北京）. 中国肿瘤, 31(7), 488-527（临床问题 7、13）. https://doi.org/10.11735/j.issn.1004-0242.2022.07.A002（同文刊于中华肿瘤杂志, 44(7), 634-666. https://doi.org/10.3760/cma.j.cn112152-20220617-00430）；Chen R, Liu Y, Song G, et al. (2021). Effectiveness of one-time endoscopic screening programme in prevention of upper gastrointestinal cancer in China: a multicentre population-based cohort study. Gut, 70(2), 251-260. https://doi.org/10.1136/gutjnl-2019-320200；Wei WQ, Chen ZF, He YT, et al. (2015). Long-Term Follow-Up of a Community Assignment, One-Time Endoscopic Screening Study of Esophageal Cancer in China. Journal of Clinical Oncology, 33(17), 1951-1957. https://doi.org/10.1200/JCO.2014.58.0423；Jun JK, Choi KS, Lee HY, et al. (2017). Effectiveness of the Korean National Cancer Screening Program in Reducing Gastric Cancer Mortality. Gastroenterology, 152(6), 1319-1328.e7. https://doi.org/10.1053/j.gastro.2017.01.029；Zhang X, Li M, Chen S, et al. (2018). Endoscopic Screening in Asian Countries Is Associated With Reduced Gastric Cancer Mortality: A Meta-analysis and Systematic Review. Gastroenterology, 155(2), 347-354.e9. https://doi.org/10.1053/j.gastro.2018.04.026；Liu M, Yang W, Guo C, et al. (2024). Effectiveness of Endoscopic Screening on Esophageal Cancer Incidence and Mortality: A 9-Year Report of the Endoscopic Screening for Esophageal Cancer in China (ESECC) Randomized Trial. Journal of Clinical Oncology, 42(14), 1655-1664. https://doi.org/10.1200/JCO.23.01284；Hibino M, Hamashima C, Iwata M, Terasawa T. (2023). Radiographic and endoscopic screening to reduce gastric cancer mortality: a systematic review and meta-analysis. The Lancet Regional Health – Western Pacific, 35, 100741. https://doi.org/10.1016/j.lanwpc.2023.100741

Controversy: most evidence that gastroscopy reduces mortality compares people who volunteer for screening with people who are not screened. Those who seek screening already tend to be more health-conscious, so the benefits may be overestimated. The 2023 meta-analysis rated these studies' risk of bias as moderate to serious. In the village-randomized esophageal cancer trial, the mortality difference at 9 years remained within statistical uncertainty. The 2022 guideline lists harms including overdiagnosis, false positives, missed diagnoses, bleeding, perforation, cardiopulmonary events, aspiration pneumonia, and infection. Overdiagnosis means finding a cancer that would never cause symptoms during a person's lifetime. The protocol explicitly allows anesthesia or sedation for people unable to tolerate standard gastroscopy. People aged 45 and older who test positive for H. pylori already qualify as being at high risk for stomach cancer. For eradication, see Item 23 (test for H. pylori and eradicate it if positive), but eradication does not replace gastroscopy; both are needed. The protocols do not recommend barium examinations, pepsinogen testing alone, tumor markers, or PET for screening. For tumor marker packages, see Section 6, Item 7 (whole-body PET-CT and tumor marker packages). If atrophic gastritis, intestinal metaplasia, or intraepithelial neoplasia is found, follow-up should be more frequent, as directed by your doctor. Ask your local disease control center or county hospital whether your county is a high-incidence area. If you already have difficulty swallowing, you need medical assessment rather than screening; see Section 34, Item 6 (go directly to hospital for difficulty swallowing, vomiting blood, or black stools). If you are already vomiting blood or passing black, tarry stools, go to the emergency department that same day; see Section 13, Item 49 (tarry stools). If you like very hot tea, see Section 2, Item 30 (let hot drinks cool before drinking). The main beneficiary is you, and your parents can benefit too. Site editorial note: Hibino et al. (2023) rated the risk of bias in studies of newly introduced screening programs as moderate to critical; all cohort and case-control studies of ongoing screening programs were rated critical, not merely serious at worst. These ratings concern the risk that systematic bias affects study results, not the severity of gastroscopy complications. Original paper: https://doi.org/10.1016/j.lanwpc.2023.100741 .