ABSTRACT

Background Gastric cancer remains a major cause of cancer mortality worldwide, including in intermediate-risk countries. While endoscopic screening has proven effective in high-risk populations, its impact and economic value in intermediate-risk settings remain uncertain.

Objective This systematic review and meta-analysis aimed to evaluate the effectiveness and cost-effectiveness of endoscopic screening for gastric cancer in these countries.

Design A systematic review and meta-analysis was conducted following a comprehensive search in Medline, Scopus, Embase, and Web of Science, covering studies published up to 30 September 2024. A random-effects meta-analysis was performed for effectiveness studies, and economic evaluations were synthesised narratively. The study registration number at PROSPERO is CRD42024502174.

Results Thirty-two studies met inclusion criteria—24 on screening effectiveness and eight on cost-effectiveness. Across the 24 effectiveness studies, 404,159 individuals underwent upper endoscopic screening, which significantly increased detection of precancerous lesions (pooled effect size: 28%, p < 0.001) and early-stage gastric cancer among neoplasms (73.6%, p < 0.001). Screening was also associated with a 26.1% reduction in gastric cancer mortality and improved five-year survival (63.7% to 85.0%). Economic analyses suggested endoscopic screening is cost-effective in intermediate-risk settings, particularly when combined with colorectal cancer screening.

Conclusions Endoscopic screening improves early detection and survival in intermediate-risk countries. Cost-effectiveness studies support its feasibility, especially when integrated with colorectal cancer screening or risk-stratified strategies.

What is already known on this topic Endoscopic screening reduces gastric cancer mortality in high-risk countries. Evidence in intermediate-risk settings remains limited.

What this study adds This review shows that endoscopic screening improves early detection and gastric cancer prognosis in intermediate-risk countries and is cost-effective in several models.

How this study might affect research, practice or policy Findings support implementing screening where cost-effectiveness is demonstrated, aligning with ESGE MAPS III recommendations.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

The costs associated with the submission and potential publication of this manuscript will be covered by the lead author and her research consultancy, TrueConnection Lda. The funder had no role in the design, conduct, analysis, interpretation, or writing of the study, and holds no commercial or financial interest in its findings or outcomes.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

Footnotes

↵a Contacts: email: mbb.mouratoensp.unl.pt; Address: Hospital Doutor José Maria Grande, Avenida de Santo António, 7300-853, Portalegre

Contributions: conceptualization, designing, investigation, formal analysis and writing the manuscript;

↵b Contacts: email: nuno.pratasulsaale.min-saude.pt; Address: Hospital Doutor José Maria Grande, Avenida de Santo António, 7300- 853, Portalegre;

Contributions: provided assistance with protocol design, investigation, and writing;

↵c Contacts: email: andreia.b.pereiraulsaale.min-saude.pt; Address: Hospital Doutor José Maria Grande, Avenida de Santo António, 7300- 853, Portalegre;

Contributions: for investigation, and reviewing the writing of the manuscript;4

↵d Contacts: raphael.chancainca.gov.br; Address:

Contributions: designing the search expression in the various databases;

↵e Contacts: email: ines.fronteiraensp.unl.pt; Address: Avenida Padre Cruz, 1600-560 Lisboa;

Contributions: protocol design, systematic review process supervision, and manuscript review;

↵f Contacts: email: ruidinigmail.com; Address: Largo do Sr. Da Probreza, 7000-811 Évora;

Contributions: revision of the manuscript;

↵g Contacts: email: miguel.areia75gmail.com; Address: Avenida Bissaya Barreto 98, 3000-075 Coimbra.

Contributions: protocol design, systematic review process supervision, and manuscript review.

Funding: This study is supported by the main author and her company, TrueConnection Lda.

Data Availability

All data generated or analysed during this study are included in this published article (and its supplementary information files).

LIST OF ABBREVIATIONSAIArtificial IntelligenceCIConfidence IntervalEGCEarly Gastric CancerEGDEsophagogastroduodenoscopyGCGastric CancerHPHelicobacter pyloriICERIncremental Cost-Effectiveness RatioQALYQuality-Adjusted Life-YearWTPWillingness-To-Pay