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Epidemiology of gastric cancer

Epidemiology of gastric cancer
Literature review current through: Jan 2024.
This topic last updated: Jul 24, 2023.

INTRODUCTION — Gastric cancer has been described as early as 3000 BC in hieroglyphic inscriptions and papyri manuscripts from ancient Egypt. The first major statistical analysis of cancer incidence and mortality (using data gathered in Verona, Italy from 1760 to 1839) showed that gastric cancer was the most common and lethal cancer. It has remained one of the most important malignant diseases, with significant geographic and regional differences in distribution.

Gastric adenocarcinomas are primarily classified topographically as cardia (proximal or upper stomach) and non-cardia (lower stomach) based on their anatomic site (figure 1). Cancers of the gastric cardia arise in the region adjoining the esophageal-gastric junction and thus share epidemiologic characteristics with esophageal adenocarcinoma (EAC). Non-cardia cancer, also known as distal stomach cancer, is more common and arises in the lower portion of the stomach.

The epidemiology of gastric cancer is presented here. Risk factors for gastric cancer are presented separately. (See "Risk factors for gastric cancer".)

INCIDENCE

Global incidence — Gastric cancer is the fifth leading cause of cancer worldwide [1]. Global and country-specific incidence rates are available in the World Health Organization GLOBOCAN database (figure 2) [2].

The incidence of gastric cancer varies worldwide by geographic region as follows:

The highest incidence rates are in Eastern Asia (Mongolia, China, South Korea, and Japan), the Andean regions of South America, and Eastern Europe [3].

The lowest incidence rates are in North America, Northern Europe, and most countries in Africa and South Eastern Asia [4]. In the United States, over 26,000 patients are diagnosed with gastric cancer annually, and over 11,000 are expected to die from this disease [5].  

A majority (over 70 percent) of gastric cancers occur in resource-limited countries [4].

Notably, the global incidence of gastric cancer has declined rapidly over the past few decades [6-10]. Part of the decline may be due to the recognition of certain risk factors such as Helicobacter pylori and other dietary and environmental risks. However, the decline clearly began before the discovery of H. pylori. The popularization of refrigerators marks a pivotal point for the decline in incidence [11,12]. It is hypothesized that refrigerators improved the storage of food, thereby reducing salt-based preservation of food and preventing bacterial and fungal contamination. Refrigeration also allowed for fresh food and vegetables to be more readily available, which may be a valuable source of antioxidants important for cancer prevention. (See "Risk factors for gastric cancer", section on 'Environmental risk factors'.)

The rate of decline in the incidence of gastric cancer also varies between countries and regions. The decline first took place in countries with low gastric cancer incidence such as the United States (beginning in the 1930s), while the decline in countries with high incidence like Japan was slower. In the United Kingdom, there has been a consistent decline in incidence of gastric cancer, with a reduction in relative risk from 1.14 in 1971 to 1975 to 0.84 in 1996 to 2000 in males, and 1.18 in 1971 to 1975 to 0.81 in 1996 to 2000 in females [13]. In China, the decline has been less dramatic as compared with other countries. Despite an overall decrease in gastric cancer incidence in China, the incidence of early-onset gastric cancer is increasing [3]. The decreasing trends in age-standardized incidence and mortality rates have been more pronounced in females than in males [3].

Regional variation — Regional variations in the incidence of gastric cancer have also been observed, as follows:

Migration patterns – Migration, and in particular, international migration, can lead to a change in risk, as the immigrants, especially second and third generations, adopt the lifestyle and consequently the local disease patterns. Emigrants from high-incidence to low-incidence countries often experience a decreased risk of developing gastric carcinoma. Such findings strongly suggest that environmental factors have an important role in the etiology of gastric cancer and that exposure to risk factors occurs early in life. Studies of Japanese migrants to the Unites States have confirmed that early exposure to environmental rather than genetic factors have a greater influence on mortality and incidence rates [14,15]. In the subsequent generations born in the United States, the mortality rate declined towards the lower rate of White Americans.

Regional variation from north to south – A difference in incidence and mortality from north to south has been observed in several countries, with the northern areas having a higher mortality risk than those in the south. This gradient is particularly marked in the northern hemisphere [16-18], whereas in the southern hemisphere, the mortality risk tends to be higher in the southern parts [19,20]. In Japan, there appears to be a north/south divide, with gastric cancer mortality and incidence higher in the northeastern prefectures [21]. In England and Wales, there is a twofold difference in mortality and incidence rates across the country, with lower levels in the south and east and higher levels in the north and west, particularly noticeable in northwest Wales [22]. In China, the incidence and mortality of gastric cancer varies from province to province (generally very high in the north, but relatively low in the south) [18,23].

Sex — The incidence of gastric cancer is higher in males than in females, in both resource-abundant and resource-limited countries (figure 2).

Time trends

Changes in histologic pattern — The two main histologies of gastric cancer are intestinal and diffuse type. These histologies represent two biological entities that differ with regard to epidemiology, etiology, pathogenesis, and behavior. (See "Gastric cancer: Pathology and molecular pathogenesis", section on 'Intestinal versus diffuse types'.):

Intestinal type – Intestinal gastric cancer is more common in males and older age groups. It is more prevalent in high-risk areas and is likely linked to environmental factors.

Diffuse type – The diffuse or infiltrative type is equally frequent in both sexes, is more common in younger age groups, and has a worse prognosis than the intestinal type.

There has been a worldwide decline in the incidence of the intestinal type that parallels the overall decline in the incidence of gastric cancer. By contrast, the decline in the diffuse type has been more gradual. As a result, the diffuse type now accounts for approximately 30 percent of gastric carcinoma in some reported series [16,17].

Proximal tumors — Despite the decline in gastric cancer overall, there has been a dramatic increase in incidence of cancer of the gastric cardia (figure 1) [18]. The shift from distal to proximal stomach may in part be due to the decrease in the distal cancers. However, it has also been proposed that carcinoma at the cardia is a different entity from that of the rest of the gastric carcinoma.

The proximal tumors share demographic and pathologic features with Barrett's-associated esophageal adenocarcinoma and are more likely to occur in males, which parallels the male predominance in the increasing incidence of carcinoma in the lower third of the esophagus. The proximal tumors also differ from distal tumors in that they are not associated with a severe form of gastritis characterized by atrophy and/or intestinal metaplasia. Furthermore, they tend to be more aggressive than those arising from distal sites. Environmental factors or chemical carcinogens (eg, cigarette and alcohol) may be more strongly associated with cardiac carcinomas compared with more distal carcinomas [19]. (See "Epidemiology and pathobiology of esophageal cancer".)

Rise in incidence in younger adults — There has been an increase in the incidence of gastric cancer (cardia and non-cardia gastric cancers combined) among young adults (aged <50 years) in both low-incidence and high-incidence countries [20-22]. It is unclear if the rising prevalence of autoimmune gastritis and dysbiosis secondary to the increased use of antibiotics and acid suppressants has led to an increase in incidence in younger adults [4].

MORTALITY — Gastric cancer is the fourth leading cause of cancer deaths worldwide [4]. Mortality rates are high because most patients with gastric cancer present with advanced disease [24]. However, there has been a steady decline in gastric cancer mortality worldwide, with the rate of decline varying by region [4,23]. Global and country-specific mortality rates are available in the World Health Organization GLOBOCAN database [2].  

Observational data also suggest that mortality from gastric cancer differs by race and ethnicity. In the United States, gastric cancer mortality rates are lower in White Americans (2.1 per 100,000) compared with those who identify as American Indian/Alaska Native (5.5 per 100,000), Black (5 per 100,000), Hispanic/Latino (4.8 per 100,000), or Asian American/Pacific Islander (4.6 per 100,000) [5].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gastric cancer".)

SUMMARY AND RECOMMENDATIONS

Incidence – Gastric cancer is a leading cause of cancer worldwide. (See 'Global incidence' above.)

The incidence of gastric cancer varies worldwide by geographic region (figure 2). The highest incidence rates are in Eastern Asia, the Andean regions of South America, and Eastern Europe, while the lowest rates are in North America, Northern Europe, and most countries in Africa and South Eastern Asia.

The global incidence of gastric cancer has declined rapidly over the past few decades, but the rate of decline varies between countries and regions. This decline may be due to the recognition of certain risk factors such as H. pylori and other dietary and environmental risks. (See "Risk factors for gastric cancer", section on 'Environmental risk factors'.)

Other regional factors also impact incidence, such as migration patterns. (See 'Regional variation' above.)

Important trends in gastric cancer incidence  

Histology – There is a more dramatic decline in the worldwide incidence of intestinal type compared with diffuse type gastric cancer. The decline in the incidence of the intestinal type parallels the overall decline in the incidence of gastric cancer; by contrast, the decline in the incidence of the diffuse type has been more gradual. (See 'Changes in histologic pattern' above.)

Location – There is an increase in incidence of cancer of the gastric cardia (figure 1). The shift from distal to proximal stomach may in part be due to the decrease in the distal cancers. (See 'Proximal tumors' above.)

Age – There is an increase in the incidence of gastric cancer (cardia and non-cardiac gastric cancers combined) among young adults (aged <50 years) in both low-incidence and high-incidence countries. (See 'Rise in incidence in younger adults' above.)

Mortality – Gastric cancer is the fourth leading cause of cancer deaths worldwide. Mortality rates are high because most patients with gastric cancer present with advanced disease. However, there has been a steady decline in gastric cancer mortality worldwide, with the rate of decline varying by region. (See 'Mortality' above.)

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