Dyspepsia Care as a Missed Gateway to Gastric Cancer Prevention in High-Risk U.S. Populations

Dyspepsia is among the most common gastrointestinal complaints, affecting nearly one in five adults annually. Guidelines diverge in their recommendations: the American College of Gastroenterology and Canadian Association of Gastroenterology endorse Helicobacter pylori "test-and-treat" for patients under 60 years, with upper endoscopy for those aged 60 and above or with alarm features. By contrast, the American Society for Gastrointestinal Endoscopy advises endoscopy for patients with new-onset dyspepsia beginning at age ≥ 50, even without alarm features. The British Society of Gastroenterology emphasizes risk context, recommending earlier endoscopy (age > 40 years) for individuals from regions with a high incidence of gastric cancer or with a family history of gastric cancer. These differences underscore uncertainty around age thresholds and the limitations of uniform, age-based strategies. In the United States, where several high-risk populations carry disproportionately elevated gastric cancer risk, a tailored, ethnicity- and life-course-informed approach is warranted. Embedding ancestry, nativity, and family history into dyspepsia evaluation would reframe H. pylori eradication as primary prevention and lower thresholds for endoscopy in high-risk groups. Such a strategy would rationalize endoscopy use, advance equity, and reduce preventable deaths. Reframing dyspepsia as an opportunity for prevention is both a clinical and equity imperative.