Multifactorial ecological framework for intestinal-type gastric cancer

Gastric cancer (GC) remains one of the leading causes of cancer-related mortality worldwide, with projections indicating increasing incidence and marked geographic variability across populations. Although multiple hypotheses have been proposed to explain this heterogeneity, including those related to Helicobacter pylori infection and its management, no comprehensive framework currently integrates the diverse determinants of GC risk. Given the multifactorial nature of gastric carcinogenesis, there is a need for integrative approaches that consider biological, environmental, behavioural, and microbial factors within a population health perspective. In this theory and hypothesis article, we propose a complementary multifactorial ecological framework to interpret GC risk across spatial scales. This framework is intended as a conceptual model to generate testable hypotheses rather than as a quantitative predictive tool. By situating population-specific risk factors within Correa's precancerous cascade, the proposed framework provides a structured basis for comparative epidemiological analysis, supports the generation of future research hypotheses, and may inform context-specific prevention and surveillance strategies while advancing the ecological understanding of gastric carcinogenesis.