e23446 Background: Gastric cancer is frequently diagnosed at advanced stages in the United States. Although select high-risk populations may undergo upper endoscopic (EGD) evaluation prior to diagnosis, these procedures are often performed for non-surveillance indications. The relationship between pre-diagnostic EGD exposure and metastatic status at presentation remains incompletely characterized. Understanding this association may clarify real-world diagnostic pathways and inform future risk-based screening strategies. Methods: A retrospective cohort study using Epic SlicerDicer identified adults ≥18 years diagnosed with gastric adenocarcinoma at Tufts Medical Center between January 2021 and January 2026, excluding patients with prior gastric cancer. Patients with one or more risk factors for gastric cancer as defined by the 2025 AGA Clinical Practice Update were included: Asian race, Hispanic ethnicity, interpreter requirement, and prior diagnoses of Helicobacter pylori infection, gastric intestinal metaplasia, or chronic atrophic gastritis. Pre-diagnostic EGD exposure was defined as EGD performed 6–36 months before the index cancer diagnosis; procedures within 6 months were excluded to distinguish diagnostic from antecedent evaluation. Metastatic disease at diagnosis was defined by ICD-10 codes for secondary malignancy or malignant ascites. Associations were assessed using chi-square testing with calculation of odds ratios (OR) and 95% confidence intervals (CI). Results: Among 147 patients with gastric cancer and ≥1 risk factor for gastric cancer, 69 underwent EGD 6–36 months prior to diagnosis. Metastatic disease at diagnosis occurred in 19 patients (27.5%) with prior EGD exposure compared with 28 patients (35.9%) without prior EGD. Pre-diagnostic endoscopy was associated with numerically lower rates of metastatic disease, although this difference was not statistically significant (OR 0.68, 95% CI 0.34–1.35; p = 0.27). Conclusions: Among patients with gastric cancer from recognized high-risk groups, antecedent EGD exposure was associated with a lower proportion of metastatic disease at diagnosis, though statistical significance was not observed. Because endoscopy indication could not be determined, findings likely reflect a combination of symptom-driven evaluation and surveillance-related follow-up, and lead-time bias cannot be excluded. These results characterize real-world pathways preceding gastric cancer diagnosis and highlight potential opportunities to improve targeted evaluation in high-risk populations. Association between pre-diagnostic upper endoscopy exposure and metastatic status at diagnosis. Pre-diagnostic EGD (6–36 mo) Metastatic, n (%) Non-metastatic, n (%) Total Yes 19 (27.5%) 50 (72.5%) 69 No 28 (35.9%) 50 (64.1%) 78 Total 47 100 147 OR 0.68 (95% CI 0.34–1.35); p = 0.27.
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