Gastric cancer (GC) remains one of the most lethal cancers worldwide. Although its overall incidence in the U.S. appears low, this masks deep disparities in who is affected, when they are diagnosed, and how they fare [1,2]. Immigrants from countries with high rates of H. pylori infection and GC—including many Asian and Latin American communities—face disproportionately high risk [3-5]. Yet despite decades of global evidence identifying H. pylori as the leading modifiable risk factor for non-cardia GC, the U.S. still lacks formal screening guidelines, a national prevention strategy, and widespread public or provider awareness [6,7].

While other countries with centralized healthcare systems have successfully reduced GC through national H. pylori screening and eradication efforts [8,9], replicating those strategies in the U.S. is not feasible. What is needed instead is a model tailored to the U.S. context—one that reflects its demographic complexity and decentralized healthcare structure.

This commentary proposes a new direction for GC prevention in the U.S.: a migration-informed H. pylori screening strategy that integrates nativity, ancestry, clinical symptoms, family and personal history, dietary patterns, and other sociocultural factors to better identify high-risk individuals. It further integrates community-based outreach with structured behavioral assessment to capture both clinical and contextual determinants of risk. By combining biological screening with insights into knowledge, attitudes, and practices (KAP), this approach supports more targeted and scalable prevention in a fragmented healthcare system.

To clarify the framework used in this commentary, we define three central terms at the outset. A migration-informed strategy incorporates factors such as country of origin, duration of residence in the U.S., and other migration-related variables to assess disease risk. A nativity-sensitive approach distinguishes between U.S.-born and foreign-born individuals to better understand patterns of exposure. Meanwhile, community-anchored (based) interventions refer to programs that are designed and implemented in collaboration with trusted local organizations embedded within the communities they aim to serve.

Over the past two decades, several East Asian countries have shown that systematic H. pylori screening and treatment can significantly reduce GC incidence and mortality [10-12]. These national programs, supported by centralized health systems and population-level data, target individuals before precancerous changes develop. In South Korea, biennial endoscopic screening for adults over 40 has improved early detection and survival [8]. Japan, too, has improved survival through its national GC screening program [9].

By contrast, the U.S. lacks a coordinated system for H. pylori screening, even for its highest-risk populations. Testing is typically limited to individuals with dyspepsia or ulcers, despite strong evidence that many infected people—especially in immigrant populations—are asymptomatic [7,13]. The 2025 AGA Clinical Practice Update offers important guidance for managing high-risk individuals but falls short of proposing a comprehensive, community-level implementation strategy adapted to the realities of an immigrant-rich U.S. healthcare system [7].

Recent large-scale U.S. studies highlight the disproportionate burden of Helicobacter pylori infection among racial, ethnic, and linguistic minority groups. In a national Veterans Health cohort of over 913000 individuals, H. pylori was diagnosed in 25.8%, with highest rates among non-Hispanic Black (40.2%) and Hispanic (36.7%) individuals, compared to 20.1% in non-Hispanic Whites [4]. In another analysis of over 750000 patients from a community-based system, nonserologic positivity was significantly higher in Asian (23.2%), Black (25.1%), and Hispanic (28.1%) populations, and in individuals with a non-English language preference (32.9%) versus English speakers (15.8%) [14]. These disparities underscore the need for targeted screening strategies in high-risk communities.

High-burden states such as California—with large immigrant populations—report significantly higher age-adjusted GC incidence rates than the national average. According to the California Cancer Registry, certain ethnic groups experience substantially elevated rates of GC. Among individuals aged 50 and older, for instance, the risk of noncardia gastric adenocarcinoma is 1.8- to 7.3-fold higher in most non-white populations, and 12.0- to 14.5-fold higher among Korean American men and women, compared to non-Hispanic Whites [5]. Yet, most remain unscreened for H. pylori. In these high-risk populations, testing remains sporadic and follow-up care is poorly coordinated. There is currently no standardized or reimbursable H. pylori or GC screening program in the U.S., contributing to delayed diagnoses and poorer survival outcomes.

According to U.S. Census data, approximately 19% of the U.S. population identifies as Hispanic or Latino and about 6% as Asian [15] —groups that include a large proportion of foreign-born individuals from regions with high Helicobacter pylori prevalence. While some recent studies have examined H. pylori infection in Black and Hispanic communities [16,17], there remains a notable lack of community-based data on Asian Americans—despite their consistently higher risk for both H. pylori infection and GC. This persistent data gap reinforces the urgency of prevention strategies tailored to nativity, language, and early-life exposure history, particularly in Asian subgroups where disease burden is among the highest.

In the absence of national screening programs, the U.S. must find ways to target individuals at highest risk—without relying solely on broad racial or ethnic categories. While data show that Asian, Hispanic, and Black populations experience elevated rates of H. pylori infection and GC, this risk is far from uniform [4,5,14]. Country of origin, nativity status (foreign-born vs. U.S.-born), age at immigration, language spoken at home, and family history all interact to shape individual risk—yet these migration-related variables are often overlooked in both clinical practice and research. Although less well studied, second-generation individuals also carry elevated risk due to shared household environments or intergenerational exposures, underscoring the need for broader consideration in screening strategies [3,18].

A migration-informed model, as previously defined, would enable clinicians and public health agencies to identify those who may benefit from H. pylori testing—even in the absence of symptoms [19]. It offers a data-driven, equitable framework for translating nuanced risk factors into actionable clinical decisions. This approach also supports the development of a stratification tool—the Migration-Based GC Risk Index—which could inform future screening guidelines and optimize resource allocation in decentralized health systems.

Building a migration-informed framework for GC prevention must begin in the community—where risk is concentrated and access to care is often most limited. In many high-risk U.S. populations, traditional healthcare settings remain inaccessible or underutilized due to insurance barriers, language discordance, mistrust, or logistical challenges [2,20]. As outlined earlier, community-anchored efforts can bridge gaps in care by bringing culturally aligned screening and education directly to familiar, trusted settings.

One such model would involve piloting a community-based initiative to explore how multilingual education and H. pylori screening can be delivered through trusted local partners, using non-invasive tools such as the urea breath test and serologic assays. Coordinated with organizations embedded in immigrant communities, the effort aims to reach individuals often overlooked by routine care. While still in its early stages, this type of program may offer a replicable community-anchored approach, highlighting the need for continued evaluation, investment, and policy support to guide broader implementation.

Importantly, the screening is paired with a structured survey that captures not only clinical and demographic data (e.g., migration history, family history, lifestyle factors), but also key informational and psychosocial elements—including H. pylori awareness, perceived cancer risk, sources of health information, and care-seeking patterns. Additional items explore dietary habits, symptom interpretation, and trust in healthcare, all of which may influence infection risk, test uptake, and adherence to follow-up.

This integrated approach enables the construction of a multidimensional dataset that connects biological testing with the sociocultural context of risk. In turn, it informs more nuanced risk modeling, identifies barriers to early detection, and supports the development of culturally grounded outreach strategies. By embedding insight-driven data collection within real-world screening efforts, this model highlights both the feasibility and the added value of combining clinical and sociocultural information to advance equitable prevention.

The long-term goal is to develop a Migration-Based Gastric Cancer Risk Index—a clinically actionable tool to stratify individuals for H. pylori screening and early detection. The index would draw on accessible variables such as nativity, country of birth, length of time in the U.S., primary language, family history of GC or ulcers, prior H. pylori diagnosis or treatment, as well as clinical symptoms, dietary habits, and smoking history. These factors serve as proxies for early-life exposure and potential ongoing familial or environmental risk. Because they are commonly documented in clinical and public health settings, they offer a practical and scalable foundation for personalized risk stratification.

Each variable would be weighted based on its relative risk contribution, and individuals exceeding a defined threshold would be recommended for H. pylori testing. The tool could be integrated into electronic health records for clinical use or deployed in community-based outreach by public health practitioners. As data accumulate, the model could be refined to reflect shifting epidemiologic and migration patterns.

The index will be prospectively validated using data from ongoing community screening initiatives, with predictive performance assessed against confirmed H. pylori infection status and, where available, endoscopic or histologic findings. If successful, the index could enhance targeted decision-making, inform screening eligibility, guide payer policy, and help public health agencies prioritize high-need communities—offering an actionable, equity-focused alternative to universal screening.

For screening strategies to be effective, real-world data must drive implementation. Community-based programs—like those described earlier—play a critical role in generating policy-relevant evidence that reflects lived experience and reveals unmet need, particularly among immigrant communities facing structural access barriers [20]. When combined with structured KAP-informed assessment, these efforts surface both behavioral and structural barriers, providing the foundation for targeted public health messaging and scalable intervention models.

A demographically informed GC risk index can serve as a bridge between grassroots screening data and formal policy mechanisms. With rigorous modeling and validation, it can inform cost-effectiveness analyses, guide reimbursement policies, and support integration into clinical guidelines. In this way, community-anchored innovation becomes a lever for broader systemic change, moving beyond isolated pilots toward coordinated, equity-driven national strategies.

The absence of a national H. pylori screening policy has hindered efforts to prevent GC in high-risk U.S. communities. A tailored, community-based approach offers a promising alternative—meeting people where they are through culturally adapted outreach, accessible testing, and trusted local partnerships. These efforts can generate real-world data to inform smarter, risk-based prevention strategies grounded in nativity and other lived determinants of disease. Identifying gaps in awareness and care-seeking behaviors will further guide effective implementation. A long-term goal is the development of a Migration-Informed GC Risk Index to help clinicians and health systems more precisely identify individuals who may benefit from early testing. This vision reflects a shift toward a more equitable, data-driven model for GC prevention—rooted in community realities and responsive to the evolving fabric of the U.S. population.