Gastric adenocarcinoma (GAC) remains a major public health concern in the U.S., characterized by late presentation and poor outcomes. While the Correa cascade describes a multistep progression from precursor lesions (PLs) to cancer, its applicability to U.S. GAC cases remains uncertain.

To evaluate the prevalence of histologic PLs in patients diagnosed with GAC and assess opportunities for earlier detection.

We conducted a retrospective review of patients diagnosed with GAC at a tertiary care center from 2003 to 2023. Histologic PLs including atrophic gastritis, gastric intestinal metaplasia (GIM), and dysplasia were identified in GAC resection specimens. Prior esophagogastroduodenoscopy (EGD) and Helicobacter pylori data were also reviewed. Comparisons were made across clinical, histologic, and treatment characteristics by PL presence in GAC resection specimens.

Among 118 patients (97.5% male, mean age 72.6), PLs were present in 35.6% of GAC resection specimens, most commonly GIM (78.6%). Of these, 26.2% had undergone prior EGD, and only 36.4% had previously documented PLs. Intestinal-type GAC was more common in patients with PLs (73.8 vs. 18.4%, p < 0.001), while diffuse-type predominated in those without. Time from H. pylori diagnosis to GAC was longer in patients with PLs (222 vs. 166 months, p = 0.03), but only 33.9% had H. pylori testing prior to diagnosis.

Over one-third of GAC cases had PLs present at diagnosis, yet few had prior endoscopic detection, highlighting missed prevention opportunities.