Gastro–oesophageal cancers, encompassing stomach and oesophageal malignancies, are increasingly impacting populations in Western societies—including younger individuals. In Australia alone, the age-standardised incidence for stomach cancer in 2024 was 7.6 per 100,000 persons, and 5.1 per 100,000 for oesophageal cancers. Despite substantial improvements in diagnostic imaging, surgical techniques, oncology treatments, and supportive care, these cancers continue to have significantly lower 5-year survival rates than the overall average for all cancers. Compared to the national average survival rate of 71.2%, stomach cancer remains at 38%, and oesophageal cancer at just 23%.
These data highlight an urgent need for earlier diagnosis, better triaging, and timely specialist referrals to improve outcomes.
Late Diagnosis Is the Norm, Not the Exception
The primary determinant of long-term survival in gastro–oesophageal cancers is the stage at diagnosis. When detected early—limited to the mucosal layer—patients have a greater than 70% 5-year survival rate. However, less than one-third of patients are diagnosed at such an early stage. Once cancers spread to regional lymph nodes or show deeper invasion, survival drops to 20–40%, and for those with metastatic disease, the outlook plummets to ~5% for oesophageal and ~7% for gastric cancers.
READ MORE: Endometriosis May Double Risk of Premature Menopause, Large Global Study Finds
This disparity between early and late-stage survival demonstrates a critical opportunity for intervention—particularly in how patients are triaged and referred.
Delays in Diagnosis: A Multifaceted Challenge
The delay in diagnosis is complex and multifactorial. While most patients first present to their general practitioner (GP), many report multiple red-flag symptoms such as dysphagia, weight loss, odynophagia, and epigastric pain, which should trigger immediate referral to endoscopy. Yet, a UK study found that nearly 25% of symptomatic patients underwent three or more GP consultations before receiving a hospital referral, resulting in delays of 90 days or more.
Such delays allow cancers to progress, diminishing the potential benefits of early detection and curative treatment.
Contributing Factors to Delay
Several overlapping issues contribute to this delay:
- Nonspecific symptom presentation, such as indigestion or nausea, which can overlap with benign gastrointestinal disorders.
- Temporary symptom relief from over-the-counter medications like proton pump inhibitors (PPIs) or dietary changes, leading to false reassurance.
- Limited awareness among clinicians regarding the changing demographic and epidemiological profile of gastro–oesophageal cancer.
- Lack of validated risk stratification tools for use in primary care settings to assist with referral decisions.
- Barriers to endoscopy access, particularly in rural and remote areas, where referral pathways are opaque, and public waitlists are long.
The consequence is a system that, despite its resources, inadvertently allows high-risk patients to slip through the cracks.
A New Educational Resource for General Practitioners
To address this issue, Associate Professor Ralph Audehm and Associate Professor David Liu, in collaboration with Bristol-Myers Squibb, have developed a practical educational brochure titled Understanding Oesophagogastric Cancer. Distributed electronically to over 2,700 general practitioners across Australia, this resource aligns with the Cancer Council’s Optimal Care Pathway and Cancer Australia’s 2023–2033 Plan.
The brochure aims to:
- Raise awareness of timely diagnosis
- Identify high-risk subgroups (Table 2)
- Provide a symptom-based risk assessment guide (Figure 1)
- Clarify endoscopic referral pathways and triaging criteria
This tool is intended to empower GPs to act decisively when faced with suggestive symptoms and guide patients into timely specialist care.
Open Access Endoscopy and Alternative Referral Routes
Beyond educational interventions, the authors recommend broader use of open access endoscopy services—both in public and private settings. This model allows for direct referral to diagnostic procedures without requiring a prior outpatient consult, effectively bypassing long waitlists and improving time to diagnosis.
In rural areas where public system access is more restricted, GPs should consider discussing private options with patients or referring directly to gastrointestinal specialists even before an endoscopy is performed. While these services may be out-of-pocket for some patients, they can potentially result in life-saving early detection.
Barriers That Still Need Addressing
Despite these advances, several structural changes are still required to optimise outcomes:
- Funding for a validated GP triage tool that integrates symptom severity, risk factors, and referral urgency.
- Public awareness campaigns focused on early symptoms of gastro–oesophageal cancer.
- Standardising practice across primary and tertiary care to eliminate variation and delay.
- Targeted screening of high-risk populations such as patients over 60 with reflux, heavy smokers, or those with a family history of gastric cancer.
Recognising Red Flags Early Can Save Lives
According to Table 1, GPs should maintain high suspicion when patients present with:
- Dysphagia
- Epigastric pain persisting more than two weeks
- Unexplained weight loss
- Anaemia without clear cause
- Odynophagia
- Food bolus obstruction
- Early satiety
- Haematemesis or melaena
- Persistent nausea and bloating
These symptoms, especially when co-occurring, should prompt immediate endoscopic referral and consideration for specialist input.
Understanding Risk Factors by Cancer Type
Different types of gastro–oesophageal cancers have distinct risk profiles (Table 2). For example:
- Oesophageal squamous cell carcinoma is linked with alcohol, smoking, caustic injury, and achalasia.
- Oesophageal adenocarcinoma shares risk factors like GORD, Barrett’s oesophagus, and obesity.
- Gastric adenocarcinoma is commonly associated with Helicobacter pylori infection, smoking, alcohol, and a family history of stomach cancer.
Awareness of these patterns allows clinicians to proactively assess risk even in the absence of overt symptoms.
Conclusion: The Path Forward
Improving outcomes for patients with gastro–oesophageal cancer begins with early recognition, timely referrals, and efficient diagnostic access. By arming primary care practitioners with the tools and knowledge to identify high-risk individuals, the health system can significantly reduce the proportion of late-stage diagnoses.
To that end, general practitioners are urged to:
- Refer early for endoscopy or specialist review when red-flag symptoms are present
- Document symptoms clearly to facilitate triage
- Explore open access pathways in both public and private systems
- Advocate for better tools to stratify cancer risk and standardise referral urgency
As Associate Professor David Liu concludes, “A timely diagnosis could drastically alter the trajectory of gastro–oesophageal cancer. We need to make sure no patient is left waiting when the clock is ticking.”
