Early detection of gastrointestinal cancers in low- and middle-income countries: A risk-stratified framework and implementation roadmap.

Low and middle-income countries (LMICs) like India bear a substantial burden of gastrointestinal (GI) cancer morbidity and mortality, largely attributable to late-stage diagnosis, which limits curative treatment options and drives poor survival outcomes. Although population-based endoscopic screening programs in East Asia have demonstrated significant mortality reduction, such approaches are not currently feasible in India due to population scale, heterogeneous infrastructure and workforce constraints. Consequently, India requires a pragmatic strategy focused on earlier detection within routine clinical practice. This review proposes a quality-first, phased framework for early GI cancer detection in India, emphasizing targeted screening and risk-based surveillance rather than population-wide endoscopic screening. High-quality conventional white light endoscopy (WLE) supported by adequate inspection time, systematic examination protocols, optimal mucosal preparation and objective quality metrics forms the foundational step, as most early GI neoplasia is detectable with optimized WLE. Image-enhanced endoscopy (IEE), including chromoendoscopy and digital optical technologies, is positioned as a complementary tool that provides incremental benefit when selectively deployed in quality-assured settings for high-risk populations and lesion characterization. Emerging Indian data demonstrates the feasibility of detecting early gastric cancer following structured training and systematic inspection, with curative endoscopic sub-mucosal dissection achievable in appropriately selected cases. However, widespread implementation faces barriers including equipment costs, training gaps, high procedural volumes, short inspection times and variable procedural quality. To address these challenges, a staged implementation roadmap is outlined: (1) adoption of risk-targeted screening in high-incidence regions and high-risk individuals; (2) standardization of endoscopic quality measures, including systematic inspection and minimum examination times; (3) integration of structured diagnostic training and selective IEE exposure into gastroenterology curricula and (4) expansion of access through hub-and-spoke networks, shared equipment models and low-cost chromoendoscopy in resource-limited settings. Coordinated action across clinicians, training programs, institutions, professional societies and policymakers is essential to transitioning GI cancer care in India from late-stage palliation toward early detection and curative endoscopic therapy.