South Korea Revises Cancer Screening Guidelines, Questions Efficacy for Elderly

South Korea's national cancer screening guidelines have undergone a significant revision after a decade, with a particular focus on stomach and liver cancer, aiming to refine screening targets and methods based on the latest research and domestic medical conditions.

The National Cancer Center updated its recommendations on July 24, focusing on stomach and liver cancer, with revisions for colorectal cancer expected soon. The core changes include a strong recommendation for individuals aged 40 and above to undergo a stomach endoscopy every two years. For liver cancer, high-risk individuals, such as those with liver cirrhosis or Hepatitis B and C, are advised to have regular liver ultrasounds and blood tests (AFP and serum alpha-fetoprotein) every six months.

Notably, imaging tests like computed tomography (CT) and magnetic resonance imaging (MRI), previously considered for liver cancer screening, have been removed from the primary screening methods due to limited evidence of their effectiveness. Similarly, the gastrointestinal X-ray examination, previously an option for stomach cancer screening, has also been excluded.

A significant shift has occurred regarding stomach cancer screening for the elderly. While the previous guidelines strongly recommended screening for adults aged 40-74 and advised against it for those over 85, the new guidelines focus on the 40-74 age group and do not offer specific recommendations for those over 75, citing a lack of evidence for mortality reduction. However, the explicit statement advising against screening for those over 85 has been removed, potentially causing confusion.

In response, the National Cancer Center clarified that the absence of specific recommendations for those over 75 does not mean screening should be avoided. Instead, it signifies that "it is difficult to determine the recommendation based on current evidence." The center plans to re-evaluate this as more research becomes available. This approach reflects a growing medical concern about the effectiveness of national cancer screenings for the elderly.

National cancer screenings aim to detect cancer early, reduce the burden of cancer-related diseases and mortality, and lower treatment costs. However, as individuals age, the efficiency of these screenings decreases. The risk of death from causes other than cancer increases, limiting the benefits of early cancer detection. Conversely, the risks associated with screening, such as complications from invasive procedures like bleeding or perforation, false positive results leading to unnecessary anxiety and further testing, and overdiagnosis of clinically insignificant lesions, become more significant.

Studies have raised concerns about the potential harms of routine screenings for the elderly. Research published in 2025 by the Korean Society of Gastrointestinal Endoscopy indicated that elderly individuals undergoing biennial stomach endoscopies might face an increased overall risk of death. For those aged 70-79, no significant benefit from screening was observed, and for those over 80, the risk of death from stomach cancer was actually more than double compared to non-screened groups. The risk of complications from endoscopy also increased more than fivefold in those over 80, suggesting that for the elderly, screening might pose greater harm than benefit.

These risks are primarily attributed to complications from endoscopic procedures and false positive results. While the incidence of major complications like bleeding and perforation from endoscopy is low (0.170 and 0.034 per 1,000 procedures, respectively), these risks can increase five to sixfold in individuals over 80 or those with underlying health conditions. Dr. Kang Seok-beom, head of the National Cancer Center's Cancer Screening Business Division, expressed concern that "for the elderly, the risk of complications from invasive endoscopic procedures increases, and in the case of sedation endoscopy, which includes anesthesia, reduced cardiopulmonary function can lead to unpredictable accidents." He also noted that false positive findings, leading to unnecessary further tests and significant psychological stress, can easily result in health deterioration and frailty in older individuals.

South Korea is rapidly aging, with the proportion of the population aged 65 and over exceeding 20%. The number of elderly individuals undergoing national cancer screenings continues to rise. In the past year, over 136,000 individuals aged 85 and older, and 1.24 million aged 75 and older, received screenings. This constitutes approximately 1% and 10% of the total 13.74 million national screening participants, respectively, with a steady annual increase. Similarly, among the 8.56 million who received stomach cancer screenings, 720,000 (8.4%) were aged 75 and older, and 64,000 (0.7%) were 85 and older.

Given this trend, the medical community, including the National Cancer Center, emphasizes the need for screening methods that are safer and more suitable for the elderly. The prevailing view internationally and domestically is that for individuals over 75, a personalized screening approach is necessary, considering their health status, life expectancy, and the risks associated with tests, rather than a one-size-fits-all approach. This is particularly true for the very elderly (85 and above). The Korean Academy of Medical Sciences is leading discussions on improving over-screening and treatment environments through its "Choosing Wisely" campaign, advocating for healthy elderly individuals to be screened while considering the health status of frail elderly individuals.