Gastric cancer continues to be a significant cause of cancer deaths worldwide. Although the age-standardised incidence and mortality rate has been on the decline, an ageing population will continue to sustain the number of new cases of gastric cancer.1 Gastric cancer, if detected and treated early, has an excellent prognosis. Gastric cancer (GC), the intestinal type, occurs through a stepwise progression of premalignant precursors which are endoscopically detectable and whose natural history has been characterised. These precursors, such as intestinal metaplasia, offer an opportunity for targeted endoscopic surveillance and intervention for early gastric cancer. They are also commonly encountered on routine endoscopy and their further management requires clarification. In this article, we will review the management of Helicobacter pylori (H. pylori) in gastric cancer prevention and developments in the endoscopic surveillance, detection and treatment of early gastric cancer.