Core tip: Current evidence shows that patients with gastric dysplasia, severe and extensive gastric atrophy, extensive gastric intestinal metaplasia and the incomplete subtype of intestinal metaplasia are at high risk for gastric cancer development. Key issues in selecting approaches to identifying these subjects are the ability to reduce gastric cancer mortality and cost-effectiveness of the approach. Resource limitations are an important barrier in many regions worldwide. Thus, an applicable approach in real-life practice should be not only evidence-based but also resource-sensitive. In this review, we discuss the current understanding from western and eastern perspectives, and the possibility of an integrated, resource-sensitive approach.