PURPOSE OF REVIEW: The paper aims to discuss the global trends in gastric cancer incidence in relation to important factors involved in the pathogenesis of gastric cancer. RECENT FINDINGS: Despite a significant worldwide decline, gastric cancer remains a common cause of cancer death. The decline has been multifactorial and preceded the fall in Helicobacter pylori prevalence. The initial decline was associated with changes in food preservation and availability, especially of fresh fruits and vegetables, followed by a decline in the primary etiologic factor, H. pylori. Gastric cancer incidence remains high in East Asia, intermediate in Latin America, and low in developed countries. Significant racial/ethnic variability exists. The rapid decline in incidence in East Asia will continue as primary and secondary prevention strategies are implemented. The incidence in Latin America is unlikely to decline significantly over the next few decades given high H. pylori prevalence in the young. Ultimately, global H. pylori eradication will be needed to largely eliminate gastric cancer.