The European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with gastric cancer (GC), published in late 2022 and the updated ESMO Gastric Cancer Living Guideline published in July 2023, were adapted in August 2023, according to previously established standard methodology, to produce the Pan-Asian adapted (PAGA) ESMO consensus guidelines for the management of Asian patients with GC. The adapted guidelines presented in this manuscript represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with GC representing the oncological societies of China (CSCO), Indonesia (ISHMO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO), coordinated by ESMO and the Japanese Society of Medical Oncology (JSMO). The voting was based on scientific evidence and was independent of the current treatment practices, drug access restrictions and reimbursement decisions in the different Asian regions represented by the 10 oncological societies. The latter are discussed separately in the manuscript. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with GC across the different regions of Asia, drawing on the evidence provided by both Western and Asian trials, whilst respecting the differences in screening practices, molecular profiling and age and stage at presentation. Attention is drawn to the disparity in the drug approvals and reimbursement strategies, between the different regions of Asia., Competing Interests: Disclosure KS declares speaker’s engagement from Janssen Pharmaceutical; advisory role from AbbVie, Amgen, Astellas Pharma, Boehringer Ingelheim, Bristol-Meyers Squibb (BMS), Daiichi Sankyo, GlaxoSmithKline, Guardant Health Japan Corp, Lilly, Merck Sharp & Dohme (MSD), Novartis, Ono Pharmaceutical, Pfizer, Taiho Pharmaceutical and Takeda; institutional research grant from Amgen, Astellas, Chugai Pharmaceutical, Daiichi Sankyo, Eisai, MSD, Ono Pharmaceutical and Taiho Pharmaceutical. TF declares speaker’s engagement from Amgen, Bayer, Bristol, Lilly, MSD, Roche and Servier; non-remunerated PI role from Adapt Immune, Beigene and Daiichi Sankyo. HK declares speaker’s engagement from Bayer Yakuhin, Bristol-Meyers Squibb, Chugai Pharmaceutical, Daiichi Sankyo, Eli Lilly Japan, GlaxoSmithKline, Merck Biopharma, MSD, Ono Pharmaceutical, Otsuka Pharmaceutical, Tiaho Pharmaceutical, Takeda Pharmaceutical, Teijin Pharma and Yakult Pharmaceutical Industry; advisory role from Daiichi Sankyo; institutional research grant from Amgen, AstraZeneca, Brisot-Myers Squibb, Chugai Pharmaceutical, Covance Japan Inc, Daiichi Sankyo, Eisai, Eli Lilly, Japan, EP-CRSU Co, EPS Corporation, EPS International, GlaxoSmithKline, IQVIA Services Japan, Janssen Pharmaceutical, Japan Clinical Research Operations, Kissei Pharmaceutical, Kobayashi Pharmaceutical, Mebix Inc, Medical Research Support, Mochida Pharmaceutical, MSD, Nippon Boehringer Ingelheim, Nippon Kayaku, Novartis Pharma, Ono Pharmaceutical, Otsuka Pharmaceutical, PAREXEL International Corp, PPD-SNBL, PRA Health Sciences, Sanofi, SRL, SymBio Pharmaceuticals, SYNEOS Health Clinical, Sysmex Corporation, Taiho Pharmaceutical, Takeda Pharmaceutical. GC declares speaker’s engagement from AstraZeneca, Daiichi Sankyo, Novartis, Pfizer and Roche; writer’s engagement from Pfizer; advisory role from AstraZeneca, BMS, Celcuity, Daiichi Sankyo, Exact Sciences, Gilead, Lilly, Menarini, Merck, Pfizer, Roche and Veracyte; funding as coordinating PI from Relay Therapeutics; institutional funding from Astellas, AstraZeneca, Blueprint Medicine, BMS, Daiichi Sankyo, Kymab, Merck, Novartis, Philogen, Relay Therapeutics, Roche and Sanofi; non-remunerated advisory role for Italian National Health Council, Europa Donna patient advocacy association, EUSOMA and Fondazione Beretta Cancer Research Foundation; non-remunerated activity as chair of ESMO clinical practice guidelines and member of board of directors for Lega Italiana Lotta ai Tumori. YN declares speaker’s engagement from BMS, Daiichi Sankyo, Eli Lilly, Ono Pharma, Taiho and Yakult; advisory role from Daiichi Sankyo; funding as local PI from AstraZeneca, BMS, Daiichi Sankyo and Ono Pharma. SOW declares speaker’s engagement from AstraZeneca, Merck, MSD, Novartis, Pfizer and Sanofi Aventis; funding as local PI from Sanofi Aventis; non-remunerated advisory role to non-profit cancer survivor Sahabat Peduli Kanker. SYR declares speaker’s engagement from Daiichi Sankyo, Lilly and MSD; steering committee/advisory role from Amgen, Astellas, Indivumed and LG Biochemical; institutional funding/research grant from BMS, Daiichi Sankyo, Lilly and MSD; funding as coordinating/local PI from Astra Zeneca, Beigine, Incyte, Indivumed, Merck, MSD and Zymeworks. WIWZ declares speaker’s engagement from AstraZeneca Malaysia, DKSH Malaysia, Eisai and MSD; advisory role from Astellas Pharma Inc., AstraZeneca Malaysia, MSD Malaysia and Roche Malaysia; funding as local PI from Amgen Inc., AstraZeneca, Beigene, Merck and Roche; non-remunerated role as an Asia Pacific Regional Council Member, International Cancer Corp Group member for ASCO and ATLAS board member for ATLAS group. DLS declares speaker’s engagement from Abbott Nutrition, Pfizer and Zuellig Pharma; expert testimony role from AstraZeneca and MSD; writing engagement from Pfizer; employment from Unilab Inc; sponsorship of cancer centre activities from Kalbe Farma. MN declares speaker’s engagement from BMS, DKSH, MSD and Taiho; advisory role from AstraZeneca, BMS, MSD and Novartis; travel support from Eisai; stocks/shares in Amgen, AstraZeneca and Carsgen Therapeutics. KHY declares an advisory role from AstraZeneca, Daiichi Sankyo, Merck, Novartis, Ono and PhytoHealth; non-remunerated membership of American Association for Cancer Research (since 1995) and American Society of Clinical Oncology (since 1996). PS declares speaker’s engagement from Amgen, AstraZeneca, Bayer, BMS, DKSH, Janssen, Juniper biologics, MSD, Mundipharma, Novartis, Pfizer, Roche, Taiho and ZP Therapeutics; advisory role from Amgen, AstraZeneca, BMS, Eisai, Ipsen, Janssen, MSD, Pfizer, Novartis, and Roche; funding as local PI from Amgen, AstraZeneca, Exscientia, Janssen, MSD, Mirati Therapeutics, Novartis and Roche. ESi declares speaker’s engagement from Amgen, Roche and Taiho; advisory role from Amgen, AstraZeneca, GSK, Janssen, Merck, Roche, Servier and Taiho; a non-remunerated PI role from AstraZeneca and Mirai; non-remunerated receipt of product samples from Roche. WPY declares speaker’s engagement from AstraZeneca, Bristol-Myers Squibb, DKSH Singapore, MSD Pharma and Novartis; advisory role from Amgen and Ipsen Pharma; funding as local PI from Amgen and Novartis. MNI declares speaker’s engagement from Novartis and Pfizer; advisory role from Maiwp Healthcare and Pusrawi Hospital; funding as coordinating/local PI from Amgen, AstraZeneca, Intraimmune, Mirati, MSD and Novartis; non-remunerated activity as PI from MSD and Novartis. KWL declares speaker’s engagement from Boryung; advisory role from Astellas, Bayer, BMS, Daiichi Sankyo, MSD, Metafines and Vifor Pharma; funding as local PI from ABLBIO, ALX Oncology, Amgen, Arcus Biosciences, Astellas Pharma, AstraZeneca, BeiGene, Bolt Therapeutics, Daiichi Sankyo, Exelixis, Genexine, Green Cross Corp, InventisBio, Leap Therapeutics, LSK Biopharma, Macrogenics, MedPacto, Merck KGaA, MSD, Oncologie, Ono Pharmaceutical, Pfizer, Pharmacyclics, Seagen, Taiho Pharmaceutical, Trishula Therapeutics, Y-BIOLOGICS and Zymeworks; non-remunerated activity in leadership role from ALX Oncology and SMC chair of ASPEN-06 study. RRP declares speaker’s engagement from Diastika, Eisai, Ferron, Takeda and Tanabe; employment from Cipto Mangunkusumo National General Hospital and EMC Hospital Pulomas; a role as a moderator for Johnson and Johnson; non-remunerated activities as officer for Indonesian College of Internal Medicine, Indonesian Society for Digestive Endoscopy, Indonesian Society of Gastroenterology and Indonesian Society of Internal Medicine. JL declares non-remunerated membership roles with ASCO and CSCO. AL declares speaker’s engagement from Amgen, AstraZeneca, Eli Lilly, Hi Esai, Johnson and Johnson, Merck, MSD, Nestle, Novartis and Pfizer; consultancy/advisory role from AstraZeneca, Eli Lilly, Merck, MSD, Novartis and Pfizer; funding as local PI from Arcus Biosciences, AstraZeneca, MSD and Roche; institutional funding from Pfizer; non-remunerated activity as member of the Philippine Society of Medical Oncology. TY declares speaker’s engagement from Bayer Yakuhin, Chugai Pharmaceutical, Merck Biopharma, MSD, Ono Pharmaceutical and Takeda Pharmaceutical; consultancy role from Sumitomo Corp; institutional research grant from Amgen, Chugai Pharmaceutical, Daiichi Sankyo, Eisai, FALCO Biosystems, Genomedia Inc, Molecular Health GmbH, MSD, Nippon Boehringer Ingelheim, Ono Pharmaceutical, Pfizer Japan, Roche Diagnostics, Sanofi, Sysmex Corp and Taiho Pharmaceutical. EB declares speaker’s engagement from Bayer, BMS, Chugai, Eli Lilly, Janssen, Merck, MSD, Novartis, Ono, Taiho, Takeda and Tsumura; advisory role from Astellas, AstraZeneca and Daiichi Sankyo; institutional research grant from Chugai, Eli Lilly and Taiho. GP declares employment by ESMO; non-remunerated membership of ASCO, Hellenic Cooperative Oncology Group (HeCOG) and Hellenic Society of Medical Oncology. HS declares an advisory role from Ono Pharmaceutical and Zymeworks; funding as local PI from Amgen, Astellas, Daiichi Sankyo, MSD and Ono Pharmaceutical; institutional grant funding from Ono Pharmaceutical and Takeda Pharmaceuticals. AC declares speaker’s engagement from Amgen, Foundation Medicine, Merck Serono and Roche; advisory role from Amgen, AnHeart Therapeutics, Merck Serono, Roche and Transgene; funding as local PI from Actuate Therapeutic, Adaptimmune, Amcure, Amgen, Astellas, AstraZeneca, Bayer, BeiGene, BMS, FibroGen, Genentech, Lilly, MedImmune, Merck Serono, MSD, Natera, Novartis, Servier, Sierra Oncology, Takeda and Replimmune; editorial role from Annals of Oncology, ESMO Open and Cancer Treatment Reviews; non-remunerated role as General and Scientific Director of INCLIVA Biomedical Research Institute. CI declares speaker’s engagement from AstraZeneca, Bayer, Bristol Myers Squibb, Chugai, Daiichi Sankyo, Incyte, Kyowa-Kirin, Lilly Japan, M3, Merck, MSD, Nihon Kayaku, Novartis, Ono, Taiho and Takeda; expert testimony role from Merck; royalties from Hitachi and Riken Genesis; institutional funding/research grant from Asahi-Kasei, Chugai, Daiichi-Sankyo, Hitachi, Kyowa-Kirin, Nihon Kayuka and Taiho. ESm declares speaker’s engagement from Amgen, Bristol-Meyers Squibb, Cor2Ed, Daiichi Sankyo, Elsevier, Imedex, Merck, Novartis, Peervoice, Prova Education, Servier and TouchIME; steering committee/advisory role from Amgen, Astellas, AstraZeneca, Bristol-Meyers Squibb, My Personal Therapeutics, Roche, Servier, Viracta and Zymeworks; expert testimony role from Bristol-Meyers Squibb; institutional research grant from Bristol-Meyers Squibb; funding as coordinating/local PI from Amgen, AstraZeneca, Basilea, Daiichi Sankyo, Merus, Mirati, MSD and Roche; independent data monitoring committee role from Beigene, Everest Clinical Research and Zymeworks; EORTC GI clinical trials group role; non-remunerated leadership role from UK & Ireland Oesophagogastric Group (UKIOG). All other authors have declared no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)