Background Gastric cancer remains a major cause of mortality and morbidity worldwide, and the total number of gastric cancer cases is predicted to rise as a result of population growth. The pathogenesis of gastric cancer represents a paradigm for microbially induced and inflammation-driven malignancies, and understanding this will be the best means of defeating this cancer. Sources of data We reviewed the relevant English language literature in relation to gastric cancer with particular reference to the role of Helicobacter pylori. We summarize what is known of the epidemiology, aetiology and pathogenesis of gastric cancer. We also describe current approaches to the detection and management of early gastric cancer and discuss the prevention strategies. Areas of agreement H. pylori is the most important aetiological risk factor for this cancer, and the pathogenesis involves the combined effects of host genetics, bacterial virulence and environmental factors. Areas of disagreement Although most accept that removing Helicobacter could prevent gastric cancer, there are still no definitive trials to prove this concept. There is also some anxiety about the long-term effects of removing such a prevalent chronic infection from large sections of the population. Conclusions Gastric cancer is now arguably one of the most understood malignancies, and real progress is being made towards eradicating this global killer. Much work still needs to be done to define the optimal approach for eradicating the causative agent, namely H. pylori infection.