The recommended treatment strategy for locally advanced gastric cancer in elderly patients aged 75 years and older: a Surveillance, Epidemiology, and End Results database analysis

Survival benefits of postoperative adjuvant chemotherapy in adults aged ≥ 80 years with locally advanced gastric cancer: insights from a population-based study

BACKGROUND AND AIMS

Postoperative adjuvant chemotherapy in older adults aged ≥ 80 years with locally advanced gastric cancer (LAGC) remains debated owing to concerns over treatment tolerance and limited data. We aimed to assess the effectiveness of postoperative adjuvant chemotherapy in adults aged ≥ 80 years with LAGC using data from the Surveillance, Epidemiology, and End Results database.

METHODS AND RESULTS

A total of 2395 patients with LAGC aged ≥ 80 years who underwent radical surgery between 2004 and 2015 were identified. Propensity score matching (1:1) was applied to pair 422 patients receiving adjuvant chemotherapy with 1973 patients who underwent surgery alone. Multivariate logistic regression identified independent predictors of adjuvant chemotherapy, including the period from 2012-2015, pN1-2 and pN3 stages, and radiation therapy. Conversely, age ≥ 85 years predicted decreased chemotherapy use. Cancer-specific survival (CSS) and overall survival (OS) were compared using multivariate Cox analysis, showing significantly longer OS and CSS in the adjuvant chemotherapy group, before and after matching. Subgroup analysis revealed that patients aged 80-84 years and those with N + stages benefited most from adjuvant chemotherapy, whereas patients aged ≥ 90 years did not show significant benefit.

CONCLUSION

Postoperative adjuvant chemotherapy should be considered for patients aged ≥ 80 years with LAGC, especially those with lymph node involvement, as it offers significant survival benefits. However, as age approaches 90 years, the benefits of adjuvant chemotherapy may diminish, warranting more cautious application.

Analysis of the safety and efficacy of laparoscopic gastrojejunostomy following neoadjuvant chemotherapy for gastric pyloric obstruction

Objective

To explore the safety and feasibility of laparoscopic gastrojejunostomy combined with neoadjuvant chemotherapy (NACT) in patients with locally advanced gastric cancer and pyloric obstruction.

Methods

We included patients with locally advanced gastric cancer who underwent laparoscopic gastrojejunostomy (LGJ) or endoscopic stenting (ES) between May 2017 and October 2022. The prognostic nutritional index (PNI) was used to evaluate the patient nutritional status. Platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratios were used to evaluate the inflammatory status of patients. The Kaplan-Meier method was used to analyze survival conditions, and the log-rank test was used to compare survival differences. A multivariate logistic regression analysis was performed to identify the factors related that might affect the prognosis.

Results

During the study period, 41 patients received LGJ and 37 patients received endoscopic stenting (ES). Patients in the ES group had higher rates of postoperative complications, particularly bleeding (0 vs. 16.2%, P<0.05). After two cycles NACT, the proportion of PNI≥45 patients in LGJ group was significantly higher than that in ES group (P<0.05). Furthermore, the proportion of patients with PLR<162 in the ES group was significantly higher than that in the LGJ group (P<0.05), and compared to the ES group, patients in the LGJ group were able to tolerate more cycles of NACT (6 vs. 4 cycles). A higher median survival time was observed in the LGJ group, and the multivariate logistic regression analysis confirmed treatment selection as an independent risk factor for overall survival (HR, 6.362; 95% CI:3.285-12.321, P<0.001).

Conclusion

NACT after LGJ shows potential for reducing tumor stage and improving patient prognosis.

Developing and validating nomograms for predicting the survival in patients with clinical local-advanced gastric cancer

Background

Many patients with gastric cancer are at a locally advanced stage during initial diagnosis. TNM staging is inaccurate in predicting survival. This study aims to develop two more accurate survival prediction models for patients with locally advanced gastric cancer (LAGC) and guide clinical decision-making.

Methods

We recruited 2794 patients diagnosed with LAGC (2010–2015) from the Surveillance, Epidemiology, and End Results (SEER) database and performed external validation using data from 115 patients with LAGC at Yantai Affiliated Hospital of Binzhou Medical University. Univariate and multifactorial survival analyses were screened for meaningful independent prognostic factors and were used to build survival prediction models. Concordance index (C-index), receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA) were evaluated for nomograms. Finally, the differences and relationships of survival and prognosis between the three different risk groups were described using the Kaplan–Meier method.

Results

Cox proportional risk regression model analysis identified independent prognostic factors for patients with LAGC, and variables associated with overall survival (OS) included age, race, marital status, T-stage, N-stage, grade, histologic type, surgery, and chemotherapy. Variables associated with cancer-specific survival (CSS) included age, race, T-stage, N-stage, grade, histological type, surgery, and chemotherapy. In the training cohort, C-index of nomogram for predicting OS was 0.722 (95% confidence interval [95% CI]: 0.708–0.736] and CSS was 0.728 (95% CI: 0.713–0.743). In the external validation cohort, C-index of nomogram for predicted OS was 0.728 (95% CI:0.672–0.784) and CSS was 0.727 (95% CI:0.668–0.786). The calibration curves showed good concordance between the predicted and actual results. C-index, ROC, and DCA results indicated that our nomograms could more accurately predict OS and CSS than TNM staging and had a higher clinical benefit. Finally, to facilitate clinical use, we set up two web servers based on nomograms.

Conclusion

The nomograms established in this study have better risk assessment ability than the clinical staging system, which can help clinicians predict the individual survival of LAGC patients more accurately and thus develop appropriate treatment strategies.

Survival benefits of gastrectomy compared to conservative observation for older patients with resectable gastric cancer: a propensity score matched analysis

PURPOSE

Radical gastrectomy is considered the first choice of curative treatment for older patients with gastric cancer (GC). However, there is limited data on the survival benefits of gastrectomy for older patients with GC.

METHODS

This was a retrospective observational study where medical records of patients aged ≥ 75 years with clinically resectable primary GC, comprising 115 patients who underwent radical surgery (S group) and 33 patients who received conservative therapy (non-S group) (total cohort) and 44 propensity-matched patients (matched cohort), were reviewed. Survival and independent risk factors, including comorbidities and systemic nutritional and inflammatory statuses, were evaluated.

RESULTS

In the total cohort, the 5-year overall survival (OS) in the S group was significantly higher than that in the non-S group (53.7% vs 19.7%, P < 0.0001). In the matched cohort, the 3-year OS in the S group was significantly higher than that in the non-S group (59.4% vs 15.9%, P < 0.01). Multivariate analysis of the total cohort showed that no surgery was an independent prognostic factor for poor OS (hazard ratio (HR) 3.70, 95% confidence interval (CI) 1.91-7.20, P = 0.0001). In the S group in the total cohort, the multivariate analysis showed that renal disease (HR 2.51, 95% CI 1.23-5.12, P < 0.05) was an independent prognostic factor for poor OS.

CONCLUSIONS

Gastrectomy for older patients improved the prognosis; however, careful patient selection is essential, especially among those with renal disease.

Optimal treatment for elderly patients with resectable proximal gastric carcinoma: a real world study based on National Cancer Database

Background

High perioperative morbidity, mortality, and uncertain outcome of surgery in octogenarians with proximal gastric carcinoma (PGC) pose a dilemma for both patients and physicians. We aim to evaluate the risks and survival benefits of different strategies treated in this group.

Methods

Octogenarians (≥80 years) with resectable proximal gastric carcinoma who were recommended for surgery were identified from National Cancer Database during 2004–2013.

Results

Patients age ≥ 80 years with PGC were less likely to be recommended or eventually undergo surgery compared to younger patients. Patients with surgery had a significantly better survival than those without surgery (5-year OS: 26% vs. 7%, p < 0.001), especially in early stage patients. However, additional chemotherapy (HR: 0.94, 95% CI: 0.82–1.08, P = 0.36) or radiotherapy (HR: 0.97, 95% CI: 0.84–1.13, P = 0.72) had limited benefits. On multivariate analysis, surgery (HR: 0.66, 95% CI: 0.51–0.86, P = 0.002) was a significant independent prognostic factor, while extensive surgery had no survival benefit (Combined organ resection: HR: 1.88, 95% CI: 1.22–2.91, P = 0.004; number of lymph nodes examined: HR: 0.99, 95% CI: 0.97–1.00, P = 0.10). Surgery performed at academic and research (AR) medical center had the best survival outcome (5-year OS: 30% in AR vs. 18–27% in other programs, P < 0.001) and lowest risk (30-day mortality: 1.5% in AR vs. 3.6–6.6% in other programs, P < 0.001; 90-day mortality: 6.2% in AR vs. 13.6–16.4% in other programs, P < 0.001) compared to other facilities.

Conclusions

Less-invasive approach performed at academic and research medical center might be the optimal treatment for elderly patients aged ≥80 yrs. with early stage resectable PGC.

The role of surgery and radiation in advanced gastric cancer: A population-based study of Surveillance, Epidemiology, and End Results database

Background

Chemotherapy is the standard approach for advanced gastric cancer, while the role of local therapy such as surgery and radiation for this population remains controversial. Our purpose is to evaluate the effect of local therapies on cancer specific survival (CSS) for advanced gastric cancer patients.

Methods

Four subgroups of patients in different treatment strategies: surgery, radiation (RT), surgery and radiation (Surgery+RT), no surgery/no radiation (No Surgery/No RT) were identified from the Surveillance, Epidemiology, and End Results (SEER)-registered database. The risk factors and the survival outcomes were analyzed by multivariable Cox regression models and Kaplan-Meier methods.

Results

A total of 10,354 patients were eligible with 6658 males and 3696 females. The 5-year CSS in the four subgroups of “Surgery”, “RT”, “Surgery+RT” and “No Surgery/No RT” were respectively 8.9%. 5.7%, 19.8% and 3.2%, which were significantly different in multivariate Cox regression (P<0.001) and univariate log-rank test (P<0.001). Advanced stage categories were defined as stage I, II and III of T/N category according to different initial T and N status following American Joint Committee on Cancer (AJCC) staging principle. Further analysis showed that patients in the group of “Surgery+RT” have significant benefits of survival specifically on stage II and III of T/N category. “Surgery+RT” group and “Surgery” group patients have similar survival time in stage I of T/N category. Moreover, we also found CSS benefits from the administration of “Surgery+RT” in the patients aged both ≥75 and <75 years. Remarkably, patients in “Surgery” group have no different survival time with “RT” group in age category of 75 years and older.

Conclusions

Local therapies, including surgery, radiation, and combination of both might associate to improve survival in advanced gastric cancer patients, but confounding due to disease extent and physical status cannot be excluded.

The impacts of surgery of the primary cancer and radiotherapy on the survival of patients with metastatic rectal cancer

The role of surgery of the primary cancer and radiation in metastatic colorectal cancer (mCRC) is still controversial currently, and evidence implied that colon cancer (CC) and rectal cancer (RC) should be treated with difference. Hence we focused on metastatic rectal cancer (mRC) solely to compare the cancer cause-specific survival (CSS) of patients receiving varied treatments of the primary cancer: no treatment, surgery only, radiation only, and surgery plus radiation, based on the records of the Surveillance, Epidemiology, and End Results (SEER) database. A total of 8669 patients were included. Results demonstrated that the 2-year CSS was 28.1% for no treatment group, 30.7% for only radiation group, 50.2% for only surgery group, and 66.5% for surgery plus radiation group, reaching statistical difference (P < 0.001). Furthermore, the CSSs of mRC patients in the surgery group were similar regardless of resection ranges (P = 0.44). Besides, we analyzed the prognostic factors for mRC and found carcinoembryonic antigen (CEA) level, metastasis (M) stage, Tumor (T) stage, tumor size, differentiate grade, age and marital status should be taken into consideration when estimating the prognosis. Particularly, patients with normal CEA level or M1a stage showed a significant survival advantage. Overall, present study suggested that surgery of the primary cancer and radiation might help to improve the survival of mRC patients, especially when both treatments were conducted. Our results may assist clinicians to make better treatment strategy for patients with mRC.