Conditional survival analysis in Korean patients with gastric cancer undergoing curative gastrectomy

Sequential changes in conditional survival of patients undergoing curative gastrectomy for gastric cancer

BACKGROUND

Long-term data on the prognosis of patients who survived >5 years after gastrectomy for gastric cancer (GC) remain scarce. This study aimed to investigate sequential changes in conditional survival (CS) in patients with stage I-III GC who underwent R0 gastrectomy.

METHODS

Of 1129 patients with stage I to III GC who underwent R0 gastrectomy, the causes of death were assessed, and sequential changes in conditional overall survival (cOS), conditional disease-specific survival (cDSS), and conditional non-disease-specific survival (cNDSS) were calculated and compared. In a subgroup of 709 patients who survived >5 years, the associations between cOS, cDSS, cNDSS, and clinicopathologic factors were analyzed.

RESULTS

Over a median follow-up of 63 months, 203 patients (18.0%) died of GC, and 132 patients (11.7%) died of non-GC causes. The 5-year cDSS consistently increased over 10 years after gastrectomy for stage II and III GC. The cDSS and cNDSS intersected at 7 years after gastrectomy for stage II GC, whereas these measures crossed at 8 years after gastrectomy for stage III GC. In the 709 5-year survivors, multivariate analysis identified disease stage as being significantly associated with cOS and cDSS. Moreover, age ≥ 80 years, male sex, and preoperative comorbidities were associated with lower cNDSS.

CONCLUSION

Surveillance for GC relapse was crucial during the first 7 and 8 years after gastrectomy for stages II and III, respectively. Conversely, surveillance for second primary cancers and benign diseases became relatively more important 0, 7, and 8 years after gastrectomy for stages I, II, and III, respectively. In 5-year survivors, age ≥ 80 years, male sex, and preoperative comorbidities were associated with mortality unrelated to GC.

Prognostic factors for relapse-free 5-year survivors after gastrectomy for gastric cancer

BACKGROUND

Few studies have examined the prognosis of long-term survivors with gastric cancer (GC) after gastrectomy. This study aimed to identify the prognostic factors for 5-year recurrence-free survivors after gastrectomy for GC.

METHODS

A total of 721 patients with pathologic stage Ⅰ to Ⅲ GC who underwent gastrectomy between 2005 and 2018 and survived for 5 years without recurrence were enrolled. Conditional overall survival (cOS), conditional disease-specific survival (cDSS), and conditional non-disease-specific survival (cNDSS) of 5-year recurrence-free survivors were calculated. The association between cOS, cDSS, and cNDSS and clinicopathologic factors was evaluated using univariate and multivariate analyses.

RESULTS

The mean age of the patients was 70.5 ± 10.1 years, 68.5% of the patients were male, and 491, 128, and 102 had stage Ⅰ, Ⅱ, and Ⅲ GC, respectively. Of note, 17 patients relapsed, and 65 patients died (disease-specific, non-disease-specific, and unknown: 12, 45, and 6, respectively) during a median follow-up of 36 months. The 5-year cOS, cDSS, and cNDSS rates were 90.3%, 97.3%, and 93.3%, respectively. Multivariate analysis showed that age of ≥80 years and neutrophil-to-lymphocyte ratio (NLR) of ≥2.7 were significantly associated with poorer cOS. Stage Ⅲ GC was associated with decreased cDSS, and age of ≥80 years, NLR of ≥2.7, and mean corpuscular volume (MCV) of ≥93.4 fL were associated with lower cNDSS.

CONCLUSION

Age of ≥80 years, stage Ⅲ GC, NLR of ≥2.7, and MCV of ≥93.4 fL were unfavorable prognostic factors for 5-year recurrence-free survivors after gastrectomy for GC. Long-term surveillance after gastrectomy could be tailored based on these factors.

Exploring a novel risk model based on core disulfidptosis-related genes in periodontitis: Bioinformatics analyses and experimental validation

Bacteria in dental plaque invade periodontal tissues, causing chronic inflammation known as periodontitis. Despite advancements in understanding periodontitis, its molecular pathogenesis remains incompletely elucidated. In this study, a total of 247 samples were retrieved from the Gene Expression Omnibus (GEO) database, comprising 183 from individuals with periodontitis and 64 from healthy controls. Differentially expressed DRGs (DE-DRGs) were identified, and their expression correlations were analyzed. Immune cell infiltration and its association with DE-DRGs were assessed. Gene Set Variation Analysis (GSVA) was performed to determine key functions and pathways related to DE-DRGs. Characteristic DE-DRGs (CDE-DRGs) were identified using the Least Absolute Shrinkage and Selection Operator (LASSO) analysis, and a risk model and personalized nomogram were constructed. Model performance was validated through calibration and decision curve analysis (DCA). External experiments, including qRT-PCR and Western blot, confirmed the differential expression of DE-DRGs. Fourteen DE-DRGs were identified. Expression analysis revealed a strong synergistic correlation between MYH9 and ACTB (coefficient = 0.86) and an antagonistic correlation between NCKAP1 and FLNA (coefficient = -0.52). Immune profiling showed significant differences in the proportions of 22 immune cell types between groups, with 14 DE-DRGs correlated with immune infiltration levels. Cluster analysis of periodontitis samples revealed distinct patterns of DE-DRGs expression and immune cell infiltration across two clusters. A risk model incorporating four CDE-DRGs (DSTN, SLC7A11, SLC3A2, and RPN1) was developed, alongside a personalized nomogram for predicting periodontitis risk. qRT-PCR and Western blot analyses demonstrated downregulation of DSTN, SLC3A2, IQGAP1, CD2AP, and NCKAP1 and upregulation of SLC7A11, RPN1, FLNA, MYH9, TLN1, ACTB, MYH10, CAPZB, and PDLIM1 in periodontitis tissues. This study identified key DRGs in periodontitis, developed a predictive risk model and nomogram, and detailed the immune infiltration profile and its association with DRGs. These findings provide insights into the molecular pathogenesis of periodontitis and suggest potential strategies for personalized risk assessment, early diagnosis, and targeted therapy.

Conditional Survival of Patients with Limited-Stage Small Cell Lung Cancer After Surgery: A National Real-World Cohort Study

BACKGROUND

The prognosis of limited-stage small cell lung cancer (LS-SCLC) after surgery usually is estimated at diagnosis, but how the prognosis actually evolves over time for patients who survived for a predefined time is unknown.

METHODS

Data on patients with a diagnosis of LS-SCLC after surgery between 2004 and 2015 were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. The 5-year conditional cancer-specific survival (CCSS) and conditional overall survival (COS) were calculated.

RESULTS

This study analyzed 997 patients (555 women, 55.7%) with a median age, of 67 years (interquartile range [IQR], 60-73 years). The 5-year CCSS and COS increased from 44.7% and 38.3%, respectively, at diagnosis to 83.7% and 67.9% at 5 years after diagnosis. Although there were large differences with different stages (stages I, II, and III) at diagnosis (respectively 59.5%, 28.4%; 28.1% for CCSS and 50.6%, 24.8%, and 23.6% for COS), the gap decreased with time, and the rates were similar after 5 years (respectively 85.0%, 80.3%, and 79.4% for CCSS; 65.6%, 56.9%, and 61.3% for COS). The 5-year conditional survival for the patients who received lobectomy was better than for those who received sublobectomy or pneumonectomy. Multivariable analyses showed that only age and resection type were independent predictors for CCSS and COS, respectively, throughout the period.

CONCLUSION

Conditional survival estimates for LS-SCLC generally increased over time, with the most significant improvement in patients with advanced stage of disease. Resection type and old age represented extremely important determinants of prognosis after a lengthy event-free follow-up period.

Conditional survival in patients treated for gastric cancer with a curative intent

BACKGROUND AND OBJECTIVES

Conditional survival (CS) provides the probability that a patient who has already survived a certain number of years after treatment will survive an additional number of years. We aim to study the CS of patients with gastric cancer.

METHODS

Patients who underwent curative intent treatment for gastric cancer in a single institution between 2007 and 2018 were included in the analysis. The probability (CS) that a patient who has already survived x years will survive an additional y year, was calculated as CS (y/x) = S(x + y)/S(x).

RESULTS

The probability of surviving an additional 3 years if a patient had already survived 1, 2, 3, 4, and 5 years after treatment were 64.2%, 74.5%, 81.6%, 83.2%, and 88.2%, respectively whereas the 4-, 5-, 6-, 7-, and 8-year actuarial OS were only 47.2%, 43.2%, 41%, 39.4%, and 38.2%, respectively. The independent prognostic factors associated with poor survival were age >60 years, T stage ≥T3, N stage ≥N2, proximal tumor location, and lymph node ratio > 0.18. Patients with these high-risk features showed the greatest increase in CS3 over time.

CONCLUSION

CS estimates provided a more dynamic prognostic information over time for patients treated for gastric cancer with curative intent.

Incidence and risk factors of tuberculosis in patients following gastrectomy or endoscopic submucosal dissection: a cohort analysis of country-level data

BACKGROUND

Gastric cancer adversely affects nutrition and immunity, while increasing the risk of tuberculosis (TB). This study investigated the incidence and risk factors for TB in gastric cancer patients who had undergone gastrectomy or endoscopic submucosal dissection (ESD).

METHODS

This retrospective cohort study was conducted using Korean national insurance claims data. We defined three study groups (total gastrectomy, subtotal gastrectomy, and ESD) of patients diagnosed with gastric cancer plus a cancer-free control group. The latent TB infection (LTBI) screening status, TB incidence, and potential confounders in each cohort were analyzed, and the risk of TB was analyzed using a Cox proportional hazard model.

RESULTS

LTBI tests were performed in less than 1% of all patients, and the TB incidence rates were 473.8, 287.4, 199.4, 111.1 events/100,000 person-years in the total gastrectomy, subtotal gastrectomy, ESD, and control cohorts, respectively. Compared to the control cohort, the total gastrectomy cohort showed the highest hazard ratio (HR) for TB incidence (HR: 2.896, 95% CI: 2.559-2.337), while the ESD cohort showed a significantly increased risk (HR: 1.578, 95% CI: 1.957-1.980). Age, body mass index, and lack of exercise were risk factors in all cohorts. Comorbidities were also considered risk factors, depending on the cohort type.

CONCLUSIONS

Patients who underwent gastrectomy or ESD had an increased risk of TB, and this risk was correlated with the scope of gastrectomy. Considering the low rate of LTBI diagnostic tests and increased risk of TB in the study cohorts, more specific and practical guidelines for TB management are required for gastric cancer patients.

Conditional Survival of Patients Who Underwent Curative Resection for Esophageal Squamous Cell Carcinoma

OBJECTIVE

To analyze conditional survival estimates of patients with esophageal cancer who underwent curative resection.

SUMMARY BACKGROUND DATA

Conditional survival reflects dynamic prognosis updated to the current status and is a more relevant indicator for current healthcare and life decisions.

METHODS

This study included 1883 patients who underwent complete resection for esophageal squamous cell carcinoma at a tertiary cancer center from 1994 to 2016. We calculated 5-year (5Y) conditional overall survival (COS), conditional recurrence-free survival (CRFS), and conditional relative survival (CRS) estimates from diagnosis to 5 years of survival.

RESULTS

The 5Y COS, CRFS, and CRS increased from 63.7%, 65.2%, and 70.2% at diagnosis to 75.8%, 91.9%, and 86.4 at 5 years after diagnosis, respectively. While there were large differences with different stages (stage I, II, III) at diagnosis (81.2%, 64.9%, and 37.3% for COS; 85.1, 65.1%, and 67.9% for CRFS; 89.2%, 72.1%, and 41.1% for CRS), the gap decreased with time; rates were similar after 5 years (77.1%, 75.7%, and 72.6% for COS; 91.7%, 90.6%, and 94.5% for CRFS, and 89.3%, 85.4%, and 78.3% in CRS, respectively). The 5Y COS, CRFS, and CRS were persistently lower in older patients even after 5 years.

CONCLUSIONS

Conditional survival estimates generally increase over time, and the largest improvements were observed for patients with advanced stage. Availability of updated prognosis at various time points allows clinicians to better guide their patients. Our results also imply substantial residual risk of recurrence and sustained excess mortality compared to the general population even after 5 years.

Risk of Psoriasis in Postgastrectomy Gastric Cancer Survivors: A Nationwide Population-Based Cohort Study

Background

Although patients with psoriasis have an increased risk of cancers, little is known about the risk of psoriasis in cancer patients.

Objective

We aimed to comparatively analyze the incidence and risk factors of psoriasis in gastric cancer patients who underwent gastrectomy and in the general population.

Methods

A nationwide retrospective cohort of 52,608 gastric cancer survivors (2007~2015) was compared to 123,438 matched controls from the general population to estimate the incidence and hazard ratio (HR) of new-onset psoriasis. We also calculated the HRs for psoriasis according to adjuvant cancer treatment, obesity, and vitamin B₁₂ supplementation in gastric cancer survivors.

Results

During a mean follow-up of 6.85 years, 645 of the 52,608 gastric cancer patients developed psoriasis, while 1,806 in the 123,438 matched control group developed psoriasis. Gastric cancer patients had a decreased risk of psoriasis (HR, 0.86; 95% confidence interval, 0.79~0.94), especially those who underwent subtotal gastrectomy. We found that vitamin B₁₂ supplementation for more than 3 years had an additive effect on decreasing the risk of psoriasis in gastric cancer patients who underwent subtotal gastrectomy. Total gastrectomy, radio/chemotherapy, and obesity did not affect the risk of psoriasis in gastric cancer survivors.

Conclusion

The incidence of psoriasis is slightly lower in gastric cancer survivors than in the general population. Our results suggest that the development of psoriasis may be reduced by removing the source of systemic inflammation caused by Helicobacter pylori infection through subtotal gastrectomy in gastric cancer survivors.

Conditional Survival and Annual Hazard Estimates of Classical Hodgkin Lymphoma

Background

In the present study, we have tried to understand how the level of risk and survival probability changes over time for patients with classical Hodgkin’s lymphoma by employing conditional survival and annual hazard as dynamic estimates of prognosis and survival.

Methods

This retrospective study reviewed the clinical data of patients with newly diagnosed classical Hodgkin’s lymphoma admitted to Peking University Cancer Hospital between January 1, 2008, and December 31, 2017. Conditional survival and annual hazard rate were defined as the survival probability and yearly event rate, respectively, assuming that patients have survived for a defined time.

Results

A total of 384 patients were included (median age, 32 years; range, 6–77 years), of which 218 (56.8%) patients had early-stage disease. The median follow-up time was 41.3 months. The 5-year conditional overall survival (COS) rates remained favorable and showed an increase from 89% at treatment to 94% at year 5, while the 5-year conditional failure-free survival (CFFS) rate increased from 70% at treatment to 96% at year 5. The annual hazard of failure decreased from over 15% at diagnosis to less than 5% after 3 years. Early-stage patients had constantly lower annual estimates for hazard of death (range, 0–3.0%) and failure (range, 0–14.3%). However, the hazard of failure in advanced-stage patients decreased from 24.2% at diagnosis to below 8% after 3 years, whereas the hazard of death was always at relatively low levels. Patients with a high IPS risk score (≥3) had significantly lower COS and CFFS during the first 4 years. Patients who received the BEACOPP regimen had better 5-year COS and 5-year CFFS than those who received the ABVD regimen.

Conclusion

The survival probability increased and hazard of failure decreased over time.

Evaluation of Human Epidermal Growth Factor Receptor 2 Overexpression, Clinicopathological Characteristics, and Factors Affecting Survival in Gastric Cancer

Objectives:

The objective of the study was to evaluate the human epidermal growth factor receptor 2 (HER2) overexpression, clinicopathological features, and factors affecting survival in patients with gastric cancer.

Methods:

The study is a retrospective study conducted with 128 cases of gastric cancer who were admitted to Şişli Hamidiye Etfal Training and Research Hospital between 2005 and 2012. Patients’ demographic characteristics, performance score, tumor localization, information about surgery, HER2 measurements, histopathological characteristics, stage, treatment features, metastasis sites, and overall survival time were obtained from medical records. Immunohistochemical analysis was performed for HER2 scoring.

Results:

There were 89 (69.5%) men and 39 (30.5%) women in the study group, and the median age of the patients was 64 years. The median survival time of the patients was 24.43 months. The survival rate of the patients was calculated as 35.4±5.9%. Overall survival time was found to be shorter in the group with higher HER2 levels and also those with advanced-stage cancer. The survival rate was found to be significantly lower in patients with perineural invasion and advanced stage. However, the survival rate was not associated with lymphovascular invasion, surgical margin involvement, and HER2 levels. In the multivariate Cox Regression analysis performed to assess the effects of gender, histological subtype, stage, and surgical margin on overall survival, disease stage was found to be the only factor effective on survival. Gender, histological subtype, and the surgical margin did not affect prognosis.

Conclusion:

The survival rate in gastric cancers was found to be lower in those with advanced-stage disease. Higher HER2 level and the disease stage were associated with shorter overall survival time.

Does Delaying Time in Cancer Treatment Affect Mortality? A Retrospective Cohort Study of Korean Lung and Gastric Cancer Patients

The aim of this study is to investigate the association between delays in surgical treatment and five- and one- year mortality in patients with lung or gastric cancer. The National Health Insurance claims data from 2006 to 2015 were used. The association between time to surgical treatment, in which the cut-off value was set at average time (30 or 50 days), and five year mortality was analyzed using the Cox proportional hazard model. Subgroup analysis was performed based on treatment type and location of medical institution. A total of 810 lung and 2659 gastric cancer patients were included, in which 74.8% of lung and 71.2% of gastric cancer patients received surgery within average. Compared to lung cancer patients who received treatment within 50 days, the five-year (HR 1.826, 95% CI 1.437–2.321) mortality of those who received treatment afterwards was higher. The findings were not significant for gastric cancer based on the after 30 days standard (HR: 1.003, 95% CI: 0.822–1.225). In lung cancer patients, time-to-treatment and mortality risk were significantly different depending on region. Delays in surgical treatment were associated with mortality in lung cancer patients. The findings imply the importance of monitoring and assuring timely treatment in lung cancer patients.

Conditional Survival of female patients with operable invasive Breast Cancer in US: A population-based study

Background: Conditional survival (CS) is used to describe the dynamic possibility of survival, considering the changes of death risk with time lapsing. This study aimed to estimate the conditional disease-specific survival (CDS) for the female with operable invasive breast cancer.

Methods: The data was obtained from Surveillance, Epidemiology, and End Result Program of the National Cancer Institute. The hazard rate was calculated using kernel density smoothing method. The disease-specific survival (DSS) rates were estimated and compared using Kaplan-Meier method and log-rank test. The Cox regression model was used to adjust confounding factors. The CDS was calculated by CDS(y|x)=DSS(x + y)/DSS(x), where DSS(x) representatives the DSS at x year.

Results: The 5-year, 10-year, and 15-year DSS was 88.7%, 82.0%, and 78.3%, respectively. The hazard rate after surgery increased initially and peaked at about 1.5 years, then decreased gradually. Meanwhile, the CDS decreased just after surgery then increased continuously, which showed a contrary trend with hazard rate. Patients with high risk factors had greater survival gap between cumulative DSS and CDS. The changing trend of CDS in patients with high risk factors was more significant, and the CDS gap between low-risk patients and high-risk patients gradually decreased over time.

Conclusion: CS could provide a more precise long-term prognostic evaluation compared to traditional cumulative survival, especially for long-time survivors with high risk.

Conditional Survival and Time of Biochemical Recurrence of Localized Prostate Cancer in Japanese Patients Undergoing Laparoscopic Radical Prostatectomies

PURPOSE

Using conditional survival (CS) analysis, we investigated whether the duration of survival without biochemical recurrence (BCR) of prostate cancer after laparoscopic radical prostatectomies (LRP) affected the BCR rate. We also investigated the impact of well-known risk factors for BCR.

METHODS

Between 2002 and 2014, 627 consecutive patients underwent LRPs at our institution. Prostate-specific antigen (PSA) concentrations above 0.2  ng/mL were defined as BCR. Conditional BCR-free survival rates were determined through Kaplan-Meier analysis. Assessment of potential BCR risk factors was performed using a Cox proportional hazard analysis.

RESULTS

The 10-year BCR-free rates after LRP increased to 82.4%, 84.5%, 86.6%, 90.1%, and 94.7% in patients surviving 1, 2, 3, 5, and 7.5 years without BCR, respectively. Multivariate analyses of age, PSA concentrations, neoadjuvant therapy, and pathological findings were performed for all patients. In all patients, positive surgical margins (PSM) and Gleason Grade Groups (GG) ≥ 4 were independent risk factors for BCR (p < 0.001, hazard ratio [HR] = 2.45; and p < 0.001, HR = 2.83, respectively,). Similarly, PSM and GG ≥ 4 were significant risk factors in patients surviving 1-5 years without BCR. No clear risk factors were observed in patients surviving > 5 years without BCR after LRPs.

CONCLUSIONS

The BCR-free rate increased with time after LRP. It is recommended that patients with PSM, GG ≥ 4, or with both factors are strictly monitored for 5 years postoperatively. CS analysis is particularly useful for predicting the postoperative course of patients.

The C-reactive protein to albumin ratio predicts postoperative complication in patients who undergo gastrectomy for gastric cancer

The aim of this study was to evaluate the preoperative C-reactive protein (CRP) to albumin ratio (CAR) of patients with gastric cancer and to investigate the factors correlated with perioperative complications. From March 2016 to December 2019, 128 patients who underwent curative gastrectomy for gastric cancer were enrolled in a retrospective study. The preoperative cutoff value of the CAR for predicting postoperative complications was 0.265 on receiver operating characteristic (ROC) curve analysis. Clinical characteristics were compared between patients with complications (Clavien-Dindo grade ≥2, n = 20) and without complications (Clavien-Dindo grade <2, n = 108). On univariate and multivariate analyses, estimated blood loss (EBL) during the operation (HR 1.003, p = 0.039) and CAR (HR 2.832, p = 0.045) were independent predictors of postoperative complications. In conclusion, preoperative CAR appears to be a predictor of postoperative complications in the patients undergoing surgical treatment of gastric cancer.

Late recurrence of gastric carcinoma 15 years after surgery

A 70-year-old man who had undergone total gastrectomy 15 years ago for mucinous gastric carcinoma on the lesser curvature of the cardia, visited our hospital complaining of cough. Chest X-ray showed a right hilar shadow and an infiltrative shadow in the left middle lung field, which was not seen in the previous year. Whole-body positron emission tomography-computed tomography (CT) revealed abnormal uptake in the irregular consolidation of the left lung, enlarged right hilar lymph nodes, and a mass lesion on the right adrenal gland. Advanced primary lung adenocarcinoma with multi-organ metastasis was suspected and a CT-guided percutaneous lung biopsy was performed. Histopathological examination showed immunostaining patterns in complete accordance with those of the resected specimen of stomach, and the diagnosis of late recurrence of gastric carcinoma was confirmed. Pulmonary metastasis might have occurred as a direct hematogenous metastasis rather than through the liver. He achieved 31 months survival after the diagnosis receiving some sequences of chemotherapy. Late recurrence over 10 years after gastrectomy is extremely rare and significant predictive factors of late recurrence are not known. We hope that this case will help in detecting significant factors predictive of late recurrence after gastrectomy for gastric carcinoma.

Dynamic evaluation of conditional survival in patients with oral squamous cell carcinoma after surgical resection: A large-scale prospective study

OBJECTIVE

To dynamically estimate conditional survival (CS) probabilities for patients with oral squamous cell carcinoma (OSCC) after surgical resection.

METHOD

A large-scale prospective study was performed involving 1147 eligible OSCC patients from December 2002 to June 2018. Follow-up was completed on January 8, 2019. Cox proportional hazards models were utilized to assess prognostic factors related to overall survival (OS). Three-year CS (CS3) of patients who had already survived x years was calculated as the formula CS3 = OS(x+3)/OS(x).

RESULTS

CS3 estimates at the time of 0, 1, 3, 5-year survival demonstrated a tendency increase over time, and improved from 78.47% to 82.25%, while the postoperative actuarial OS decreased from 78.47% at 3 years to 57.12% at 8 years. Moreover, the differences between CS3 and actuarial OS were more obvious among patients with unfavorable tumor characteristics. Disparities in CS3 across all subgroups of tumor features illustrated more prominent at baseline (d range: 0.24 to 0.40), while the gaps would narrow if those patients have already survived 5 years (d range: -0.01 to 0.18).

CONCLUSION

Our findings suggest that survival profiles of OSCC patients evolve and increase over time following resection, especially for those with unfavorable tumor features at initial diagnosis. CS estimates may provide more accurate prediction and guide surveillance schedules.

Increased Risk of Osteoporotic Fracture in Postgastrectomy Gastric Cancer Survivors Compared With Matched Controls: A Nationwide Cohort Study in Korea

OBJECTIVES

Gastrectomy can lead to bone loss. Previous studies have suggested that there is an increased risk of fracture in gastric cancer survivors. However, these studies were performed without proper control groups. Therefore, we used Korean national health insurance data to compare the fracture risk in gastric cancer survivors who received gastrectomy to that of the general population.

METHODS

A total of 133,179 gastric cancer survivors were included and matched to noncancer controls using 1:1 propensity score matching. Cox proportional hazards regression analysis was used to determine the relative risk of fracture between the gastric cancer survivors and matched controls. We also examined the factors associated with fracture in gastric cancer survivors.

RESULTS

Compared with the matched controls, gastric cancer survivors had an elevated risk of osteoporotic fracture (hazard ratio [HR] 1.61, 95% confidence interval [CI] 1.53-1.70), which was most prominent in patients who underwent total gastrectomy (HR 2.18, 95% CI 1.96-2.44) and adjuvant chemotherapy (HR 2.01, 95% CI 1.81-2.23). In multivariate analysis, anemia was significantly associated with increased fracture risk (aHR 1.34, 95% CI 1.13-1.59), while decrease in weight >5% was not (aHR 1.06, 95% CI 0.89-1.25).

DISCUSSION

Gastric cancer survivors who underwent gastrectomy had an increased osteoporotic fracture risk than did matched controls. Total gastrectomy, adjuvant chemotherapy, and anemia were associated with an even higher risk in these patients. Additional studies are needed to establish optimal strategies, such as screening for osteoporosis and preventive interventions, that will reduce fracture risk in this population.

Dynamic prediction of long-term survival in patients with primary gastric diffuse large B-cell lymphoma: a SEER population-based study

BACKGROUND

This study investigated a large number of patients to develop a predictive nomogram for survival and a web-based survival rate calculator that can dynamically predict the long-term survival of patients with primary gastric diffuse large B-cell lymphoma.

METHODS

A total of 2647 patients diagnosed with primary gastric diffuse large B-cell lymphoma from 1998 to 2014 were extracted from the SEER database. We used the Lasso Cox regression model to identify independent risk factors for long-term survival and to develop a predictive nomogram for survival and a web-based survival rate calculator.

RESULTS

The median (mean) follow-up time was 30 months (52.8 months). Cancer-specific survival rates decreased with time, while the 5-year conditional survival increased with time. Cancer-specific deaths were not constant. Cancer-specific deaths of patients within the first 2 years were high, while the risk remained relatively constant after 2 years. The independent risk factors included surgery, chemotherapy, tumor stage and age, according to the Lasso Cox regression analysis. We developed a predictive nomogram and a web-based survival rate calculator ( https://linjuli1991.shinyapps.io/dynnomapp/ ). The calibration plot suggested that the actual value exhibited good agreement with the predicted value.

CONCLUSIONS

We found that patients with primary gastric diffuse large B-cell lymphoma had a high risk of death during the first 2 years. Additional active follow-up strategies should be provided during this period. This is the first study to develop a predictive nomogram and a web-based survival rate calculator that can provide evidence for individual treatment and follow-up.

Postoperative dynamic survival of gastric cancer patients: A multi-institutional, international analysis of 22 265 patients

BACKGROUND

How to best evaluate the disease-specific survival (DSS) of gastric cancer (GC) survivors over time is unclear.

METHODS

Clinicopathological data from 22 265 patients who underwent curative intend resection for GC were retrospectively analyzed. Changes in the patients' 3-year conditional disease-specific survival (CS3) were analyzed. We used time-dependent Cox regression to analyze which variables had long-term effects on DSS and devised a dynamic predictive model based on the length of survival.

RESULTS

Based on 1-, 3-, and 5-year survivorships, the CS3 of the population increased gradually from 62% to 68.1%, 83.7%, and 90.6%, respectively. Subgroup analysis showed that the CS3 of patients who had poor prognostic factors initially demonstrated the greatest increase in postoperative survival time (eg, N3b: 26.6%-84.1%, Δ57.5% vs N0: 84.1%-93.3%, Δ9.2%). Time-dependent Cox regression analysis showed the following predictor variables constantly affecting DSS: age, the number of examined lymph nodes (LNs), T stage, N stage, and site (P < .05). These variables served as the basis for a dynamic prediction model.

CONCLUSIONS

The influence of prognostic factors on DSS and CS3 changed dramatically over time. We developed an effective model for predicting the DSS of patients with GC based on the length of survival time.

Conditional survival analysis of four treatment strategies for patients with stage I non-small cell lung cancer

Conditional survival (CS) is used to describe dynamic survival possibility, taking account of the change in the survival risk that occurs with longevity. The present study aimed to explore the CS of four treatment strategies for stage I non-small cell lung cancer (NSCLC), staged according to the eighth edition of the American Joint Committee on Cancer/Union for International Cancer Control NSCLC staging system. Using the Surveillance, Epidemiology and End Results Program cohort obtained between 2004-2014, the current study first extracted data for 27,116 patients with stage I NSCLC. The actuarial cancer-specific survival rates (ACSs) and conditional cancer-specific survival rates of four treatment strategies were then compared. ACS was assessed using the Kaplan-Meier method and a log-rank test. The 3-year conditional cancer-specific survival (CCS3) of patients who had already survived for n years was calculated as CCS3=ACS(n+3)/ACS(n). Cox regression and propensity-score matching (PSM) was applied to adjust confounding factors. The 5-year ACS of patients who underwent lobectomy, sublobar resection, radiation and observation was 80.3, 72.0, 40.8 and 19.6%, respectively. The 5-year CCS3 of patients who underwent lobectomy, sublobar resection, radiation and observation was 91.7, 86.4, 77.0 and 58.2%, respectively. CCS3 increased with an increase in survival time and patients who underwent lobectomy had the highest CCS3 estimates and flattest growth, with the smallest survival gap between CCS3 and ACS. The results were similar in the PSM analysis. In conclusion, CS estimates may provide a more accurate survival prediction for patients with stage I NSCLC, and may assist with treatment decisions and surveillance strategies. In addition, the current study provided evidence that suggests lobectomy may be the optimal treatment strategy for stage I NSCLC compared with sublobar resection.

A Proposal of a Personalized Surveillance Strategy for Gastric Cancer: A Retrospective Analysis of 9191 Patients

Background

In gastric cancer, various surveillance strategies are suggested in international guidelines. The current study is intended to evaluate the current strategies and provide more personalized proposals for personalized cancer medicine.

Materials and Methods

In the aggregate, 9191 patients with gastric cancer after gastrectomy from 1998 to 2009 were selected from the Surveillance, Epidemiology, and End Results database. Disease-specific survival was analyzed by Kaplan-Meier method and the log-rank test. Cox proportional hazards regression analyses were used to confirm the independent prognostic factors. As well, hazard ratio (HR) curves were used to compare the risk of death over time. Conditional survival (CS) was applied to dynamically assess the prognosis after each follow-up.

Results

Comparisons from HR curves on different stages showed that earlier stages had distinctly lower HR than advanced stages. The curve of stage IIA was flat and more likely the same as that of stage I while that of stage IIB is like that of stage III with an obvious peak. After estimating CS at intervals of three months, six months, and 12 months in different periods, stages I and IIA had high levels of CS all along, while there were visible differences among CS levels of stages IIB and III.

Conclusions

The frequency of follow-up for early stages, like stages I and IIA, could be every six months or longer in the first three years and annually thereafter. And those with unfavorable conditions, such as stages IIB and III, could be followed up much more frequently and sufficiently than usual.

Risk of Coronary Heart Disease and Ischemic Stroke Incidence in Gastric Cancer Survivors: A Nationwide Study in Korea

BACKGROUND

Small studies suggest improvement of cardiovascular risk profiles and reduced cardiovascular mortality after gastrectomy for gastric cancer. In our study using national health insurance data, we investigated coronary heart disease (CHD) and ischemic stroke incidence among gastric cancer patients who received gastrectomy compared with general population controls.

METHODS

A total of 98,936 gastric cancer patients were included in the study and matched to non-cancer controls via 1:1 propensity score matching. Competing risk regression analysis was used to determine the relative risk of CHD and ischemic stroke, with cancer mortality as the competing risk. Changes in cardiovascular risk profile before and after gastrectomy were tested, and factors associated with CHD or ischemic stroke incidence among gastric cancer patients were analyzed.

RESULTS

Compared with the matched controls, gastric cancer patients who received gastrectomy were shown to have a decreased risk for both CHD (subdistribution hazard ratio [SHR] 0.60, 95% confidence interval [CI] 0.57-0.63) and ischemic stroke (SHR 0.72, 95% CI 0.69-0.75). Decreases in body mass index (BMI), blood pressure, blood sugar, and lipid and hemoglobin levels were marked after gastrectomy. Among gastric cancer patients, those who lost > 5% of their body weight were at lower risk of developing CHD (SHR 0.82, 95% CI 0.71-0.96) and ischemic stroke (SHR 0.85, 95% CI 0.75-0.98).

CONCLUSIONS

CHD and ischemic stroke risk decreased after gastrectomy. The amount of weight loss and accompanying metabolic changes seemed to mediate the reduction of such risk. Reassessment of cardiovascular risk factors after gastrectomy and consideration of cardiovascular risk in the selection of treatment modality are suggested.

Prediction of Conditional Probability of Survival After Surgery for Gastric Cancer: A Study Based on Eastern and Western Large Data Sets

BACKGROUND

The dynamic prognosis of patients who have undergone curative surgery for gastric cancer has yet to be reported. Our objective was to devise an accurate tool for predicting the conditional probability of survival for these patients.

METHODS

We analyzed 11,551 gastric cancer patients from the Surveillance, Epidemiology, and End Results database. Two-thirds of the patients were selected randomly for the development set and one-third for the validation set. Two nomograms were constructed to predict the conditional probability of overall survival and the conditional probability of disease-specific survival, using conditional survival methods. We then applied these nomograms to the 4,001 patients in the database from Fujian Medical University Union Hospital, Fuzhou, China, one of the most active Chinese institutes.

RESULTS

The 5-year conditional probability of overall survival of the patients was 41.6% immediately after resection and increased to 52.8%, 68.2%, and 80.4% at 1, 2, and 3 years after gastrectomy. The 5-year conditional probability of disease-specific survival "increased" from 48.9% at the time of gastrectomy to 59.8%, 74.7%, and 85.5% for patients surviving 1, 2, and 3 years, respectively. Sex; race; age; depth of tumor invasion; lymph node metastasis; and tumor size, site, and grade were associated with overall survival and disease-specific survival (P <.05). Within the Surveillance, Epidemiology, and End Results validation set, the accuracy of the conditional probability of overall survival nomogram was 0.77, 0.81, 0.82, and 0.82 at 1, 3, 5, and 10 years after gastrectomy, respectively. Within the other validation set from the Fujian Medical University Union Hospital (n = 4,001), the accuracy of the conditional probability of overall survival nomogram was 0.76, 0.79, 0.77, and 0.77 at 1, 3, 5, and 10 years, respectively. The accuracy of the conditional probability of disease-specific survival model was also favorable. The calibration curve demonstrated good agreement between the predicted and observed survival rates.

CONCLUSION

Based on the large Eastern and Western data sets, we developed and validated the first conditional nomogram for prediction of conditional probability of survival for patients with gastric cancer to allow consideration of the duration of survivorship.

Conditional survival of patients with gastric cancer who undergo curative resection: A multi-institutional analysis in China

BACKGROUND

Conditional survival estimates, which take into consideration the changing risk with increasing survival time, provide a dynamic survival probability and more accurate survival information for clinician decision making. The objective of the current study was to evaluate the conditional disease-specific survival (DSS) for patients with gastric cancer who underwent curative surgery in China.

METHODS

In total, 7658 patients with gastric cancer from a multi-institutional cohort in China were included in the analyses. Actuarial DSS was estimated using the Kaplan-Meier method. Three-year conditional DSS (CDS3 ) of patients who had already survived for x years was estimated as CDS3 = DSS(x + 3)/DSS(x). Cox proportional hazards regression analyses were used to identify the factors related to DSS.

RESULTS

The 1-year, 3-year, and 5-year actuarial DSS rates were 88.2%, 64.5%, and 54.6%, respectively. By using CDS estimates, the probabilities that patients would remain alive for an additional 3 years given that they had already survived for 1, 3, and 5 years were 66.6%, 80.2%, and 88.3%, respectively. Patients who had unfavorable tumor characteristics diagnosed initially at surgery had the greatest improvement in CDS and the largest survival gap between actuarial DSS and CDS.

CONCLUSIONS

The current results indicate that CDS estimates for Chinese patients with gastric cancer who underwent surgery were dynamic and increased with time elapsed. Patients who had unfavorable tumor characteristics had the greatest improvement in CDS. This valuable information could provide more a precise evaluation of long-term prognosis and may serve as an important prognostic index in clinical practice. Cancer 2018;124:916-24. © 2017 American Cancer Society.

Conditional survival analysis for patients with intraductal papillary mucinous neoplasms (IPMNs) undergoing curative resection

BACKGROUND

Conditional survival (CS) analysis represents a novel method that may provide more clinically relevant perspectives to cancer management compared to conventional survival analysis. The purpose of this study was to evaluate conditional survival for patients with intraductal papillary mucinous neoplasms (IPMNs) undergoing curative resection.

METHODS

A retrospective search of the Surveillance Epidemiology and End Results (SEER) database was performed. Three-year conditional survival (i.e. probability that a patient will survive an additional 3 years if they have already survived x years) was calculated using the formula 3-CS(x)=OS(x+3)/OS(x), where OS represents overall survival.

RESULTS

Overall, 1303 patients were identified, with mean age of 65.2 ± 12.2 years. 3-CS at 1, 3 and 5 years after diagnosis was 35.8%, 47.5% and 44.7%. Patients with stage III/IV disease demonstrated small differences in 3-CS at 1-3 years after diagnosis compared to patients with stage I/II disease (I/II: 35.1%-46.9%, III/IV: 22.1%-42.3%, d range 0.09-0.28), while their 3-CS was superior at 4-5 years after diagnosis (I/II: 41.5%-45.7%, III/IV: 57.9%-64.7%, d range 0.24-0.47). Differences in 3-CS based on tumor grade displayed a different pattern, with small differences at 1-3 years after diagnosis (well-differentiated (WD)/moderately-differentiated (MD): 34.6%-50%, poorly-differentiated (PD)/undifferentiated (UD): 23.2%-40%, d range 0.18-0.24), before becoming prominent at 4-5 years after diagnosis (WD/MD: 50%-51.7%, PD/UD: 24.1%-30%, d range 0.4-0.55).

CONCLUSIONS

Conditional survival for patients with IPMNs undergoing resection improves over time, especially for patients with high-risk features. This information may be used to provide individualized approaches to surveillance and treatment.

Original article: role of adjuvant chemotherapy in a perioperative chemotherapy regimen for gastric cancer

Background

Multimodal treatment strategies – perioperative chemotherapy (CTx) and radical surgery – are currently accepted as treatment standard for locally advanced gastric cancer. However, the role of adjuvant postoperative CTx (postCTx) in addition to neoadjuvant preoperative CTx (preCTx) in this setting remains controversial.

Methods

Between 4/2006 and 12/2013, 116 patients with locally advanced gastric cancer were treated with preCTx. 72 patients (62 %), in whom complete tumor resection (R0, subtotal/total gastrectomy with D2-lymphadenectomy) was achieved, were divided into two groups, one of which receiving adjuvant therapy (n = 52) and one without (n = 20). These groups were analyzed with regard to survival and exclusion criteria for adjuvant therapy.

Results

Postoperative complications, as well as their severity grade, did not correlate with fewer postCTx cycles administered (p = n.s.). Long-term survival was shorter in patients receiving postCTx in comparison to patients without postCTx, but did not show statistical significance. In per protocol analysis by excluding two patients with perioperative death, a shorter 3-year survival rate was observed in patients receiving postCTx compared to patients without postCTx (3-year survival: 71.2 % postCTx group vs. 90.0 % non-postCTx group; p = 0.038).

Conclusion

These results appear contradicting to the anticipated outcome. While speculative, they question the value of post-CTx. Prospectively randomized studies are needed to elucidate the role of postCTx.

Different lymph node staging systems in patients with gastric cancer from Korean: What is the best prognostic assessment tool?

To investigate whether the log odds of positive lymph nodes (LODDS) system is a more accurate prognostic tool than the number-based (pN) or ratio-based (rN) lymph node staging system in Korean patients with gastric cancer (GC).The LODDS is a recently proposed staging modality in surgical oncology. However, it is unclear whether LODDS is superior to the pN or rN system in terms of predicting the prognosis of GC patients who underwent radical gastrectomy with extended lymphadenectomy and had a greater number of retrieved lymph nodes.Clinicopathological data from 3929 patients who had undergone curative gastrectomy for GC were reviewed. In addition, overall survival rates according to pN and rN classification stratified by the LODDS were analyzed. A multivariate analysis of survival rate was performed using a Cox proportional hazard model.pN, rN, and LODDS were significantly correlated with 5-year survival rate. Spearman correlation test showed no correlation between LODDS and number of lymph nodes retrieved. The receiver operating characteristic (ROC) curves showed that the 3 staging systems had comparable prognostic accuracy (P < 0.05). Survival analysis according to pN and rN classification stratified by the LODDS staging system demonstrated that LODDS is superior to pN and rN.The LODDS is independently and significantly associated with the OS of Korean patients with GC, and its prognostic value is superior to that of the other lymph node staging systems in Korean patients.

Characteristics of gastric cancer recurrence five or more years after curative gastrectomy

OBJECTIVE

To investigate the characteristics of recurrences that occurred 5 or more years after curative resection for gastric cancer.

METHODS

We analyzed recurrences among 1,299 patients with gastric cancer who underwent curative operations at the Department of Surgery, Inje University Seoul Paik Hospital between September 1998 and December 2002. Recurrences were classified as within 2 years (early), 2-5 years (intermediate), and more than 5 years (late) after gastrectomy. The clinicopathologic findings of the patients with late recurrence were compared with those of patients in the other two recurrence groups, with special reference to the patterns of recurrence. Both univariate and multivariate analyses were performed, incorporating factors such as operation type, T-stage, N-stage, stage, lymphatic invasion, neural invasion, histology, tumor size, and recurrence site.

RESULTS

At the time of last follow-up, recurrence occurred in 266 (20.5%) patients. Recurrence times were classified as <2 years (182 patients), 2-5 years (61 patients), or >5 years (23 patients). The late recurrence rate was 8.6%. The occurrence of recurrence >5 years after gastrectomy was significantly correlated with age, operation type, T-stage, N-stage, stage, lymphatic invasion, neural invasion, histology, tumor size, location and recurrence site (P<0.05). The main recurrence patterns in the 23 patients with late recurrence were locoregional metastasis (10 patients, 43.5%), peritoneal seeding (8 patients, 34.8%), hematogenous metastasis (2 patients, 8.7%), and multiple metastasis (3 patients, 13.0%). A multivariate analysis showed that larger tumor size and younger age were independent prognostic factors for late recurrence. Additionally, locoregional and peritoneal recurrences were significantly more common than hematogenous recurrences.

CONCLUSIONS

Although late recurrence was uncommon, younger age and larger tumor size were associated with high risk. Follow-up surveillance is recommended for locoregional and peritoneal metastasis.