Surgical outcomes and survival after gastrectomy in octogenarians with gastric cancer

doi:10.1016/j.jss.2015.05.046

Journal of Surgical Research

Volume 198, Issue 1, September 2015, Pages 80-86

https://doi.org/10.1016/j.jss.2015.05.046 Get rights and content

Abstract

Background

The aim of this study was to evaluate the surgical outcomes and survival after gastrectomy in octogenarians and identify the optimal treatment for these patients.

Methods

The medical records of 1262 patients with gastric cancer who underwent gastrectomy from January 2003 to December 2012 were reviewed retrospectively. Patients were divided into two age groups: octogenarians (≥80 y, n = 75) and nonoctogenarians (<80 y, n = 1187). The patients' clinicopathologic data, surgical outcomes, and survival were evaluated.

Results

Octogenarians exhibited a higher proportion of female patients, poorer performance scale scores, higher comorbidities, and more advanced tumor–node–metastasis (TNM) stages than did nonoctogenarians. There was no difference in the surgical curability between the two groups, although octogenarians were more likely to have higher postoperative morbidity and mortality than those of nonoctogenarians. In an analysis of risk factors affecting survival after gastrectomy for octogenarians, only advanced TNM stage was an independent prognostic factor. Overall survival was significantly lower in octogenarians than in nonoctogenarians, whereas disease-specific survival was comparable between the two groups. There was no difference in the disease-specific survival for each stage of cancer after adjustment for tumor stage.

Conclusions

Octogenarians had higher postoperative morbidity and mortality rates but comparable cancer-specific survival compared with nonoctogenarians. Only an advanced TNM stage influenced the prognosis of octogenarians. Early detection and thorough postoperative care would improve the overall survival for octogenarians with gastric cancer.

Introduction

The worldwide incidence and mortality of gastric cancer have fallen dramatically during the past several decades. Nonetheless, gastric cancer is the fourth most common cancer and the second leading cause of cancer death worldwide, thus remaining a major public health issue [1]. Treatment guidelines for gastric cancer have been issued, and a standard therapeutic strategy for gastric cancer according to stage has been established. Gastrectomy with D2 lymph node dissection has been increasingly regarded as the standard surgical procedure for most patients with operable gastric cancer [2], [3].

With the aging of the population, 10%–20% of patients with gastric cancer in developed countries are aged ≥80 y [4]. Although the living conditions and quality of medical care have dramatically improved in many countries, most patients in this age group have comorbidities such as cardiovascular disease and renal or respiratory dysfunction. Some studies have reported that gastrectomy with curative intent for elderly patients is associated with increased postoperative morbidity and mortality [5], [6], whereas other studies have reported that elderly patients can safely undergo gastrectomy [7]. Thus, no consensus has been established on whether these therapeutic strategies are appropriate for treating gastric cancer in elderly patients, especially octogenarians, and controversy still exists.

In the present study, we compared the clinicopathologic findings and surgical outcomes of gastric cancer between octogenarians and nonoctogenarians. We also investigated risk factors and survival to identify the optimal treatment regimen for octogenarians with gastric cancer.

Section snippets

Patients

A total of 1262 patients with gastric cancer who underwent gastrectomy from January 2003 to December 2012 at St. Vincent's Hospital, the Catholic University of Korea were enrolled in this retrospective study. Patients with a history of gastric surgery, neoadjuvant chemotherapy, or palliative procedures such as bypass surgery or exploratory laparotomy were excluded. The patients were classified into two age groups: octogenarians (aged ≥80 y, n = 75) and nonoctogenarians (aged <80 y, n = 1187).

Clinicopathologic characteristics

The clinicopathologic characteristics of the two study groups are shown in Table 1. The mean age was 82.2 ± 2.3 y (range, 80–89 y) among the octogenarians and 59.8 ± 11.8 y (range, 22–79 y) among the nonoctogenarians. The octogenarians exhibited a higher proportion of female patients, poorer Eastern cooperative oncology group scores, and higher comorbidities. There were no differences in the type of gastrectomy or extent of lymphadenectomy between the two groups. In terms of cancer invasion,

Discussion

The proportion of elderly patients diagnosed with malignancies has been increasing, although the prevalence of gastric cancer has approached a plateau or even slightly decreased in recent years [9]. In general, elderly patients have complicated comorbidities and decreased organ reserve; as a result, the postoperative morbidity and mortality rates after gastrectomy with curative intent are higher in elderly than in young patients. Although several recent studies have demonstrated that advances

Conclusions

Octogenarians had higher postoperative morbidity and mortality rates but their cancer-specific survival was comparable with that of nonoctogenarians. The only independent prognostic factor was TNM stage; neither performance scale nor comorbidities had an impact on prognosis. There is a need to pay more attention to early detection because equivalent long-term survival is achievable in the selected octogenarians. Careful patient selection is also important in those with advanced stage.

Acknowledgment

Author contributions: K.H.J., J.H.K., and H.M.C. designed the research; J.H.K., K.H.J. performed the research; K.H.J. and H.M.C. analyzed the data; and K.H.J. and J.H.K. wrote the manuscript.

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Gastric cancer is one of the most frequent and deadly tumours worldwide. However, the evidence that currently exists for the treatment of older adults is limited and is derived mainly from clinical trials in which older patients are poorly represented.
In this article, a group of experts selected from the Oncogeriatrics Section of the Spanish Society of Medical Oncology (SEOM), the Spanish Group for the Treatment of Digestive Tumours (TTD), and the Spanish Multidisciplinary Group on Digestive Cancer (GEMCAD) reviews the existing scientific evidence for older patients (≥65 years old) with gastric cancer and establishes a series of recommendations that allow optimization of management during all phases of the disease. Geriatric assessment (GA) and a multidisciplinary approach should be fundamental parts of the process. In early stages, endoscopic submucosal resection or laparoscopic gastrectomy is recommended depending on the stage. In locally advanced stage, the tolerability of triplet regimens has been established; however, as in the metastatic stage, platinum- and fluoropyrimidine-based regimens with the possibility of lower dose intensity are recommended resulting in similar efficacy. Likewise, the administration of trastuzumab, ramucirumab and immunotherapy for unresectable metastatic or locally advanced disease is safe. Supportive treatment acquires special importance in a population with different life expectancies than at a younger age. It is essential to consider the general state of the patient and the psychosocial dimension.
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However, in practice it is often difficult to remove chronological age from the clinical decision-making equation [8]. With appropriate patient selection, short-term mortality may be similar between older and younger patients following tumor resections across cancer types [9–21]. Despite this evidence and the increase in resection rates among octogenarians over the last decade, older patients are still less likely to receive consultations with specialists and undergo treatment than younger patients [22–26].
Older adults with cancer may not receive the same opportunities for treatment as younger patients. In this retrospective population-based cohort study, we explored whether age was an independent predictor of receiving specialist consultation and treatment.
Patients age 45–99 were identified from the Ontario Cancer Registry having a primary solid tumor diagnosed between 01/Jan/2010 and 31/Dec/2019. We used logistic regression adjusted sociodemographic and clinical characteristics to compare the likelihood of consultation or receipt of treatment using linear splines at critical ages of 65, 80, and 90 years.
A total 168,232 (42%), 165,205 (41%), 57,360 (14%), and 7810 (2%) patients were diagnosed age 45–64, 65–79, 80–89, and 90–99, respectively. The likelihood of surgical consultation decreased as patients reached 65 years [adjusted odds ratio (aOR) 0.86 (0.84–0.89)], which decreased further among octogenarians [aOR 0.63 (0.59–0.67)]. Similar results were observed for consultation with a medical oncologist and radiation oncologist. Receipt of surgery also decreased with age. Three-month post-operative mortality was higher among older patients [aRR 1.38 (1.26–1.50) per 10 years, p < 0.0001], an effect that remained similar as patients reached age 65 + years of age (p = 0.09 for change). For stage I patients, 3-month post-operative survival was high across all age groups, ranging from 99.8% in 45–64 year-olds, 99.4% in 65–79 year-olds, and 98.1% among octogenarians and nonagenarians (lung, colorectal, breast, cervical cancer patients).
Older patients were less likely to have specialist consultations. More comprehensive data collection on clinical factors and referral patterns is needed to improve care for elderly cancer patients.
Surgical resection of gastric gastrointestinal stromal tumors (GIST) in octogenarians
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In this study, we found an appreciable 90-day perioperative mortality rate in octogenarians undergoing surgery for gastric GIST. This rate is congruent with prior studies on gastric resections for gastric cancer with reported 30-day mortality rates of 4–7.2% vs 0.3–2.5% among octogenarians and non-octogenarians, respectively.16,17 In this study, we found that those octogenarians who underwent surgical resection were more likely to have tumors in the body of the stomach or antrum/pylorus and not present in the fundus or cardia, which may necessitate a lengthier or more complex surgery.
Localized gastrointestinal stromal tumors (GISTs) are rare tumors typically managed with surgery, but outcomes among octogenarians remain less studied.
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Identified octogenarians (N = 949) who underwent resection (N = 632) had improved adjusted OS (71% vs 59.6%, HR 0.75, p 0.049) as compared to non-resected patients. Following matching, 90-day mortality was 5.7% and 11% in resected and non-resected patients (p 0.052), respectively. After exclusion of patients with 90-day mortality, resected patients maintained an OS advantage (77.3% vs 71.1%, HR 0.64, p 0.028).
The majority of octogenarians with localized gastric GIST are treated with surgery portending improved survival but an appreciable mortality, suggesting a necessity for careful selection of older patients for surgery.
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Gastroesophageal adenocarcinoma is a disease of older adults with very poor survival rates. Its incidence has risen dramatically across the world in recent decades. Current treatment approaches for older adults are based largely on extrapolated evidence from clinical trials conducted in younger and fitter participants than those more commonly encountered in clinical practice. Understanding how to apply available evidence to our patients in the clinic setting is essential given the high morbidity of both curative and palliative treatment. This review aims to use available data to inform the management of an older adult with gastroesophageal adenocarcinoma.
Prediction of postoperative mortality and morbidity in octogenarians with gastric cancer - Comparison of P-POSSUM, O-POSSUM, and E-POSSUM: A retrospective single-center cohort study
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The purpose of this study was to evaluate various POSSUM scoring systems in predicting postoperative morbidity and mortality in elderly patients with gastric cancer.
A total of 1262 patients with gastric cancer who underwent curative gastrectomy between January 2006 and December 2013 were retrospectively reviewed. The subjects were stratified by age into <80 years old and ≥80 years old. To assess the predictability and efficacy of various POSSUM scores (POSSUM, P-POSSUM, O-POSSUM, and E-POSSUM), the observed-to-expected (O:E) ratio and area under the receiver operating characteristic curve (AUC) were calculated and compared with actual postoperative morbidity and mortality.
Among the 1262 patients, 75 were elderly (≥80 years old). The observed mortality rates were 0.5% (n = 6) in the whole cohort, and 4.0% (n = 3) in elderly patients. The predicted mortalities of POSSUM, P-POSSUM, E-POSSUM, and O-POSSUM for elderly patients were 13.2%, 5.3%, 5.7%, and 21.8%, respectively (O:E ratio = 0.3, 0.75, 0.7, and 0.18, respectively). P-POSSUM and E-POSSUM showed superior discriminatory power compared to POSSUM and O-POSSUM. In terms of morbidity, E-POSSUM showed better predictive capabilities than POSSUM in elderly patients (O:E ratio = 0.56 and 0.74, respectively).
All POSSUM scoring systems tend to overestimate postoperative mortality and morbidity in gastric cancer patients. E-POSSUM and P-POSSUM provided a better prediction of mortality and morbidity after curative gastrectomy in elderly patients compared to other POSSUM scores.
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This is, however, very close to the median age of diagnosis, which is 69 in the current era.8-10 Furthermore, most series examining the perioperative outcomes of octogenarians are limited in size.11,12 Therefore, we examined the American College of Surgeon's National Surgical Quality Improvement Program participant user file (ACS-NSQIP PUF) to examine the perioperative outcomes of octogenarians undergoing gastrectomy for malignancy.
Studies on perioperative outcomes of octogenarians with gastric cancer are limited by small sample size. Our aim was to determine the outcomes of gastrectomy and the variation of treatments associated with advanced age (≥80 y).
The National Surgical Quality Improvement Program database was queried from 2005 to 2011. Patients who underwent gastrectomy for malignancy were identified using International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes.
Of 2591 cases, 487 patients were octogenarians (≥80) and 2104 were nonoctogenarians (<80). Overall, 4.9% of patients had disseminated cancer. Octogenarians had higher 30-d mortality (7.2% versus 2.5%, P < 0.01) and more major complications (31.4% versus 25.5%, P < 0.01), though fewer octogenarians underwent total gastrectomy (24.0% versus 43.2%, P < 0.01) and extended lymphadenectomy (10.1% versus 17.4%, P < 0.01) than the nonoctogenarian cohort. On multivariate analysis, age ≥80 y was associated with major complications (OR, 1.3; 95% CI, 1.03-1.6; P = 0.03) and increased mortality (OR, 3.0; 95% CI, 1.9-4.9; P < 0.01).
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GastrointestinalSurgical outcomes and survival after gastrectomy in octogenarians with gastric cancer

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Patients

Clinicopathologic characteristics

Discussion

Conclusions

Acknowledgment

Lancet Oncol

Ageing Res Rev

J Gastrointest Surg

J Surg Res

Eur J Surg Oncol

Epidemiology of gastric cancer

World J Gastroenterol

Japanese gastric cancer treatment guidelines 2010 (ver. 3)

Gastric Cancer

Morbidity and mortality in the Italian Gastric Cancer Study Group randomized clinical trial of D1 versus D2 resection for gastric cancer

Br J Surg

Guideline recommended gastric cancer care in the elderly: insights into the applicability of cancer trials to real world

Ann Surg Oncol

Total gastrectomy. Updated operative mortality and long-term survival with particular reference to patients older than 70 years of age

Ann Surg

Is extended lymph node dissection necessary for gastric cancer in elderly patients?

Eur J Surg

Surgical outcomes of gastrectomy for elderly patients with gastric cancer

World J Surg

Gastrointestinal
Surgical outcomes and survival after gastrectomy in octogenarians with gastric cancer