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GASTRIC CANCER IN THE VERY ELDERLY: BENEFIT OF SURGERY AND SYSTEMIC TREATMENT IN A U.S. POPULATION STUDY
Erin K. Greenleaf*1, Christopher S. Hollenbeak1, Joyce Wong2
1Surgery, Penn State Hershey Medical Center, HERSHEY, PA; 2Surgery, Lennox Hill Hospital, New York, NY
INTRODUCTION: Treatment of gastric cancer (GC) is associated with potential morbidity, particularly among the elderly. This study assesses the survival impact of treatment strategy, including surgery and systemic therapy, for GC among octogenarians and older.
METHODS: The 2003-2012 ACS National Cancer Database was abstracted for octogenarians and older with resectable (stages I-III) GC. Patients were stratified by treatment strategy: surgery with perioperative chemotherapy (neoadjuvant or adjuvant chemotherapy), surgery only, chemotherapy only, and no treatment. Univariate and multivariate analyses were performed.
RESULTS: Of >80-year-old patients with resectable GC, 4.6% (n=187) underwent surgery with chemotherapy, 24.6% (n=1,002) underwent surgery only, 25.5% (n=1,037) underwent chemotherapy only, and 45.4% (N=1,848) received no therapeutic intervention following diagnosis. Patients who underwent surgery with perioperative chemotherapy were younger (median age 81 years, p<0.0001), more frequently male (p<0.0001), white (p=0.002), and privately insured (p=0.005), but with higher clinical stage (p<0.0001). Patients who received no treatment were older (median age 84 years), more frequently female, more often black, and insured with Medicare. Among those undergoing resection, female sex (OR=0.69, p=0.043) and clinical T3 disease (OR=12.91, p=0.018) were the only covariates associated with odds of receiving perioperative chemotherapy, after controlling for demographics, comorbidities, and tumor-related factors. In survival analysis, relative to patients who received no surgery, patients who underwent systemic treatment alone or surgery alone had no added survival benefit. With stages II and III disease, median survival was similar between patients receiving systemic treatment only, surgery only, and no treatment (stage II, 11.6 vs. 13.3 vs. 12.1 months, respectively; stage III, 9.6 vs 7.3 vs. 9.4 months, respectively). However, when octogenarians received perioperative chemotherapy in addition to surgical resection, there was a 24% less hazard of mortality (HR=0.76, p=0.006). For all stages, median survival for patients receiving perioperative chemotherapy was greater (stage I, 25.99 months; stage II, 18.97 months; stage III, 18.46 months) than for all other treatment cohorts.
CONCLUSIONS: Among the very elderly, gastrectomy for GC does not provide a survival benefit unless surgery is accompanied by systemic therapy, although few actually receive this treatment strategy. It appears that surgery alone or systemic therapy alone does not confer added survival benefit over no treatment. Therefore, if elderly patients are fit enough to receive multimodality treatment, clinicians should recommend a multimodality approach, similar to their younger peers.
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