Co-morbidities Rather than Age Impact Outcomes in Patients Receiving Preoperative Therapy for Gastroesophageal Adenocarcinoma

Optimal timing of surgery for gastric cancer after neoadjuvant chemotherapy: a systematic review and meta-analysis

BACKGROUND

Following neoadjuvant chemotherapy, surgical resection is one of the most preferred treatment options for locally advanced gastric cancer patients. However, the optimal time interval between chemotherapy and surgery is unclear. This review aimed to identify the optimal time interval between neoadjuvant chemotherapy and surgery for advanced gastric cancer.

METHODS

Beginning on November 12, 2022, we searched the PubMed, Cochrane Library, Web of Science databases, and Embase.com databases for relevant English-language research. Two authors independently screened the studies, assessed their quality, extracted the data, and analyzed the results. The primary goal was to investigate the relationship between the time interval to surgery (TTS) and long-term survival outcomes for patients. This study has been registered with PROSPERO (CRD42022365196).

RESULTS

After an initial search of 4880 articles, the meta-analysis review ultimately included only five retrospective studies. Ultimately, this meta-analysis included 1171 patients, of which 411 patients had TTS of < 4 weeks, 507 patients had TTS of 4-6 weeks, and 253 patients had TTS of > 6 weeks. In survival analysis, patients with TTS of > 6 weeks had poorer overall survival outcomes than patients with TTS of 4-6 weeks (HR = 1.34, 95% CI: 1.03-1.75, P = 0.03). No significant differences were found in terms of disease-free survival the groups.

CONCLUSION

Based on the current clinical evidence, patients with locally advanced gastric cancer may benefit better with a TTS of 4-6 weeks; however, this option still needs additional study.

Cancer-Related Fatigue After Esophageal Cancer Surgery: Impact of Postoperative Complications

Background

The impact of postoperative complications on cancer-related fatigue is unknown. This nationwide prospective cohort study aimed to assess the trajectory of cancer-related fatigue and the influence of predefined postoperative complications on cancer-related fatigue up to 2 years after esophageal cancer surgery.

Methods

The patients in this study underwent esophagectomy between 2013 and 2019 in Sweden. The exposure was predefined postoperative complications. The outcome was cancer-related fatigue measured by the fatigue scale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and the EORTC QLQ-Fatigue 12 (QLQ-FA12) questionnaire. Linear mixed-effects models provided adjusted fatigue scores and mean score differences (MDs) with 95% confidence intervals (CIs) between patients with and without predefined complications.

Results

The study enrolled 331 patients. The QLQ-C30 fatigue score increased with clinical relevance among patients with any complications (MD, 5.8; 95% CI, 2.6–9.0) who had a higher Clavien-Dindo classification (grades 2 to 3a: MD, 7.3; 95% CI, 3.1–11.5), a medical complication (MD, 6.9; 95% CI, 3.0–10.7), or a pulmonary complication (MD, 6.9; 95% CI, 2.1–11.6) for 1–1.5 years and remained stable until 2 years after esophagectomy. Similar patterns were found in the QLQ-FA12 fatigue and QLQ-FA12 physical and emotional subscales, but not in the cognitive subscales.

Conclusions

Complications in general and medical and pulmonary complications in particular might be associated with increased cancer-related fatigue after esophagectomy.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-11049-z.

National Underutilization of Neoadjuvant Chemotherapy for Gastric Cancer

BACKGROUND

Since the publication of the landmark MAGIC trial in 2006, neoadjuvant chemotherapy has become the standard of care for stage II/III gastric cancer. Nevertheless, many patients still do not begin their treatment with neoadjuvant chemotherapy. The objective of our study was to identify factors associated with underutilization of neoadjuvant chemotherapy for stage II/III gastric cancer.

METHODS

Patients with pathological stage II and III primary gastric cancer between 2004 and 2015 were identified from the American College of Surgeons National Cancer Database. Patients who received neoadjuvant chemotherapy were compared with those who underwent surgery only or surgery followed by chemotherapy. Predictors of receipt of neoadjuvant chemotherapy were identified using multivariable logistic regression model. Median survival was calculated for each treatment strategy.

RESULTS

We included 15,947 patients with pathological stage II/III gastric cancer. The proportion of patients receiving neoadjuvant chemotherapy increased from less than 5% before 2006 to 27.5% in 2015. On multivariable analysis, factors associated with no receipt of neoadjuvant therapy included treatment year before 2006 and age greater than 80. Treatment at high-volume centers, academic research programs, or integrated network cancer programs and undergoing total/subtotal or en bloc gastrectomy predicted receipt of neoadjuvant chemotherapy.

CONCLUSIONS

Ten years after the publication of the MAGIC trial, fewer than 1/3 of patients with stage II/III gastric cancer are receiving neoadjuvant chemotherapy, which has been shown to improve disease-specific survival. Further studies are needed to understand these disparities and ensure both patients and providers are having evidence-based discussions about multimodal therapy for gastric cancer.

Safety and feasibility of laparoscopic gastrectomy accompanied by D1+ lymph node dissection for early gastric cancer in elderly patients

INTRODUCTION

The age of patients with gastric cancer has increased worldwide. The aim of this study was to investigate the safety and feasibility of laparoscopic gastrectomy (LG) for early gastric cancer in elderly patients.

METHODS

We retrospectively investigated 221 consecutive patients who underwent LG for early gastric cancer during a 5-year period (January 2010 to December 2014). We divided the patients into two groups: elderly patients (≥75 years old) and younger patients (<75 years old). We compared these two groups with respect to clinical characteristics, histopathological findings, intraoperative factors, and postoperative outcomes.

RESULTS

The preoperative characteristics were similar in both groups. Except for the number of harvested lymph nodes (42.0 vs 34.9; P = 0.0016), the short-term operative outcomes, including postoperative complications and histopathological findings, were comparable between the two groups. Although significantly fewer lymph nodes were harvested in the elderly group, the overall survival and relapse-free survival rates did not significantly differ between the groups. Postoperative complications, such as acute cholecystitis and internal hernia, occurred during the long-term postoperative period after LG, and these unexpected complications were more frequently observed in elderly patients. All elderly patients required additional emergent surgeries for delayed complications.

CONCLUSION

The outcomes of LG for early gastric cancer in elderly patients seem to be reasonable. Aggressive lymph node dissection may be omissible in elderly patients with acceptable results. LG can be a safe and feasible procedure in elderly patients. However, the higher rate of delayed but urgent complications during the long-term postoperative period must be considered.

Outcomes by treatment modality in elderly patients with localized gastric and esophageal cancer

Background

We aimed to assess current treatment patterns and outcomes in elderly patients with localized gastric and esophageal (ge) cancers.

Methods

This retrospective analysis considered patients 75 years of age or older with ge cancers treated during 2012-2014. Patient demographics and tumour characteristics were collected. Overall survival (os) and disease-free survival were assessed by univariable and multivariable Cox proportional hazards regression, adjusting for demographics. Logistic regression analyses were used to examine factors affecting treatment choices.

Results

The 110 patients in the study cohort had a median age of 81 years (range: 75-99 years). Primary disease sites were esophageal (55%) and gastric (45%). Treatment received included radiation therapy alone (29%), surgery alone (26%), surgery plus perioperative therapy (14%), chemoradiation alone (10%), and supportive care alone (14%). In multivariable analyses, surgery (hazard ratio: 0.48; 95% confidence interval: 0.26 to 0.90; p = 0.02) was the only independent predictor for improved os. Patients with a good Eastern Cooperative Oncology Group performance status (p = 0.008), gastric disease site (p = 0.02), and adenocarcinoma histology (p = 0.01) were more likely to undergo surgery.

Conclusions

At our institution, few patients 75 years of age and older received multimodality therapy for localized ge cancers. Outcomes were better for patients who underwent surgery than for those who did not. To ensure optimal treatment selection, comprehensive geriatric assessment should be considered for patients 75 years of age and older with localized ge cancers.

Underutilization of Treatment for Regional Gastric Cancer Among the Elderly in the USA

BACKGROUND

In the USA, a quarter of elderly patients do not receive any treatment for regional gastric cancer, which results in poorer outcomes. We sought to identify factors associated with undertreatment of regional gastric cancer in this population, as well as to assess overall survival in the undertreated population.

METHODS

Elderly patients (aged ≥ 65 years) diagnosed with regional gastric cancer between 2001 and 2009 were identified from the Surveillance Epidemiology and End Results (SEER)-Medicare linked databases. Treatment was defined as receiving any medical or surgical therapy for gastric cancer. Logistic regression analysis was used to identify factors associated with failure to receive treatment. Overall survival was analyzed using the Kaplan-Meier method and Cox proportional hazard model.

RESULTS

Of 5972 patients with regional gastric cancer, 1586 (26.5%) received no treatment. Median age was 78 years; 56.1% of patients were men. On multivariable analysis, the factors strongly associated with lack of therapy were age ≥ 80 years, black race, lower education level, and diagnosis before 2007. As expected, patients who received therapy had better overall survival (log-rank test, p < 0.001). Specifically, median survival and 5-year survival were 16.5 months and 20.5% for treated patients, compared with 9.1 months and 19.0% for untreated patients.

CONCLUSIONS

Elderly patients with gastric cancer have better overall 5-year survival after receiving treatment for their cancer. Disparities in the use of treatment for curable cancers are associated with older age, black race, lower educational level, and diagnosis before 2007.

Treatment of localized gastric and gastroesophageal adenocarcinoma: the role of accurate staging and preoperative therapy

Gastric cancer is the third most common cause of cancer death worldwide, although it is not in the top 10 causes of cancer death in Northern America. Due to clear differences in incidence, screening, risk factors, tumor biology, and treatment between gastric cancers from Eastern and Western countries, our treatment is primarily guided by trials from Western countries. Patients undergo an extensive staging evaluation including high-quality CT imaging, endoscopic ultrasound, and diagnostic laparoscopy with peritoneal washings for cytology. Patients are presented in multidisciplinary conference with input from medical, radiation, and surgical oncology, in addition to further evaluation of existing studies and biopsy results by diagnostic radiology and pathology colleagues. Due to the well-documented difficulty in tolerating postoperative therapy, patients are frequently treated with preoperative chemotherapy and chemoradiotherapy. Extended lymph node (D2) dissection is routinely performed during subtotal or total gastrectomy. Ongoing trials in Western populations comparing preoperative chemotherapy to chemoradiotherapy will help inform the decision regarding the optimal treatment for patients with resectable gastric cancer. Additional studies are needed to identify predictors of treatment response to identify the optimal preoperative or perioperative approach. As peritoneal disease is the most common site of recurrence, studies are also urgently needed for more accurate methods of detecting peritoneal disease at diagnosis, and also investigating potential treatment modalities such as hyperthermic intraperitoneal chemotherapy.