To the best of our knowledge, this is the first study that direct compare TACE and systemic chemotherapy in the treatment for elderly patients with AGCC. The present study showed that the efficacy was comparable between TACE and systemic chemotherapy in the treatment of elderly AGCC patients. In terms of symptom relief, TACE was superior to systemic chemotherapy in terms of efficiency and durability in alleviating dysphagia symptoms, improving patient nutritional status and HRQOL. Therefore, the evidence provided in our study shows that TACE-based therapy can bring higher clinical benefits than systemic chemotherapy in the treatment of elderly patients with AGCC. For elderly patients, TACE is an alternative modality for AGCC treatment.
Although systemic chemotherapy still remains the mainstay of treatment for AGCC, but the long-term outcomes are not satisfactory[13, 15, 18, 23]. Besides, elderly patients with AGCC often have dysphagia, which seriously affects the nutritional status and HRQOL of patients, resulting in poor tolerance of patients for systemic chemotherapy [2, 12]. Although historically, length of survival has been considered the most important factor in assessing the degree of clinical benefit of a treatment, HRQOL has been increasingly recognized as another important factor in assessing overall clinical benefit in the treatment of advanced cancer[10].Therefore, for elderly patients with AGCC, it is of great significance to develop a treatment that can effectively alleviate dysphagia, thereby improving the nutritional status and HRQOL of patients. The results of previous studies suggest that TACE is a reasonable treatment for elderly patients with AGCC[6, 10, 25]. However, there is no direct comparison between systemic chemotherapy and TACE in the treatment of AGCC in elderly patients. Therefore, our study aimed to directly compare the differences between the two treatments in prolonging the survival time, alleviating dysphagia, improving nutritional status and HRQOL in elderly patients with AGCC.
In the present study, compared with systemic chemotherapy, TACE had obvious advantages in terms of safety and efficiency in the treatment of elderly patients with AGCC. The main reasons are as follows: (1) Arterial infusion chemotherapy injects drugs directly into the lesions through super-selective technique, there are no shortcomings such as partial excretion of systemic chemotherapeutic drugs before they come into contact with tumor cells and inactivation caused by plasma protein binding. Compared with systemic chemotherapy, the drug concentration in the primary tumor and its surrounding lymphoid tissue is significantly increased, which makes up for the shortcomings of insufficient drug concentration of local target lesions in systemic chemotherapy. This advantage ensures that TACE can not only quickly and efficiently reduce the tumor burden of the primary tumor, but also take into account the treatment of lymph node metastasis and peritoneal metastasis; (2) Arterial embolization can blocks the blood supply of the tumor, causing severe ischemia and necrosis of tumor cells, thereby inhibiting tumor growth, reducing tumor burden in a short period of time, so as to alleviate dysphagia to the greatest extent in a short time, improve nutritional status and HRQOL; (3) Because the drug is injected directly into the focus, it effectively avoids the metabolic loss of the drug in the liver, kidney and other organs. As a result, AEs are significantly reduced. (4) TACE can reduce the level of serum interleukin, has a certain anti-inflammatory effect, and regulate the immune function of the body, thus resulting in a better efficacy[6, 10, 25].
Na Li et al.[10] evaluated the safety and efficacy of TACE in 32 advanced gastric cancer patients aged over 80 years old. The results of their study demonstrated that TACE is a safe and effective option for super-aged patients with advanced gastric cancer. However, their study design lacks patients receiving only systematic chemotherapy as the control group, which is the unique advantage of our study. For the AEs, consistent with previous studies [10, 25, 26], the frequency of hepatorenal toxicity, gastrointestinal reactions and myelosuppression were significantly lower in the TACE group than in the systemic chemotherapy group. The incidence of fever in the TACE group was significantly higher than that in the systemic chemotherapy group, mostly due to the absorption heat generated by the ischemic necrosis of the tumor caused by arterial embolism. All febrile reactions were grade 1–2 and improved after relevant symptomatic and supportive treatment.
Over the past three decades, the improvement of HRQOL has become one of the important indicators to evaluate the benefits of anticancer therapy[9]. In clinical trials, when treatment-related AEs are considerable, HRQOL assessment is often necessary to help compare the overall clinical benefit of two or more treatment modalities.[5]. However, a gold standard for HRQOL assessment is still lacking. As a reliable and easy-to-use HRQOL assessment scale, FACT-G7 were wildly used to evaluate related symptoms and concerns of advanced cancers in clinical research. Compared with other scales, FACT-G7 greatly reduces the burden of advanced cancer patients for its simplicity [27]. 4 weeks after the first treatment, the HRQOL of patients in the TACE group was significantly improved compared with the baseline, while there was no significant change in the systemic chemotherapy group, which indicated that TACE could improve the HRQOL of patients more rapidly and efficiently than systemic chemotherapy, which greatly enhanced the confidence and compliance of AGCC patients. After 8 weeks of initial treatment, the HRQOL scores in the field of physical well-being subscale and functional well-being subscale were significantly changed compared with the baseline but no significant difference was found in the field of emotion. The reason may be that after 4 weeks of treatment, as the patient's dysphagia have improved, the physical and functional conditions have also improved, but for the patient's emotional status, 8 weeks may be relatively short. The emotional status has not changed, and it is possible that emotional status was relatively stable and will not change with the treatment of the disease
We observed that within 3 days after the initial treatment, 25 patients in the TACE group had more dysphagia than before, considering the ischemia and edema of tumor tissue and surrounding gastric wall caused by arterial embolism, so the space occupying effect was aggravated, thus aggravating the symptoms of dysphagia.
Our study has several limitations. First, this study is a retrospective study with a small sample size. In the future, multi-center and large-sample prospective studies are needed to improve the evidence level of the research conclusions. In addition, according to the inclusion criteria, 29 patients in the TACE group and 36 patients in the systemic chemotherapy group were excluded, and there may be selection bias in this process. Finally, since all the enrolled patients are elderly people, and some indicators in the study are self-assessment by patients, there are cases where some patients are unclear and lead to biased assessment.