As the population ages, it is well anticipated that the number of elderly patients with early gastric cancer would continue to increase6, 14. Although curative gastrectomy is a preferred treatment for early gastric cancer (EGC)15, a less invasive alternative, endoscopic treatment, is very attractive in this respect. While gastrectomy could provide adequate curative resection of EGC, it also caused higher risk of perioperative morbidities and gastrointestinal dysfunction as well as decreased quality of life16–18. Therefore, the optimal treatment strategy for elderly population is a challenge for gastroenterologists and raises great concerns. For elderly patients with some comorbidities, the less invasive treatment, endoscopic treatment, might be a more suitable approach compared to surgery19. According to previous studies, ET, either ESD or EMR had been proved as a feasible and safe technique for the early gastric cancer with appropriate indications 20–22. Besides, it was reported that the clinical and survival outcomes of ET were not inferior to those of surgery, especially for ESD23. Therefore, it is reasonable to presume that ET was a safety and promising tool for EGC that fulfilled certain indication criterion. At presently, however, limited studies directly compared survival outcomes of ET with those of surgery, especially for elderly patients. Chiu et al16. reported that similar oncological outcomes between ESD and radical gastrectomy in 144 patients with EGC. Compared with surgery group, ESD group had better perioperative outcomes, less complication rate, and hospital stay16. In another study by Park et al23. Outcomes of surgery and ESD were compared in 518 elderly patients with EGC and overall survival did not differ among two groups. In addition to limited patients’ size, those population were all from Asia and the conclusion may not be applicable to Western patients. Therefore, large population-based studies from other regions need to be conducted.
In present study, we included 5639 patients to investigated the survival outcomes of different treatments in elderly patients with EGC. Among them, 2193 patients (52%) received either gastrectomy or endoscopic treatments. Gastrectomy was still the mainstay of treatment for older patients with EGC. However, no disease-specific survival difference between ET and surgery groups was noticed in the current study. Furthermore, the similar disease-specific survival rate at one, three and five years after ET or surgery also indicated the effectiveness of ET. In Cox regression, tumour stage, grade, extension and year at diagnosis were also significantly associated with cancer-specific mortality. Given the lack of detailed data in the SEER database regarding ET, this study could not identify whether it was performed by ESD or EMR. The results of this study appear to be in accordance with former studies. According to previous studies, ET, especial for ESD, had high resection rates with minimal associated adverse events24. Compared with surgery, the advantage of ET is maintaining general function of stomach and good quality of life after treatment. Therefore, for elderly patients, the less invasive treatment might be a preferred choice in consideration of the aforementioned complications for surgery.
Despite of a larger population-based study, our study still had some limitations that warrant further discussions. Firstly, this study was the retrospective analysis from a single country and obvious selection bias was inevitable according to the treatment modality. Secondly, the database did not include comorbidities, disease progression or recurrence, and details on endoscopic resection procedures. Despite these limitations, our study also provided some evidence about feasibility and validity of ET for elderly patients with EGC.
In conclusion, ET is a promising and safe therapy for elderly patients with EGC. Because of similar survival outcomes between the patients who undergo ET and surgery, ET could be considered as an initial treatment option for elderly patients, which might have implications for therapy decision making. More well-designed large clinical studies are further needed to confirm the utility of ESD among elderly patients with EGC.