Endoscopic submucosal dissection for early gastric cancer in the elderly: Spanish multicenter prospective study during initial experience

TL;DR

This study shows that endoscopic submucosal dissection (ESD) is a safe and effective treatment for early gastric cancer in elderly patients, though survival rates are lower in those over 80 due to comorbidities.

Contribution

The study provides new survival data for elderly Western patients undergoing ESD for early gastric cancer, highlighting risks and outcomes specific to octogenarians.

Findings

Five-year overall survival was 78% in patients in their 70s and 57% in those in their 80s.

ASA-PS ≥ III was the only independent risk factor for lower overall survival in octogenarians.

Delayed bleeding and 30-day mortality were higher in patients aged 80 and older.

Abstract

Data on survival for elderly Western patients undergoing endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) are scarce.

A multicenter, prospective, cohort study (2016–2022) was conducted in 26 Spanish hospitals that included patients aged > 70 years treated with ESD for EGC. The primary endpoint was overall survival in octogenarians compared with the previous decade; secondary outcomes included safety and technical success.

A total of 217 patients were included, 135 in their 70s (Group A) and 82 in their 80s (Group B). Group B had higher comorbidity (73.2% vs 46.7%;
P
< 0.001) and greater anticoagulant use (39.5% vs 17.3%;
P
< 0.001). Technical success and intraprocedural adverse events were similar, but delayed bleeding was higher in Group B (22.8% vs 8.2%;
P
= 0.003). No intraprocedural deaths occurred, but three patients in Group B (3.6%) died within 30 days (2 post-ESD, 1 post-surgery). Of 169 patients followed (77.9%), 28 died (16%), including two cancer-related deaths in Group B. Five-year overall survival (OS) was 78% in Group A and 57% in Group B (
P
= 0.03); median survival in Group B was 58.5 months. Multivariate analysis identified American Society of Anesthesiologists performance status (ASA-PS) ≥ III as the only independent risk factor for lower OS (hazard ratio 3.9; 95% confidence interval 1.3–11.3;
P
= 0.014).

Octogenarians with EGC benefit from ESD in a Western setting in terms of disease-free survival, but have lower long-term survival due to comorbidities, underscoring the importance of pre-procedure risk assessment. ESD is a proven safe technique, but in the subgroup of patients aged ≥ 80 years with severe comorbidities (ASA-PS ≥ IV), periprocedural mortality is increased and the indication should be carefully evaluated.

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