A comprehensive study on non-cancer-related mortality risk factors in elderly gastric cancer patients post-curative surgery

Recent years have seen a notable increase in gastric cancer among the elderly [1‐3]. With the global population aging, the incidence of this disease in the elderly is expected to rise further. This situation calls for a detailed examination of surgical interventions appropriate for this demographic. Managing gastric cancer in the elderly is complex, requiring a balance between effective treatment and accommodation the unique physiological and comorbid conditions of the elderly. Additionally, the typical male predominance and less aggressive nature of gastric cancer in this age group add to the complexity of management [4].

Gastric cancer surgery, critical curative intent, presents significant challenges, particularly for the elderly. Surgical procedures can compromise gastric and intestinal functions, leading to postoperative complications that are especially harmful in the elderly [3, 5, 6]. The capacity of older patients to withstand the stress of surgery is crucial; even a successful curative resection can lead to deteriorations in health and quality of life.

A major concern in the post-surgical management of elderly gastric cancer patients is the incidence of non-cancer-related fatalities. Previous study have identified key preoperative factors like sex, neutrophil-to-lymphocyte ratio, and skeletal muscle mass index as significant risk factors for non-cancer-related death in this patient group [7]. Despite these insights, a considerable number of elderly patients undergoing curative resection still succumb to non-cancer-related fatalities [8‐10]. This highlights the importance of a comprehensive understanding of the multifaceted challenges these patients face, emphasize the need to further investigate and address these challenges.

Given this context, our study aims to deepen the understanding of non-cancer-related mortality in postoperative elderly gastric cancer patients. We seek to expand upon existing research by exploring additional or interrelated factors, with the goal of uncovering nuances that have been previously overlooked. Our findings are intended to guide clinical decisions and shed light on potential interventions that could mitigate these risks, thereby enhancing postoperative care and outcomes for elderly gastric cancer patients.

The escalating incidence of gastric cancer among the elderly, reflective of broader demographic shifts towards an aging population, presents unique clinical challenges [1‐3]. This demographic shift not only intensifies the complexities inherent in managing elderly patients but also necessities a nuanced understanding of the multifactorial nature of their health outcomes, particularly the elevated incidence of non-cancer-related mortality post-surgery [2, 7‐9]. Previous research has identified individual risk factors such as sex, neutrophil-to-lymphocyte ratio, and skeletal muscle mass index [6], but did not fully address their collective impact on mortality. Our study extends this knowledge by evaluating a broader range of factors, including age, BMI, CCI, and postoperative complications. We found that advanced age (≥ 80 years), high CCI score, and lower BMI (< 18.5) significantly elevate the risk of non-cancer-related mortality. This highlights the importance of a comprehensive risk assessment, considering not only cancer-related factors but also a wider spectrum of health issues [14]. Our findings challenge existing paradigms and emphasize the need for tailored postoperative management strategies in elderly gastric cancer patients, aiming to improve overall outcomes by addressing both cancer and non-cancer-related health risks.

The adoption of MIS in gastric cancer treatment, particularly for elderly patients, represents a paradigm shift in surgical practice [15, 16]. While its less invasive nature is associated with reduced postoperative complications and expedited recovery, the implications of MIS on long-term outcomes, such as non-cancer-related mortality, are less clear. Furthermore, research indicates that the outcomes of MIS in elderly patients are comparable to those in middle-aged patients, emphasizing its efficacy regardless of age [17]. The benefits of MIS, such as diminished postoperative pain and shorter hospital stays, make it a promising approach for treating advanced gastric cancer in the elderly population [18]. Our findings suggest that, despite the recognized perioperative benefits of MIS, including enhanced safety compared to traditional open surgery (OS), its influence on non-cancer-related mortality in the elderly is not as pronounced as previously thought [19]. This observation necessitates a reevaluation of the long-term outcomes associated with MIS, especially in the context of an aging patient population. While the reasons behind this observation remain unclear in our study, it suggests a need for further investigation using national-scale databases to understand the full implications of MIS in this context.

The Comprehensive Geriatric Assessment (CGA) has been recognized as an invaluable tool in the evaluation and management of elderly cancer patients, providing a multidimensional diagnostic process to assess medical, psychosocial, and functional capabilities [20‐22]. This assessment is crucial for formulating coordinated treatment and follow-up plans. Recent evidence suggests that CGA can predict postoperative complications and survival in elderly cancer patients [23, 24], and interventions based on CGA findings have been shown to enhance outcomes in this demographic [25]. In the context of our study, while we do not directly assert the application of CGA, we propose that it could be an essential tool in the preoperative evaluation, particularly for identifying risk factors such as low BMI and high CCI scores. By integrating CGA into the preoperative assessment, there is a potential to improve surgical preparation and optimize care, especially for those patients with higher risks, potentially leading to better postoperative outcomes.

Intriguingly, our data indicated that the TNM classification, traditionally a robust prognostic factor, did not emerge as an independent determinant in our cohort. This observation might be ascribed to the selection bias of excluding initial cases, thereby sidelining tumor factors [26]. This revelation implies that in elderly patients who have undergone curative resection, other determinants, such as comorbidities and overall health status, might play a more pivotal role in shaping outcomes than the tumor's attributes.

Given the rising prevalence of gastric cancer in the elderly and the unique challenges they pose, a paradigm shift in management is called for. Tailored treatment plans that take into account not just the tumor attributes but also the patient's overall health status, functional reserves, and preferences are indispensable [27]. Multidisciplinary teams, comprising geriatricians, nutritionists, and rehabilitation specialists, should be integral to the care of these patients. Moreover, postoperative monitoring and interventions should zero in on preventing and managing non-cancer-related complications.

This study, while offering crucial insights into the non-cancer-related mortality in elderly gastric cancer patients, has several limitations warranting consideration. Foremost, being derived from a single-institution database, it may not fully represent the broader elderly patient population, limiting the generalizability of our findings. The sample size, although substantial for this specific setting, remains modest, particularly in terms of the number of non-cancer-related death events, which could affect the robustness of our conclusions. The study's retrospective design inherently carries the risk of biases in data collection and interpretation. Socioeconomic factors, which can significantly impact patient outcomes, were not included in our analysis. Furthermore, while patients with concurrent cancers were excluded, the potential influence of their prior treatments or interventions was not assessed. It is also noteworthy that our focus on elderly patients was intentional to explore specific challenges in this group, and thus, a younger patient control group was not deemed necessary for our study objectives. To address these limitations and validate our findings, future research should employ larger, multi-institutional datasets, possibly integrating a wider array of demographic and socioeconomic variables.

In conclusion, this study provides critical insights into the factors contributing to non-cancer-related mortality in elderly gastric cancer patients. Our findings underscore that advanced age, low BMI, high CCI, and overall postoperative complications significantly influence patient outcomes. This revelation highlights the need for a holistic approach in the management of these patients, wherein a comprehensive risk assessment should be considered, encompassing both cancer-related and broader health-related factors. Our research suggests that tailored postoperative management, which includes vigilant monitoring and management of complications, is imperative in improving survival outcomes. The development of such strategies should be underpinned by a multidisciplinary approach, taking into account the overall health status and individual preferences of the elderly patient population.