Five-year survival following endoscopic submucosal dissection and gastrectomy in older early gastric cancer patients in the U.S.

Abstract Gastric cancer remains a major global cancer burden and continues to contribute to cancer-related morbidity and mortality in the U.S. It predominantly affects older adults, with a median age at diagnosis of approximately 68 years and nearly 60% of cases occurring in individuals aged 65 years or older. Endoscopic submucosal dissection (ESD) may offer a less invasive alternative to gastrectomy for older patients with early-stage gastric cancer, but U.S.-based evidence remains limited, particularly with respect to outcomes stratified by invasion depth (T1a vs. T1b) and among the oldest age groups (75–79, ≥80). Using the 2022 National Cancer Database, we identified patients aged ≥75 years with first primary T1N0 gastric cancer (2004–2022) treated with ESD or gastrectomy. Propensity score full matching was used to balance demographic, clinical, tumor, and facility characteristics. Weighted Cox models estimated 5-year overall mortality, stratified by invasion depth and age group. Among 2,405 patients, 671 (27.9%) underwent ESD and 1,734 (72.1%) underwent gastrectomy. Gastrectomy was not associated with different mortality compared with ESD among patients aged 75–79 with T1a disease (hazard ratio [HR], 1.80; 95% confidence interval [CI], 0.71–4.57), T1b disease (HR, 0.49; 95% CI, 0.20–1.21), or patients aged ≥80 with T1a disease (HR, 1.01; 95% CI, 0.58–1.78). However, among patients aged ≥80 with T1b disease, gastrectomy was associated with higher mortality (HR, 2.40; 95% CI, 1.23–4.71). In this nationwide cohort of older U.S. patients with early-stage gastric cancer, gastrectomy was associated with higher mortality among patients aged ≥80 with T1b disease. These findings support consideration of less invasive approaches in selected oldest-old patients.