Palliative gastrectomy and other factors affecting overall survival in stage IV gastric adenocarcinoma patients receiving chemotherapy: A retrospective analysis

Abstract

Objective

Most patients with gastric cancer present with locally advanced or metastatic disease and usually receive palliative therapy. We sought to identify factors influencing overall survival in patients with stage IV gastric cancer receiving palliative chemotherapy.

Patients and methods

The records of 311 patients with histological diagnosis of gastric adenocarcinoma were retrospectively reviewed and 17 clinicopathological and therapeutic parameters were evaluated for their influence on overall survival.

Results

In multivariate analysis nine factors were found to independently influence survival: no previous palliative gastrectomy [Hazard ratio (HR, 12; CI 7.969–18.099)], single agent chemotherapy instead of combination chemotherapy (HR, 1.35; CI 1.068–1.721), histological grade III (HR, 1.39; 95% CI 1.098–1.782), the presence of hepatic (HR, 1.6; 95% CI 1.246–2.073) and abdominal metastasis (HR, 1.33; 95% CI 1.039–1.715), CA 72-4 > 7 U/L (HR, 1.39; 95% CI 1.026–1.887), LDH > 225 U/L (HR, 1.72; 95% CI 1.336–2.236], need for blood transfusions (HR, 1.58; 95% CI 1.213–2.082), and weight loss > 5% (HR, 1.96; 95% CI 1.352–2.853) at the time of initial diagnosis. Patients were stratified as low (0–2 factors), intermediate (3–6 factors) and high (7–9 factors) risk and the median survival was 76, 40 and 11 weeks, respectively.

Conclusion

Nine clinical and laboratory factors that adversely affect survival in patients with stage IV gastric cancer who receive chemotherapy were identified. Their concurrent presence seems to have an additive effect as patients with seven to nine factors have the worse prognosis. Palliative gastrectomy and combination chemotherapy appear to be associated with improved survival.

Introduction

Gastric cancer is an aggressive tumor, posing the second leading cause of cancer specific mortality worldwide. Disease prevalence is higher in countries of northeast Asia (Japan, Korea, China), intermediate in Europe, South America and lower in North America, Australia and New Zealand. Overall survival in the United States, Europe and China is 20–25%, however reported survival in Japan is better (52%) which could be attributed to early detection through nationwide implementation of screening programs and optimized management.¹ In Greece, mortality rates from gastric cancer have been reported to be 10.9 and 5.8/10⁵ for men and women, respectively.²

Surgery is considered to be the most appropriate treatment for gastric cancer. However, the majority of gastric cancer patients present with locally advanced or metastatic disease, despite the progress in diagnostic modalities and curative resection is feasible in only 36% of cases; moreover, even patients with presumed resectable disease have relapse rates of 40–60%.³ Evidently, palliative treatment evolves as the primary management strategy for many gastric cancer patients. A number of trials have justified the use of palliative chemotherapy as compared to best supportive care to improve patient survival.⁴ On the contrary, there is still insufficient evidence to recommend palliative gastrectomy in terms of survival benefit and therefore, the decision for surgery in current practice is individualized based on patient’s clinical status and local surgical expertise, aiming at symptom relief and maintenance of patient’s independence and function.

Given that chemotherapy and/or surgery could be associated with significant complications, there is a need to identify prognostic factors which may determine treatment response and survival in stage IV gastric cancer patients. Such an approach could refine palliative management according to the likelihood of clinical benefit. The aim of this study was to evaluate factors affecting survival in patients with stage IV gastric adenocarcinoma receiving palliative chemotherapy.