Rethinking perioperative chemotherapy in older adults with gastric cancer: a retrospective cohort study

Older adults bear a disproportionate burden of gastric cancer yet remain markedly underrepresented in perioperative chemotherapy trials, leading many to undergo upfront surgery without systemic therapy. This study evaluated postoperative outcomes and long-term survival in adults aged ≥75 years undergoing curative gastrectomy, comparing neoadjuvant chemotherapy with upfront surgery alone.

This retrospective cohort study included consecutive patients aged ≥75 years who underwent elective curative-intent gastrectomy for gastric adenocarcinoma at a tertiary academic center between 2011 and 2019. Patients were stratified into upfront surgery (UFS) and neoadjuvant chemotherapy (NEO) groups. Postoperative complications were graded using the Clavien-Dindo classification. Overall survival was analyzed using the Kaplan-Meier method and Cox proportional hazards regression.

Seventy-seven patients were included (43 UFS, 34 NEO). NEO patients were younger (median 78.3 vs. 82.6 years, p = 0.006) and all had stage III disease versus 54.2% in UFS (p < 0.001). Among NEO patients, 23.5% did not complete chemotherapy and grade ≥3 adverse events occurred in 14.7%. Complication rates (29.4% vs. 30.2%, p = 1.0), 90-day mortality (11.8% vs. 9.3%, p = 0.726), and 5-year survival (47.1% vs. 46.5%, p = 1.0) were comparable. Advanced tumor stage (HR 2.47, p = 0.025) and postoperative complications - minor (HR 3.12, p = 0.020) and major (HR 3.33, p = 0.002) - were independent predictors of worse survival. A trend toward improved survival favored the NEO group (adjusted HR 0.49, p = 0.078).

Neoadjuvant chemotherapy was feasible and safe in selected older adults undergoing gastrectomy, without increasing postoperative morbidity or mortality. Postoperative complications were the strongest survival predictors, underscoring the importance of perioperative optimization and individualized, geriatric-informed treatment strategies.