| Background and objectivesThe comprehensive prevention and treatment of gastric cancer has made great progress,but the mortality rate is still high.The prognosis of gastric cancer was closely related to the time of diagnosis and treatment.The treatment methods of early gastric cancer included endoscopic resection and surgery.Compared with traditional surgery,endoscopic resection had the advantages of less trauma,fewer complications,faster recovery,and lower cost.The curative effects of the two procedures were comparable,with a 5-year survival rate of over90%.The research on the clinical effect and cost-effectiveness evaluation of endoscopic and surgical treatment can evaluate the clinical effect of different treatment modes,explore the related factors affecting the prognosis of early gastric cancer treatment,and provide clinical epidemiological and health economics basis for clinical selection of optimal diagnosis and treatment plan.Therefore,this study systematically reviewed and evaluated related researches and literatures on the treatment of early gastric cancer.Based on the multicenter cohort study database of patients with early gastric cancer,this study described the incidence,prognosis and related factors of in-hospital adverse events in patients with early gastric cancer,and explored the relationship between disease severity and prognosis in patients with early gastric cancer.We compared the clinical outcomes of endoscopic ESD with surgical treatment.The cost-effectiveness of endoscopic ESD and surgical treatment was evaluated by the distribution characteristics and influencing factors of the treatment cost of patients with early gastric cancer,and the basis for health economics was provided for the choice of treatment mode for early gastric cancer.MethodThis research is divided into three parts:1.The first part was a retrospective cohort study of T1a-M or T1b-SM1/SM2 EGC patients who underwent ESD(n = 810)or surgery(n = 266),based on a cohort database of1076 patients with early gastric cancer.The primary outcome was all-cause mortality at the end of follow-up.Secondary outcomes included length of hospital stay,cost,perioperative mortality/serious nonfatal adverse events,requirement for adjuvant therapy,disease-specific mortality,and cancer recurrence or metastasis at the end of follow-up.Multivariate Cox regression models were used to estimate the association between treatment modality and risk of all-cause mortality.The research analysis includes: the incidence,prognosis and related factors of in-hospital adverse events in patients with early gastric cancer were described;the clinical effects of endoscopic ESD and surgical treatment were compared;the factors that affect the different treatment methods of early gastric cancer and the survival prognosis of patients were explored;after considering the effect of influencing factors,the independent effects of different treatment methods on all-cause mortality and the magnitude of the independent effect were explored.2.This study analyzed the influence of related diseases(comorbidities)and age on survival prognosis in patients with early gastric cancer,and clarified the Charlson Comorbidity Index(CCI)or the Age-Adjusted Charlson Comorbidity Index(ACCI)as a prognostic factor in patients with early gastric cancer.After excluding cases lost to follow-up,using CCI and death as research factors and health outcomes in 903 patients with early gastric cancer,the distribution characteristics of the associated disease scores in patients with early gastric cancer were described and their correlation with survival prognosis was analyzed.In639 elderly patients with early gastric cancer who underwent ESD,we analyzed the impact of CCI on survival and prognosis of patients,different additional treatment decisions after ESD,and their associations.3.This study analyzed the survival cost-effectiveness of different treatment modalities in patients with early gastric cancer.In 810 ESD-treated and 266 surgically operated early gastric cancer patients,propensity scoring was used to match covariates such as sex,age,tumor size,depth of invasion,degree of differentiation,and lymphovascular invasion to make the data of the two groups comparable.With subgroup analysis by age and surgical procedure,this study described the treatment costs of different treatment modalities(ESD and surgery)in patients with early gastric cancer aged 20-60 and aged≥60 years,and treatment costs in different age groups(20-60 and ≥60)of patients with ESD and surgery for early gastric cancer.In patients with early gastric cancer after ESD,the cost-effectiveness method was used to analyze the 5-year survival cost and net monetary benefit of age 20-60 years,and the 5-year survival cost and net monetary benefit of age≥60 years.Results1.Analysis of the effect of different treatment methods in patients with early gastric cancerPatients who underwent ESD had a lower proportion of perioperative mortality(0 vs.1.8%of patients receiving surgery;P=0.004)and nonfatal severe adverse events(3.7% vs.8.0%;P=0.014).After a median follow-up of 47 months(range,12–145 months),there were significant differences between treatments in all-cause mortality(3.4% for ESD vs.10.7%;P<0.001)or disease-specific mortality(1.3% for ESD vs.4.0%;P=0.023),but rate of cancer recurrence or metastasis was not different between the two long-surveillance groups(5.9% for ESD vs.3.6%;P=0.235).After adjusting for clinical factors,all-cause mortality significantly differed between patients who underwent ESD versus surgery(hazard ratio,0.44;95% CI,0.23–0.86;P=0.016).The interaction analysis showed no interactive role in the association between treatment modality and all-cause mortality,indicating that treatment modality was associated with all-cause mortality independently of traditional risk factors.2.Influence of comorbidities on survival and prognosis in patients with early gastric cancerAmong patients with early gastric cancer who underwent ESD and surgery,the age-adjusted Charlson comorbidity score(ACCI≥5 and ACCI<5)had an all-cause mortality rate of 8.7% and 3.2%,respectively(P<0.001);adjusted for other After variable,ACCI score was significantly associated with all-cause mortality(HR=3.04,95%CI: 1.68-5.51).Subgroup analysis by surgical method found that in patients with early gastric cancer after ESD,the Charlson comorbidity score(CCI)was associated with all-cause mortality(HR=2.82,95%CI:1.10-7.23).Subgroup analysis by age found that among patients with early gastric cancer aged≥60,compared with patients with CCI<2,the HR value of all-cause mortality in patients with early gastric cancer with CCI≥2 was 1.52(95%CI: 0.22-3.49),which did not show a statistically significant difference.In elderly patients with early gastric cancer with CCI≤1after ESD,the 5-year and 8-year overall survival rates without additional treatment were 93.7%and 75.3%,respectively,while the 5-year and 8-year overall survival rates with additional treatment were 90.3% and 81.3%,and there was no significant difference in overall survival between the two groups(P=0.836).In elderly patients with early gastric cancer with CCI≥2after ESD,the 5-and 8-year overall survival rates without additional treatment were 39.1%and 39.1%,respectively,while the 5-and 8-year overall survival rates with additional treatment were 50% and 50%,and there was no significant difference between the two groups(P=0.948).Among elderly patients with early gastric cancer without additional treatment after ESD,the overall survival in the CCI≥2 group was significantly lower than that in the CCI≤1 group(P=0.002).Among the elderly patients with early gastric cancer after ESD additional treatment,the overall survival rate of the CCI≥2 group was lower than that of the CCI≤1group,and the difference was statistically significant(P=0.034).3.Survival cost-effectiveness of different treatments in patients with early gastric cancerUsing propensity score matching,among patients with early gastric cancer aged 20-60 years,the average total cost of ESD was 3686.4(3056.3-4989.3)$ and the average surgical cost was 123.5(94.0-188.9)$ lower than the average total cost of surgery8935.7(6827.7-11304.6)$,the average operation cost was 304.9(232.3-375.3)$,and the difference was statistically significant.Among patients with early gastric cancer aged≥60years,the average total cost of ESD was 4148.7(3350.4-5437.5)$,the average surgical cost was 157.3(113.4-369.4)$,and the average total cost of surgery was 9196.7(7097.3-11880.5)$,The average operation cost was 304.9(232.3-375.3)$,and the difference was statistically significant.In the subgroups of patients with ESD and surgery for early gastric cancer,there were no significant differences in the average total cost and average surgical cost between the aged 20-60 and aged≥60 groups.After propensity score matching,among patients with early gastric cancer after ESD,the5-year survival cost of 20-60 years old was 3686.4$,the net monetary benefit(NMB)was965.5$,and the 5-year survival cost of 20-60 years old was 965.5$.It was 4305.3$,and the net monetary benefit(NMB)was 317.1$;in patients with early gastric cancer,the 5-year survival cost of ESD was lower than that of surgery,and the net monetary benefit was higher,that is,ESD surgery has better health and economic benefits.ConclusionsThe study found that perioperative adverse events,all-cause mortality,and long-term gastric cancer-specific mortality were lower in patients with early gastric cancer who received ESD,compared with the surgical group.However,there were no statistically significant differences in the rates of cancer recurrence or metastasis between the two groups.The results of this study also showed that in elderly patients with early gastric cancer after ESD,non-intervention(treatment)was an acceptable or optimal strategy for elderly patients with CCI≥2,and additional treatment could not effectively prolong the life expectancy of patients.In addition,patients with CCI≤1 had better survival prognosis than CCI≥2 patients with or without additional treatment after ESD.Compared with surgical procedures,the total and surgical costs of ESD treatment are lower,that is,ESD procedures have better health and economic benefits. |
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