Indications and Curability Criteria for Endoscopic Resection of Early Gastric Cancer in Elderly Patients: Current Standards and Future Perspectives

Abstract

Population aging has substantially altered the epidemiology and management of gastric cancer, particularly in East Asia, where a growing proportion of patients with early gastric cancer (EGC) are elderly. Current Japanese guidelines define indications and curability criteria for endoscopic resection (ER) irrespective of age. Consequently, gastrectomy with lymphadenectomy remains the standard treatment for EGC that exceeds established absolute and expanded ER indications or is classified as endoscopic curability (eCura) C-2 after ER. However, given the heterogeneity of metastatic risk and patient characteristics, uniform recommendation of gastrectomy may result in overtreatment in elderly patients. Nationwide registry data on patients undergoing gastrectomy have demonstrated that overall prognosis becomes increasingly limited and postoperative mortality rises with age, especially in men aged ≥ 75 years and women aged ≥ 80 years. These findings highlight the need to reconsider ER indications and post-resection management in elderly patients based on estimated lymph node metastasis (LNM) risk, operative mortality, and life expectancy. Recent studies suggest that expanding ER indications and redefining curability criteria in elderly patients using a higher acceptable LNM risk threshold, such as 10%, may represent a rational risk-adapted strategy. This concept is currently being evaluated in the multicenter phase III confirmatory trial conducted by the Japan Clinical Oncology Group (JCOG1902). Importantly, long-term outcomes in elderly patients with EGC are influenced by non–gastric cancer deaths. Therefore, management strategies should integrate tumor-related risk with patient-related factors, including comorbidities, nutritional status, frailty, and competing mortality risks, to achieve individualized and clinically meaningful care in this expanding population.