Early gastric cancer in super-agers: To treat or not to treat?

Although not shown in trials, high performance skill seems to be even more important in super-agers than in younger patients because of increased risks in terms of extension of procedural duration and the consequences of severe adverse events. Gastric cancer is one of the leading causes of cancerrelated mortality worldwide. The incidence is lower in most of the Western countries, like the United States, than in East Asia, where approximately half of the cases occur. However, despite a gradually decreasing incidence, the estimated number of new cases of gastric cancer in the United States in 2016 is still 26,370. Approximately 0.9% of men and women will receive diagnoses of stomach cancer at some point during their lifetime, in comparison with a rate of 0.5% for esophageal cancer. Unfortunately, only every fourth case is diagnosed at a local stage in most Western countries, and the overall 5-year survival rate is limited to 20% to 30%. Much higher rates of early detection can explain the better overall prognosis in East Asia. It can be expected that future guidelines for gastric cancer screening and surveillance of precancerous conditions could improve the diagnosis of early tumor stages in Western countries. In addition, a more thorough inspection of the stomach during endoscopy is required to reduce the substantial risk of missing early lesions. Endoscopic resection in selected cases of early gastric cancer (EGC) has been widely accepted in Asia and many Western countries. It offers advantages over open or laparoscopic surgery because of the minimally invasive approach, organ preservation, and a higher postoperative quality of life with a similar efficacy in terms of oncologic aspects. The guidelines of the Japan Gastroenterological Endoscopy Society and the Japanese Gastric Cancer Association provide diagnostic criteria for selecting patients with early tumor stages that are associated with a negligible risk of lymph node metastases. Comparative studies indicate that the clinical outcomes of endoscopic submucosal dissection (ESD) of early gastric cancer are comparable between absolute and expanded criteria. Further follow-up studies over a longer period are warranted. It remains controversial whether data from Asia can be applied to Western countries. A recent histologic study of a large number of gastrectomy specimens showed higher rates of lymph node metastases in early gastric cancer in patients from the United States than those previously reported in Asia. However, several differences between these studies have to be considered. In the