Abstract
Background
Endoscopic therapy (ET) and surgical resection (SR) are common surgical methods for the treatment of colorectal neuroendocrine tumors (CRNETs). However, for elderly patients, it remains unclear which surgical method yields better long-term outcomes.
Methods
Elderly patients ≥ 65 years with CRNETs diagnosed from 2000 to 2020 were identified from the Surveillance, Epidemiology, and End Results database. Propensity score matching (PSM) was used to minimize selection bias. The Kaplan–Meier method and Cox proportional hazards models were utilized to evaluate the effects of diverse demographic and clinical factors on overall survival (OS) and cancer-specific survival (CSS).
Results
A total of 2214 patients were included in the study, with 1417 patients in the ET group and 797 patients in the SR group. After PSM, the ET group outperformed the SR group in terms of OS (hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.44–0.70) and CSS (HR 0.21, 95% CI 0.11–0.40). Similarly, the ET group maintained its advantage in mean 1-, 3-, and 5-year OS and CSS rates compared to the SR group (P < 0.001). Multivariate Cox regression analysis identified age, sex, grade, marital status, and treatment modality as independent risk factors affecting OS, while age, sex, marital status, and treatment modality were identified as independent risk factors affecting CSS.
Conclusions
ET offered superior long-term outcomes for elderly patients ≥ 65 years with CRNETs.
Supplementary Information
The online version contains supplementary material available at 10.1007/s00464-024-11220-z.
Keywords: Colorectal neuroendocrine tumors, Elderly patients, Endoscopic therapy, Surgical resection, Long-term outcomes
Neuroendocrine tumors (NETs) are a category of tumors that stem from peptidergic neurons and neuroendocrine cells capable of secreting hormones or other bioactive substances [1, 2]. The digestive tract is the most common site of neuroendocrine neoplasms, accounting for about two thirds of NETs [3, 4]. However, colorectal NETs (CRNETs) are relatively rare, accounting for about one third of all gastrointestinal NETs [5, 6]. In recent decades, the incidence of colorectal NETs has been increasing globally. In addition to the advancement of diagnostic techniques, the increase may also be related to the rise in colonoscopy procedures and increased awareness among doctors [7–9]. Meanwhile, with the aging of the global population, the number of elderly patients with CRNETs is also increasing. However, many elderly patients not only have various comorbidities but also show a decline in physical function due to age [10, 11]. Therefore, it is particularly important to find an effective surgical method for elderly patients with CRNETs.
At present, the primary treatment options for CRNETs include endoscopic therapy (ET) or surgical resection (SR) based on the staging, while unresectable cases require pharmacological therapy [12–14]. Zhu et al. [15] compared the prognosis of T1N0M0 patients with CRNETs treated with ET and SR. The results indicated comparable overall survival (OS) and cancer-specific survival (CSS) between the two groups. Additionally, based on a subgroup analysis considering different sizes and locations, both groups exhibited similar long-term prognosis. Xu et al. [16] analyzed the prognosis of 10-20 mm CRNETs treated with ET and SR, employing an inverse probability weighting technique to adjust for potential confounders. Their findings revealed no statistically significant prognostic difference between the two groups. However, for mucosal-limited lesions without lymph node or distant metastasis, the ET group showed an advantage. Conversely, for lesions with muscular invasion or lymph node and distant metastasis, the SR group demonstrated a prognostic advantage. Nonetheless, the long-term prognosis of ET and SR specifically for elderly patients with CRNETs remains unclear. To address this knowledge gap, we conducted a study with the aim of comparing the long-term prognosis of elderly patients with CRNET treated with ET versus SR, using data from the Surveillance, Epidemiology, and End Results (SEER) database.
Methods
Patient selection
The research targeted patients who were diagnosed with CRNETs between 2000 and 2020, data for these patients was sourced from the SEER database (accessible via http://seer.cancer.gov). The SEER website provides an abundance of user manuals, tutorials, and various resources to aid users in comprehending and effectively utilizing its data. The codebook acts as a comprehensive guide that outlines the encoding and interpretation of every variable within the database, offering definitions, classifications, and possible values to assist users in accurately interpreting and applying the data. According to the SEER Program Coding and Staging Manual, codes C18.0-Cecum, C18.1-Appendix, C18.2-Ascending colon, C18.3-Hepatic flexure of colon, C18.4-Transverse colon, C18.5-Splenic flexure of colon, C18.6-Descending colon, C18.7-Sigmoid colon, C18.8-Overlapping lesion of colon, C18.9-Colon, NOS, C19.9-Rectosigmoid junction, C20.9-Rectum, NOS are defined as CRNETs. These patients were pinpointed by referring to the International Classification of Diseases for Oncology, 3rd Edition (ICD-O-3), with the code 8240/3 specifically designating carcinoid tumor, NOS. We excluded patients based on certain criteria: (1) those below 65 years; (2) patients with unknown survival information; (3) those with tumors exceeding 2.0 cm or of indeterminate size; (4) patients with unclear surgical details or methods; (5) those exhibiting lymph node metastasis; and (6) individuals with distant metastasis. A flowchart representing the research process is exhibited in Fig. 1. The exploration encompassed diverse factors like age, gender, diagnosis year, tumor grade, T stage, marital status, chemotherapy administration, cancer-specific mortality rate, overall survival status, and duration of follow-up. These factors were selected a priori based on previous research [15–18]. As per the SEER Program Coding and Staging Manual, the treatment of CRNETs is divided into ET (using codes: 11-Photodynamic therapy, 12-Electrocautery; fulguration (including the use of hot forceps for tumor destruction), 13-Cryosurgery, 14-Laser, 20-Local tumor excision, NOS, 26-Polypectomy, NOS, 27-Excisional biopsy, 21-Any combination of 20 or 26, 27 with photodynamic therapy, 22-Any combination of 20 or 26, 27 with electrocautery, 23-Any combination of 20 or 26, 27 with cryosurgery, 24-Any combination of 20 or 26, 27 with laser ablation) and SR (using codes: 30-Partial colectomy (but less than hemicolectomy) segmental resection, 40-Subtotal colectomy/hemicolectomy (total right or left colon and a portion of the transverse colon), 50-Total colectomy (removal of the colon from the cecum to the rectosigmoid junction; may include a portion of the rectum), 60-Total proctocolectomy (removal of the colon from the cecum to the rectosigmoid junction, including the entire rectum)). Marital status was bifurcated into married and unmarried, with the latter umbrella including divorced, separated, single, or widowed individuals. Our primary objective was to evaluate OS and CSS among elderly CRNETs patients. Both OS and CSS were computed from the CRNET diagnosis until death, cancer-related death, or the final follow-up, whichever occurred first. Given that the SEER database provides anonymized public data, neither IRB approval nor explicit consent was required. This study’s reporting adheres to the STROBE guidelines [19].
Fig. 1.
Flow chart of the study
Multiple imputation
To address missing data issues across multiple variables, including grade (missing in 34.2% of cases), T stage (missing in 23.1% of cases), and marital status (missing in 11.3% of cases), the random forest approach was employed. This method made use of multiple imputation (MI) through the R software (version 4.1.0) to fill in the missing data gaps.
Statistical analysis
Categorical variables were expressed in terms of frequencies and percentages, and group comparisons were carried out using the Chi-square test. For continuous variables that deviated from a normal distribution, the median and interquartile range (IQR) served as descriptive statistics, while the Mann–Whitney U test aided in comparing groups. To guarantee the comparability of the ET and SR cohorts, 1:1 propensity score matching (PSM) was applied. The propensity model encompassed factors such as age, gender, diagnosis year, tumor grade, T stage, marital status, and chemotherapy treatment, with a caliper width set at 0.01. OS and CSS were evaluated using the Kaplan–Meier method, and group disparities were explored using the log-rank test. Hazard ratios (HRs) and 95% confidence intervals (CIs) were derived from both univariate and multivariate Cox proportional hazard models. Variables found to be significant (P < 0.05) in the univariate Cox regression analysis were further included in the multivariate analysis. All statistical computations were performed using R software (version 4.1.0). Statistical significance was established at a P-value less than 0.05 for determining group differences.
Results
Patients characteristics
The study encompassed a total of 2214 patients, specifically 1417 in the ET group and 797 in the SR group. Prior to PSM, notable disparities were evident between the groups with regards to age, diagnosis year, tumor grade, T stage, and chemotherapy treatment (P < 0.05). Following 1:1 PSM, the ET and SR groups both comprised of 698 individuals each. No statistically meaningful differences were identified during the baseline data evaluation (P > 0.05) (Table 1). Table 1 outlines the detailed demographic and clinical characteristics of the patients, whereas Supplementary Table 1 presents a comprehensive comparison of these factors between the two groups before MI.
Table 1.
Comparison of the demographic and clinical characteristics of patients before and after PSM
| Variables | Before PSM | After PSM | |||||
|---|---|---|---|---|---|---|---|
| Total (n = 2,214) | ET group (n = 1,417) | SR group (n = 797) | P-value | ET group (n = 698) | SR group (n = 698) | P-value | |
| Age, years | < 0.001 | 1.000 | |||||
| < 80 | 2,007 (90.7%) | 1,326 (93.6%) | 681 (85.4%) | 643 (92.1%) | 643 (92.1%) | ||
| ≥ 80 | 207 (9.3%) | 91 (6.4%) | 116 (14.6%) | 55 (7.9%) | 55 (7.9%) | ||
| Sex | 0.226 | 0.830 | |||||
| Male | 1,024 (46.3%) | 669 (47.2%) | 355 (44.5%) | 330 (47.3%) | 326 (46.7%) | ||
| Female | 1,190 (53.7%) | 748 (52.8%) | 442 (55.5%) | 368 (52.7%) | 372 (53.3%) | ||
| Year of diagnosis | < 0.001 | 0.921 | |||||
| 2000–2006 | 223 (10.1%) | 164 (11.6%) | 59 (7.4%) | 48 (6.9%) | 51 (7.3%) | ||
| 2007–2013 | 683 (30.8%) | 555 (39.2%) | 128 (16.1%) | 111 (15.9%) | 114 (16.3%) | ||
| 2014–2020 | 1,308 (59.1%) | 698 (49.3%) | 610 (76.5%) | 539 (77.2%) | 533 (76.4%) | ||
| Grade | < 0.001 | 1.000 | |||||
| I | 1,838 (83.0%) | 1,124 (79.3%) | 714 (89.6%) | 624 (89.4%) | 624 (89.4%) | ||
| II | 376 (17.0%) | 293 (20.7%) | 83 (10.4%) | 74 (10.6%) | 74 (10.6%) | ||
| T stage | < 0.001 | 0.772 | |||||
| T1 | 2,126 (96.0%) | 1,377 (97.2%) | 749 (94.0%) | 684 (98.0%) | 680 (97.4%) | ||
| T2 | 45 (2.0%) | 30 (2.1%) | 15 (1.9%) | 10 (1.4%) | 13 (1.9%) | ||
| T3 | 43 (1.9%) | 10 (0.7%) | 33 (4.1%) | 4 (0.6%) | 5 (0.7%) | ||
| Marital status | 0.534 | 0.956 | |||||
| Married | 1,322 (59.7%) | 853 (60.2%) | 469 (58.8%) | 419 (60.0%) | 420 (60.2%) | ||
| Unmarried | 892 (40.3%) | 564 (39.8%) | 328 (41.2%) | 279 (40.0%) | 278 (39.8%) | ||
| Chemotherapy | < 0.001 | 0.526 | |||||
| No/Unknown | 2,191 (99.0%) | 1,413 (99.7%) | 778 (97.6%) | 694 (99.4%) | 692 (99.1%) | ||
| Yes | 23 (1.0%) | 4 (0.3%) | 19 (2.4%) | 4 (0.6%) | 6 (0.9%) | ||
| Survival months, median (IQR) | 54.0(23.0,97.0) | 67.0(33.0,112.5) | 34.0(11.0,63.0) | < 0.001 | 40.0(20.0,67.0) | 36.5(12.0,63.3) | 0.002 |
ET endoscopic therapy, SR surgical resection, PSM propensity score matching, IQR interquartile range
Bold values indicate P < 0.05
Survival analysis of patients with colorectal neuroendocrine tumors
Before PSM, patients in the ET group diagnosed with CRNETs showed average 1-, 3-, and 5-year OS rates of 97.3%, 92.2%, and 85.2% respectively, whereas those in the SR group demonstrated rates of 87.5%, 75.5%, and 55.5%. Similarly, the ET group exhibited average 1-, 3-, and 5-year CSS rates of 99.5%, 98.8%, and 97.9% respectively, compared to the SR group’s rates of 93.5%, 88.0%, and 77.3%. After PSM, the ET group maintained average 1-, 3-, and 5-year OS rates of 97.1%, 89.6%, and 77.4% respectively, while the SR group’s rates were 88.6%, 77.6%, and 57.5%. The ET group’s average 1-, 3-, and 5-year CSS rates were 99.3%, 98.2%, and 96.5% respectively, contrasting with the SR group’s rates of 94.4%, 89.8%, and 80.2%. Whether before or after PSM, the prognosis of the ET group was superior to that of the SR group (P < 0.001) (Table 2). Prior to PSM, the ET group had significantly better OS (HR 0.48, 95% CI 0.41–0.58, P < 0.001) (Fig. 2A) and CSS (HR 0.20, 95% CI 0.13–0.30, P < 0.001) (Fig. 2B) compared to the SR group. Even after PSM, the ET group continued to outperform the SR group in terms of OS (HR 0.56, 95% CI 0.44–0.70, P < 0.001) (Fig. 3A) and CSS (HR 0.21, 95% CI 0.11–0.40, P < 0.001) (Fig. 3B).
Table 2.
Survival rate of patients with colorectal neuroendocrine tumors in the ET group and SR group
| ET group | SR group | P-value | |
|---|---|---|---|
| Overall survival rate before PSM(%) | |||
| 1-year | 97.3 | 87.5 | < 0.001 |
| 3-year | 92.2 | 75.5 | < 0.001 |
| 5-year | 85.2 | 55.5 | < 0.001 |
| Overall survival rate after PSM(%) | |||
| 1-year | 97.1 | 88.6 | < 0.001 |
| 3-year | 89.6 | 77.6 | < 0.001 |
| 5-year | 77.4 | 57.5 | < 0.001 |
| Cancer specific survival rate before PSM(%) | |||
| 1-year | 99.5 | 93.5 | < 0.001 |
| 3-year | 98.8 | 88.0 | < 0.001 |
| 5-year | 97.9 | 77.3 | < 0.001 |
| Cancer specific survival rate after PSM(%) | |||
| 1-year | 99.3 | 94.4 | < 0.001 |
| 3-year | 98.2 | 89.8 | < 0.001 |
| 5-year | 96.5 | 80.2 | < 0.001 |
ET endoscopic therapy, SR surgical resection, PSM propensity score matching
Bold values indicate P < 0.05
Fig. 2.
Overall survival and cancer-specific survival were compared before propensity score matching A overall survival; B cancer-specific survival
Fig. 3.
Overall survival and cancer-specific survival were compared after propensity score matching A overall survival; B cancer-specific survival
Univariate and multivariate cox regression
Univariate Cox regression analysis indicated that factors such as age, sex, year of diagnosis, tumor grade, marital status, chemotherapy, and surgical method were identified as having an independent impact on OS in elderly CRNETs patients. Multivariate Cox regression analysis provided further evidence that age, sex, tumor grade, marital status, and surgical method are key independent factors in predicting OS for this specific group of patients (Table 3). Simultaneously, univariate Cox regression analysis showed that age, sex, marital status, chemotherapy, and surgical method were found to independently affect CSS in elderly CRNETs patients. Multivariate Cox regression analysis further confirmed the significance of age, sex, marital status, and surgical method as crucial independent predictors of CSS in this particular group of patients (Table 4).
Table 3.
Univariate and multivariate cox regression to analyze the overall survival of patients with colorectal neuroendocrine tumors
| Variables | Univariate | Multivariate | ||||
|---|---|---|---|---|---|---|
| HR | 95% CI | P-value | HR | 95% CI | P-value | |
| Age, years | ||||||
| < 80 | 1 | Reference | 1 | Reference | ||
| ≥ 80 | 3.45 | 2.77, 4.31 | < 0.001 | 2.89 | 2.30, 3.62 | < 0.001 |
| Sex | ||||||
| Male | 1 | Reference | 1 | Reference | ||
| Female | 0.65 | 0.55, 0.77 | < 0.001 | 0.50 | 0.41, 0.60 | < 0.001 |
| Year of diagnosis | ||||||
| 2000–2006 | 1 | Reference | 1 | Reference | ||
| 2007–2013 | 1.22 | 0.95, 1.56 | 0.121 | 1.36 | 0.96, 1.75 | 0.116 |
| 2014–2020 | 1.47 | 1.10, 1.96 | 0.009 | 1.25 | 0.93, 1.68 | 0.134 |
| Grade | ||||||
| I | 1 | Reference | 1 | Reference | ||
| II | 1.39 | 1.30, 1.50 | < 0.001 | 1.46 | 1.36, 1.59 | < 0.001 |
| T stage | ||||||
| T1 | 1 | Reference | – | – | – | |
| T2 | 1.49 | 0.91, 2.45 | 0.116 | – | – | – |
| T3 | 0.96 | 0.54, 1.71 | 0.895 | – | – | – |
| Marital status | ||||||
| Married | 1 | Reference | 1 | Reference | ||
| Unmarried | 1.40 | 1.18, 1.66 | < 0.001 | 1.56 | 1.28, 1.89 | < 0.001 |
| Chemotherapy | ||||||
| Yes | 1 | Reference | 1 | Reference | ||
| No/Unknown | 2.77 | 1.52, 5.04 | < 0.001 | 1.40 | 0.75, 2.60 | 0.288 |
| Treatment | ||||||
| ET | 1 | Reference | 1 | Reference | ||
| SR | 2.06 | 1.73, 2.46 | < 0.001 | 1.89 | 1.57, 2.27 | < 0.001 |
ET endoscopic therapy, SR surgical resection, HR hazard ratios, CI confidence interval
Bold values indicate P < 0.05
Table 4.
Univariate and multivariate cox regression to analyze the cancer specific survival of patients with colorectal neuroendocrine tumors
| Variables | Univariate | Multivariate | ||||
|---|---|---|---|---|---|---|
| HR | 95% CI | P-value | HR | 95% CI | P-value | |
| Age, years | ||||||
| < 80 | 1 | Reference | 1 | Reference | ||
| ≥ 80 | 4.10 | 2.58, 6.50 | < 0.001 | 2.89 | 1.80, 4.64 | < 0.001 |
| Sex | ||||||
| Male | 1 | Reference | 1 | Reference | ||
| Female | 0.65 | 0.43, 0.96 | 0.030 | 0.43 | 0.28, 0.67 | < 0.001 |
| Year of diagnosis | ||||||
| 2000–2006 | 1 | Reference | – | – | – | |
| 2007–2013 | 0.70 | 0.38, 1.28 | 0.251 | – | – | – |
| 2014–2020 | 1.22 | 0.67, 2.23 | 0.522 | – | – | – |
| Grade | ||||||
| I | 1 | Reference | – | – | – | |
| II | 0.86 | 0.53, 1.40 | 0.543 | – | – | – |
| T stage | ||||||
| T1 | 1 | Reference | – | – | – | |
| T2 | 0.00 | 0.00, Inf | 0.994 | – | – | – |
| T3 | 1.43 | 0.45, 4.53 | 0.539 | – | – | – |
| Marital status | ||||||
| Married | 1 | Reference | 1 | Reference | ||
| Unmarried | 1.74 | 1.18, 2.58 | 0.006 | 2.26 | 1.46, 3.51 | < 0.001 |
| Chemotherapy | ||||||
| Yes | 1 | Reference | 1 | Reference | ||
| No/Unknown | 3.58 | 1.13, 11.31 | 0.030 | 1.59 | 0.49, 5.09 | 0.438 |
| Treatment | ||||||
| ET | 1 | Reference | 1 | Reference | ||
| SR | 5.04 | 3.32, 7.67 | < 0.001 | 4.82 | 3.14, 7.40 | < 0.001 |
ET endoscopic therapy, SR surgical resection, HR hazard ratios, CI confidence interval
Bold values indicate P < 0.05
Subgroup analysis
Before PSM, the OS of the ET group was superior to that of the SR group (P < 0.05), except for the T2 and T3 stages and the chemotherapy treatment group (Fig. 4). The CSS of the ET group was superior to that of the SR group in almost all cases (P < 0.05), with the exception of the diagnosis year group from 2000 to 2006 (Fig. 5). Additionally, after PSM, the OS (Supplementary Fig. 1) and CSS (Supplementary Fig. 2) of the ET group and SR group across various subgroups were similar to those before PSM.
Fig. 4.
Subgroup analysis of overall survival between ET group and SR group before propensity score matching. ET endoscopic therapy, SR surgical resection
Fig. 5.
Subgroup analysis of cancer-specific survival between ET group and SR group before propensity score matching. ET endoscopic therapy, SR surgical resection
Discussion
In this study, we utilized the SEER database to examine the long-term prognosis of elderly patients with CRNETs undergoing ET and SR treatments. Notably, ours is the first such report to focus on the long-term outcomes of these treatments in this patient population. Both before and after PSM analysis, our findings reveal that the ET group exhibited better OS and CSS compared to the SR group (P < 0.05). Furthermore, the ET group demonstrated superior mean 1-, 3-, and 5-year OS and CSS rates when compared to the SR group (P < 0.05). Our analysis identified age, sex, tumor grade, marital status, and surgical method as independent risk factors influencing OS in elderly patients with CRNETs. For CSS, age, sex, marital status, and surgical method were determined to be the independent risk factors.
Currently, there are various ET treatments for CRNETs, including endoscopic mucosal resection (EMR), modified EMR (mEMR), endoscopic submucosal dissection (ESD), EMR with a ligation device (EMR-L), and endoscopic full-thickness resection (EFTR) [20, 21]. A prospective multicenter study by Japanese scholars analyzed the short-term outcomes of ET treatment for CRNETs, showing that for CRNETs less than 10 mm in diameter, different endoscopic techniques are equally safe and effective [22]. A meta-analysis incorporating 27 studies with 2112 patients compared the efficacy of different ET techniques for rectal NETs, concluding that EMR-L can be recommended as the preferred ET treatment for small rectal NETs [23]. When studying the long-term outcomes of ESD technique for rectal NETs, Sun et al. [24] found that ET treatment for rectal NETs has a good prognosis, and positive resection margins have no influence on survival. SR treatments for CRNETs mainly include transanal, laparoscopic, and transabdominal approaches [14]. Hayashi et al. [25] used transanal minimal invasive surgery to treat 25 patients with rectal NETs, finding the technique to be safe and effective for small rectal NET lesions. Another study analyzed the long-term outcomes of this technique for rectal NETs, showing satisfactory long-term results with relatively little impact on anal function [26]. An earlier study analyzed the efficacy of laparoscopic resection of midgut carcinoid tumors, finding it to be a safe and feasible technique despite its difficulty [27].
Although there have been many studies reporting on the efficacy of ET or SR techniques in treating CRNETs, to date, no studies have compared the long-term prognosis of ET and SR in the treatment of elderly patients with CRNETs. Previously, a study using data from the SEER database compared the prognosis of local resection versus radical surgery for the treatment of rectal NETs less than 2.0 cm in size. The results showed that the two groups had comparable CSS [28]. Studies by Zhu et al. [15] and Xu et al. [16] also found that ET and SR have comparable long-term prognoses for the treatment of CRNETs. However, our study found that for elderly patients with CRNETs less than 2.0 cm in size and without lymph node or distant metastasis, the OS and CSS of the ET group were superior to those of the SR group. This may be due to several reasons: Firstly, compared to SR, ET is more minimally invasive, making it suitable for elderly patients. Elderly individuals have decreased physical function and recovery ability, so a minimally invasive surgery can reduce physical trauma and the risk of postoperative complications. Secondly, ET typically has a lower complication rate. For elderly patients, reducing complications means faster recovery and lower medical risks. Previous studies have also found that for CRNETs less than 2.0 cm in diameter, ET treatment has a lower mortality rate, a higher complete resection rate, and lower complication and recurrence rates [14, 29, 30]. Thirdly, ET often allows for more precise tumor resection while preserving more normal tissue, helping to maintain patients’ physiological functions and quality of life. Meanwhile, the NCCN guidelines state that ET treatment may be considered for patients with rectal NETs less than 2.0 cm in diameter and without lymph node or distant metastasis [31]. Our study also confirms that endoscopic treatment improves the long-term prognosis of elderly patients with CRNETs less than 2.0 cm and without lymph node or distant metastasis. Therefore, we recommend endoscopic treatment as the first choice for such patients.
In addition to the surgical approach, this study found that advanced age, male gender, and unmarried status are also important risk factors affecting the prognosis of CRNETs patients. Consistent with our findings, Li et al. [32] found that widowed CRNETs patients had a poorer prognosis. Meanwhile, several previous studies have found that unmarried cancer patients have a relatively poor prognosis [33, 34]. This may be attributed to the fact that married patients typically receive continuous emotional support and care from their spouses, which plays an important role in fighting the disease. In contrast, unmarried patients may lack such a stable social support network, leading them to feel more isolated and helpless when facing the disease. At the same time, marriage brings psychological comfort and stability, helping to reduce patients’ psychological stress and anxiety. Unmarried patients may be more susceptible to psychological stress, thereby negatively impacting disease recovery and prognosis. Furthermore, married patients can usually obtain financial support from their spouses, making it easier to bear the expensive treatment costs. Unmarried patients may face greater economic pressure, which may prevent them from accessing the best treatment options.
Our study has several limitations. Firstly, our retrospective analysis is dependent on the SEER database, which inherently poses risks of data discrepancies and biases. Nonetheless, to offset the consequences of incomplete data and selection bias, we employed MI and PSM approaches. Secondly, the SEER database lacks details on postoperative complications, surgical margins, disease recurrence, and how surgical resection and endoscopic methods are chosen for specific patients. These factors can significantly impact the long-term prognosis of patients. Finally, it’s worth noting that the SEER database predominantly reflects the American medical scenario, and healthcare practices can differ across various regions and cultures. Hence, one should proceed with discretion when extending our study’s findings to other geographical or cultural settings.
In conclusion, ET offered superior long-term outcomes compared to SR in a selected cohort of elderly patients with CRNETs. The results, obtained through rigorous PSM and multivariate Cox regression analysis, highlight the possible advantages of ET in terms of OS and CSS. The identification of age, sex, tumor grade, marital status, and treatment modality as independent risk factors affecting OS and CSS underscores the possible importance of considering these variables in clinical decision-making. These findings contribute to the existing literature by providing valuable insights into the optimal surgical approach for managing elderly patients with CRNETs and warrant further investigation to confirm the long-term benefits of ET in this patient population.
Supplementary Information
Below is the link to the electronic supplementary material.
Supplementary file1 (PNG 725 KB)—Subgroup analysis of overall survival between ET group and SR group after propensity score matching. ET endoscopic therapy, SR: surgical resection
Supplementary file2 (PNG 672 KB)—Subgroup analysis of cancer-specific survival between ET group and SR group after propensity score matching. ET endoscopic therapy, SR surgical resection
Acknowledgements
None.
Funding
This study was supported by the Changshu Science and Technology Program (CY202339), the Suzhou Youth Science and Technology Project for the Advancement of Science, Education, and Health (KJXW2023067), and the Suzhou 23rd Batch of Science and Technology Development Plan (Clinical Trial Institution Capability Enhancement) Project (SLT 2023006).
Data availability
Publicly available datasets were analyzed in this study. These data can be found here: https://seer.cancer.gov/. The datasets supporting the conclusions of this article are included within the article.
Declarations
Disclosures
Yunfu Feng and Luojie Liu disclosed no conflict of interest for this article.
Ethical approval
There was no protocol for this study and that it has not been registered.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary file1 (PNG 725 KB)—Subgroup analysis of overall survival between ET group and SR group after propensity score matching. ET endoscopic therapy, SR: surgical resection
Supplementary file2 (PNG 672 KB)—Subgroup analysis of cancer-specific survival between ET group and SR group after propensity score matching. ET endoscopic therapy, SR surgical resection
Data Availability Statement
Publicly available datasets were analyzed in this study. These data can be found here: https://seer.cancer.gov/. The datasets supporting the conclusions of this article are included within the article.