Performance status over chronology: determinants of curative versus palliative treatment intent in older adults with gastrointestinal cancer

Abstract Background Older adults bear a rising share of India's cancer burden; however, chronological age is often used to withhold curative treatments. We quantified whether age, independent of disease stage and performance status, determines curative versus non-curative treatment intent in older adults with gastrointestinal cancer. Methods A retrospective analysis of 333 patients aged ≥65 years with histologically confirmed GI malignancies managed at a tertiary care center in India was performed. Demographic, clinical, tumor, and treatment data were also collected. The outcome, treatment intent, was dichotomized as curative versus non-curative (palliative or no treatment intent). Predictors were tested using the chi-square test and multivariable binary logistic regression, and model discrimination was assessed using the area under the receiver operating characteristic curve. Results mean age was 70.7 ± 5.2 years; 73/333 (21.9%) were aged ≥75 years, and 229 (68.8%) were male (male-to-female ratio 2.2:1). Tumors were located in the upper gastrointestinal tract tract in 151 (45.3%), lower Gastrointestinal tract in 117 (35.1%), and hepato-pancreato-biliary tract in 65 (19.5%) patients. At presentation, 242 patients (72.7%) had stage III–IV disease and 206 (61.9%) had aperformance status ≥3. Curative intent was assigned to 169 patients (50.8%). The crude curative-intent rate fell from 53.8% (aged 65–74 years) to 39.7% (≥ 75 years; OR 0.56, 95% CI 0.33–0.96, p=0.034), from 78.9% (Performance Status 0–1) to 1.1% (Performance Status 4), and from 92.3% (stage I) to 18.9% (stage IV). After adjustment, age ≥75 years was no longer significant (adjusted OR 0.54, 95% CI 0.28–1.02; p=0.059), whereas stage IV (aOR 0.09, 95% CI 0.05–0.17) and ECOG 3–4 (aOR 0.16, 95% CI 0.09–0.30) remained iassociated with non-curative intent (both p<0.001; AUC 0.85, McFadden pseudo-R 2 = 0.31). Only 117/333 patients (35.1%) received and completed cancer-directed treatment, whereas 129 (38.7%) were advised to undergo treatment but did not accept it. Conclusions Disease stage and performance status, not age, was associated with curative-versus-palliative decision; the crude age effect reflected confounding by stage and performance status. Advanced-stage, poor-performance-status presentation (72.7% stage III–IV; 61.9% Performane Status≥3) and 38.7% treatment non-acceptance argue for earlier diagnosis rather than age-based treatment limitations.