Survival Rates of Patients with Gastric Cancer According to Age and Sex: A Large-Scale Study Using Data from 14,739 Patients

Yonghoon Choi; Nayoung Kim; Ji Hyun Kim; Hyeong Ho Jo; Hyeon Jeong Oh; Hye Seung Lee; Yu Kyung Jun; Hyuk Yoon; Cheol Min Shin; Young Soo Park; Dong Ho Lee; So Hyun Kang; Young Suk Park; Sang-Hoon Ahn; Yun-Suhk Suh; Do Joong Park; Hyung Ho Kim; Ji-Won Kim; Jin Won Kim; Keun-Wook Lee; Won Chang; Yoon Jin Lee; Kyoung Ho Lee; Young Hoon Kim

doi:10.4143/crt.2025.149

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Original Article Gastrointestinal cancer Survival Rates of Patients with Gastric Cancer According to Age and Sex: A Large-Scale Study Using Data from 14,739 Patients: Yonghoon Choi¹, Nayoung Kim^1,2,3, Ji Hyun Kim¹, Hyeong Ho Jo⁴, Hyeon Jeong Oh⁵, Hye Seung Lee⁶, Yu Kyung Jun¹, Hyuk Yoon¹, Cheol Min Shin¹, Young Soo Park¹, Dong Ho Lee^1,3, So Hyun Kang⁷, Young Suk Park⁷, Sang-Hoon Ahn⁷, Yun-Suhk Suh⁷, Do Joong Park^7,8, Hyung Ho Kim^7,8, Ji-Won Kim¹, Jin Won Kim¹, Keun-Wook Lee^1,3, Won Chang⁹, Yoon Jin Lee⁹, Kyoung Ho Lee^9,10, Young Hoon Kim^9,10; Cancer Research and Treatment : Official Journal of Korean Cancer Association 2026;58(1):252-263.
DOI: https://doi.org/10.4143/crt.2025.149
Published online: April 16, 2025

¹Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea

²Research Center for Sex- and Gender-Specific Medicine, Seoul National University Bundang Hospital, Seongnam, Korea

³Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea

⁴Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea

⁵Department of Pathology, Seoul National University Bundang Hospital, Seongnam, Korea

⁶Department of Pathology, Seoul National University College of Medicine, Seoul, Korea

⁷Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea

⁸Department of Surgery, Seoul National University College of Medicine, Seoul, Korea

⁹Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea

¹⁰Department of Radiology, Seoul National University College of Medicine, Seoul, Korea

Correspondence: Nayoung Kim, Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 beon-gil, Bundang-gu, Seongnam 13620, Korea
Tel: 82-31-787-7008 E-mail: nakim49@snu.ac.kr

• Received: February 9, 2025 • Accepted: April 15, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract

Purpose
The male predominance in the incidence of gastric cancer (GC) is established; however, sex differences in the prognosis of GC remain controversial. As such, this study analyzed the prognosis of patients with GC based on age and sex.
Materials and Methods
Data from 14,739 patients diagnosed with GC at Seoul National University Bundang Hospital between 2003 and 2023 were analyzed. Baseline characteristics, histological types of GC, overall and GC-specific survival rates (age and stage stratification), and associated risk factors were analyzed.
Results
Females were significantly younger (p < 0.001) and exhibited more gastric body cancers (p < 0.001) and tumors with diffuse-type or poorly differentiated histology (p < 0.001) than males. Females exhibited an advantage over males in terms of overall survival (p=0.004), but not in GC-specific survival. However, age stratification revealed significant sex differences, that females < 50 years of age exhibited survival disadvantages (p < 0.001); however, this trend was reversed with age, and females > 60 years exhibited survival advantages (p < 0.001) for both overall and GC-specific survival. This may be explained by the lower ratio of diffuse-type GC as females age. Furthermore, in the analysis according to stage, females with stage IV disease exhibited significant survival disadvantages, with significantly younger age and a higher proportion of diffuse-type GC which exhibits aggressive features, resulting in poorer survival than in males.
Conclusion
Age and stage stratification revealed significant differences in survival between the sexes, which can be helpful for public health strategies.
Key words: Stomach neoplasm, Sex, Survival, Prognosis

Introduction

Gastric cancer (GC) is the fifth most common malignancy worldwide, particularly in East Asia, including South Korea and Japan [1]. GC is known to exhibit sex differences in terms of incidence, and the results of various studies are relatively consistent. Age-standardized incidence rates are approximately twice as high among males than those among females [2]. This difference is often explained by differences in exposure to risk factors such as Helicobacter pylori infection, alcohol consumption, tobacco smoking, and dietary habits [3,4]. Recent research has suggested the role of sex hormones in GC carcinogenesis, and that exposure to estrogen varies the risk for developing GC according to histological type [5].

However, there have been several conflicting reports addressing sex-related differences in the prognosis of patients with GC. First, the U.S. Surveillance, Epidemiology, and End Results (i.e., “SEER”) database reported a significantly better prognosis in females than in males, although the overall survival rate was relatively low [6]. A recent study from Japan reported the overall survival advantage among females [7]. In contrast, the reported prognosis was consistently better in males than in females in the Korean Central Cancer Registry (KCCR) data [8]. Additionally, females exhibited better overall survival than males, but without a statistical difference in GC-specific survival in a Korean study that analyzed data from 3,000 patients who underwent surgical treatment for GC [9]. Females with advanced-stage tumors (> stage III) exhibit a poor prognosis, while the difference between overall survival and GC-specific survival is large in males, who often die of diseases other than GC [9].

These differences may be due to differences in the characteristics of GC depending on region and race [10,11]. In terms of tumor characteristics, the Lauren classification is known to be an independent prognostic factor for patients with GC. Lauren proposed a classification of gastric carcinomas based on histological patterns: the presence of glandular structures (intestinal type) versus the absence of such structures (diffuse type) in the 1960s [12]. Intestinal-type cancers are associated with chronic H. pylori infection and atrophic gastritis, typically occur in older patients, and follow a stepwise progression from inflammation to cancer. In contrast, diffuse-type cancers are poorly differentiated with scattered cancer cells (such as signet-ring cells), tend to occur in younger individuals and females, and are more aggressive with a worse prognosis [9,10]. In the 2010 World Health Organization (WHO) classification, gastric carcinomas are categorized into four major histologic types: tubular, papillary, mucinous, and poorly cohesive carcinoma (including signet ring cell carcinoma). Tubular, papillary, and mucinous adenocarcinomas correspond to the Lauren intestinal-type, while signet ring cell carcinoma and other poorly cohesive carcinomas correspond to the Lauren diffuse-type [13]. In fact, there is a difference in the proportion of intestinal- and diffuse-type GCs according to ethnicity. For example, Koreans exhibit higher rates of the diffuse-type over intestinal-type GC than the Japanese, among whom the median age of patients with GC was 10 years older than that among Koreans [1,14,15]. There may also be differences in accessibility and use of healthcare systems, including nationwide screening programs, among countries [16]. Alternatively, there may be a third factor that affects sex differences. For example, microsatellite instability (MSI) affects the prognosis of GC. The prognosis of males and females in GC is known to be somewhat different in microsatellite stable (MSS)/low MSI (MSI-L) and high MSI (MSI-H) tumors, although this has not been clarified [17].

From this perspective, we hypothesized that the prognosis of patients diagnosed with GC will differ depending on age and sex. We aimed to analyze and stratify sex differences in the prognosis of GC according to clinicopathological factors including age, histological type, disease stage, and molecular features.

Materials and Methods

1. Study design and population

Data from 14,739 patients diagnosed with GC between May 2003 and February 2023 at Seoul National University Bundang Hospital (SNUBH; Seoul, Korea) were collected from a prospective surgical and medical GC cohort of SNUBH and analyzed. The electronic medical records (EMRs) of the patients were cross-reviewed, and data including sex, age, body mass index (BMI), information related to death (date and cause), tumor location, histological classification (Lauren and World Health Organization classifications), tumor stage, and initial treatment modality were collected. Information related to death was cross-reviewed with data from the National Statistical Office (NSO) for verification. That is, the date and confirmation of death were primarily obtained from the EMR when possible. Considering cases where this was not feasible, the list of patients was submitted to the NSO with personally identifiable information removed to obtain mortality data. For deceased individuals, the date and cause of death (represented by an International Classification of Diseases 10th revision diagnosis code consisting of one letter and two digits) were retrieved. If no death information was available from the NSO as of the reference date, the individual was considered alive. The final reference date for mortality confirmation was January 1, 2024.

2. Data variable and assessment

Patients were divided into six groups according to age (< 40, 40-49, 50-59, 60-69, 70-79, and ≥ 80 years). Tumor location was divided into upper, middle, and lower according to a previous study [18]. Histological classification was performed according to Lauren type [12] and the WHO classification [13], and two pathology specialists (H.O. and H.S.L.) performed the GC diagnosis. Treatment modalities were divided into four groups: endoscopic, surgery, chemotherapy, and conservative. BMI was calculated as weight divided by height squared (kg/m²), and participants were classified according to BMI: underweight (BMI < 18.5 kg/m²); normal weight (BMI 18.5-22.9 kg/m²); overweight (BMI 23.0-24.9 kg/m²); obese (BMI 25.0-29.9 kg/m²); and severe obesity (BMI ≥ 30.0 kg/m²). Smoking status and alcohol consumption were divided into two groups: never and current/past.

3. Statistical analysis

Differences in baseline characteristics were assessed using the chi-squared test or Student’s t test. Survival differences were assessed with univariate and multivariate analyses using a Cox proportional hazards regression model, the Kaplan-Meier method, and log-rank test. Variables with p < 0.2 in the univariable analysis were included in the multivariable model hazard ratio (HR). All statistical analyses were performed using R ver. 4.2.1 (R Foundation for Statistical Computing) and SPSS ver. 25.0 (IBM Corp.).

Results

1. Participant baseline characteristics

Baseline characteristics of the participants are summarized in Table 1. There were 9,832 males and 4,907 females, corresponding to a ratio of 2:1. There were no significant differences in disease stage between the sexes. Females were significantly younger than males (60.7 vs. 62.5 years, p < 0.001), had more gastric upper or middle body cancers (44.0% vs. 48.4%, p < 0.001), and more diffuse-type cancers (51.8% vs. 29.1%, p < 0.001). In addition, females underwent fewer endoscopic treatments (12.4% vs. 17.1%) and more surgeries (64.8% vs. 61.4%, p < 0.001) than males. Cancers with MSI were more common among females than among males (11.9% vs. 8.6%, p < 0.001), whereas p53 mutations were less common among females than among males (26.2% vs. 39.1%, p < 0.001).

2. Lauren histological types according to age and tumor stage

Histological types were analyzed according to age and Lauren classification (Fig. 1). Diffuse-type histology was found to be more common among younger males and females. The proportion of intestinal-type GC increased with age, but increased rapidly in males (Fig. 1A) and gradually in females (Fig. 1B). The proportion of diffuse-type GC was greater among females at most ages, and the proportions of intestinal- and diffuse-type GC were similar between the sexes after their 80s.

According to the Lauren classification, 72.4% of intestinal-type GC cases were stage I and 14.4% were MSI-H tumors. In contrast, 20.1% of diffuse-type GC cases were stage III and 12.7% were stage IV, and the ratio of MSI-H tumors was as low as 3.9% (S1 Table).

3. Risk factors for GC-related death

Risk factors for GC-related mortality were analyzed using Cox univariate and multivariate proportional hazards regression analyses (Table 2). Results revealed that older age (HR, 1.03 [95% confidence interval (CI), 1.02 to 1.03]; p < 0.001), diffuse-type histology (HR, 1.44 [95% CI, 1.27 to 1.65]; p < 0.001), along with advanced tumor stage (stage II: HR, 7.25 [95% CI, 5.78 to 9.10]; stage III: HR, 21.98 [95% CI, 17.87 to 27.02]; stage IV: HR, 50.34 [95% CI, 39.67 to 63.88]; p < 0.001) were independent risk factors for GC-related death according to multivariate analysis. In contrast, MSI-H tumors were associated with a lower risk for GC-related mortality compared with MSS or MSI-L tumors (HR, 0.62 [95% CI, 0.49 to 0.78]; p < 0.001). However, sex was not an independent risk factor for GC-related mortality.

4. Overall and GC-specific survival according to sex

Survival analyses were performed using the Kaplan-Meier method and the log-rank test (Fig. 2, S2 Fig.). Females exhibited a significant survival advantage over males in terms of overall survival (p=0.004) (Fig. 2A), but not GC-specific survival (Fig. 2B). However, sex differences in survival differed depending on age; more specifically, younger females (< 50 years of age) exhibited survival disadvantages in both overall (p < 0.001) (Fig. 2C) and GC-specific survival (p < 0.001) (Fig. 2D), but survival was similar in the 50s (Fig. 2E and F), and older females (> 60 years) exhibited survival advantages in both overall (p < 0.001) (Fig. 2G) and GC-specific survival (p < 0.001) (Fig. 2H). After 70 years of age, this sex-related gap in GC-specific survival disappeared (S2C-F Fig.).

Stratification analyses were performed according to age group to determine the reasons for these differences (S3 Table). First, the proportion of diffuse-type GC was high in both males and females in the group < 40 years of age, and there was no difference in tumor stage. Next, in the 40-49 years’ age group, the ratio of diffuse-type GC was higher in females than males, and the ratio of advanced tumor stage was also higher. However, there was no significant difference in tumor stage in the ≥ 50 years’ age groups, even though there was a difference in the ratio of histological types according to Lauren classification. It was also confirmed that the ratio of p53 mutations in MSI-H tumors increased with advancing age. The ratio of p53 mutations was consistently high among males, in contrast to the high proportion of MSI-H tumors among females.

5. Survival according to sex and cancer stage

Survival subgroup analyses were also performed according to cancer stage (Fig. 3). In the stratification analysis according to stage, no significant differences were observed between stages I and III (Fig. 3A-F). However, females with stage IV disease exhibited significant GC-specific survival disadvantages (p=0.029) (Fig. 3H). In the subgroup analysis of patients with stage IV disease, the differences between males and females in median survival were 2 months, females were significantly younger, and exhibited a higher proportion of diffuse-type GC than males, which exhibit aggressive features and is associated with poorer survival (Table 3).

6. Survival according to treatment methods and microsatellite status

Survival analyses in the subgroups according to initial treatment modalities and microsatellites were also performed (S4 and S5 Figs.). In the stratification analysis according to initial treatment method, females who underwent endoscopic resection or surgery exhibited overall survival advantages over males (S4A and S4C Fig.); however, no clear differences in GC-specific survival according to treatment modality were observed.

In the stratification analysis according to MSI status, no distinct sex differences in survival were observed for either overall or GC-specific survival in the total population. However, in the analysis of patients who underwent chemotherapy as initial treatment, there were no significant differences (S5G and S5H Fig.).

Discussion

In this study, we aimed to analyze the prognosis of patients diagnosed with GC, with a particular focus on sex and age. Results revealed that females were significantly younger and had more gastric body cancers and tumors with diffuse-type or poorly differentiated histology than males. Age-stratified survival analyses revealed a reversal in trends: younger females (< 50 years of age) exhibited survival disadvantages; however, older females (> 60 years) exhibited survival advantages in both overall and GC-specific survival, in association with the change in the ratio of diffuse-type GC. Furthermore, females with stage IV disease exhibited significant survival disadvantages, with a significantly younger age and a higher proportion of diffuse-type GC.

As previously reported, the prognosis of GC varies according to sex. However, there are several conflicting reports regarding sex-related differences in the prognosis of patients with GC. The U.S. SEER data [6] and a study from Japan [7] reported survival advantages in females. In contrast, recent KCCR data [8] reported better survival rates in males than those in females. In addition, a recent study from Korea reported the same conclusion; more specifically, that females diagnosed with GC exhibited poorer survival characterized by younger age, a greater ratio of poorly differentiated cancer, and signet ring cell components than their male counterparts [19]. Previously, our team analyzed the survival of 3000 patients diagnosed with GC who underwent surgical treatment according to sex [9]. Results revealed that females exhibited better overall survival compared with males (p < 0.001); however, the difference in GC-specific survival was not evident (p=0.168) [9]. We found that females with advanced-stage tumors (> stage III) exhibited a poor prognosis, while the difference between overall survival and GC-specific survival was large in males, who often died of diseases other than GC [9]. This may be due to differences in the characteristics of GC between regions and races, such as histology, ratio of diffuse-type GC with poor prognosis [10,11], or differences in accessibility and use of healthcare systems, including nationwide screening programs [14]. Collectively, these results suggest that GC-related survival in Korea has a male advantage.

However, the aforementioned study [9] only included patients who underwent surgical treatment; as such, there is a limitation because patients with stage I and IV tumors were excluded from the analysis. To overcome this limitation, we performed an extensive analysis of patients with GC at all stages, including molecular features such as p53 and MSI. The clinicopathological profiles of the enrolled patients were consistent with those reported previously [9]. The average age of females was significantly younger, with more than one-half being female in the age group < 40 years of age and approximately 40% in the 40-49 years’ age group. The high proportion of young females is histologically associated with a high proportion of diffuse-type or undifferentiated histology and stomach cancer, consequently leading to a low rate of endoscopic treatment among females. Similar to previous studies, the ratio of diffuse-type cancer was higher in both sexes at younger ages, and the ratio of intestinal-type cancer tended to increase over time. However, the incidence of intestinal cancer increased rapidly from 50 years of age in males and increased slowly in females until 80 years of age. This is explained by the protective effect of estrogen―a female sex hormone―against intestinal-type cancer [5]. With advancing age, chronic atrophic gastritis and intestinal metaplasia occur [11] and lead to GC through the adenoma-carcinoma sequence; therefore, the ratio of intestinal-type cancer increases with advancing age. The fact that the intestinal-type cancer is less common among females with high endogenous estrogen exposure has been reported continuously since 2008 [5], and there are attempts to identify the association between this sex hormone and GC through the distinction between estrogen receptor (ER) α and β [20-23]. ERα expression was associated with diffuse-type GC carcinogenesis and shorter disease-free survival [20,21], while expression of ERβ was associated with well-differentiated tumors and better prognosis [22,23]. This is supported by another study that analyzed estrogen exposure history in patients with GC in detail and revealed that the prevalence of intestinal-type GC increased in postmenopausal females and becomes similar to males approximately 20 years after menopause [10,24].

In the survival analysis, two interesting differences between the sexes were identified. The first was a reversal in trends that both the overall- and GC-specific survival exhibited a significant male advantage in the 40-49 years’ age group; however, the difference disappeared in the 50-59 years’ age group, and both the overall- and GC-specific survival exhibited a significant female advantage in the 60-69 years’ age group. We performed a subgroup analysis according to age to determine the reason and found that in the case of females in the 40-49 years’ age group, the ratio of diffuse-type cancer was significantly higher than that of males, while the ratio of advanced-stage tumors (stage III or IV) was also significantly higher than that of males and patients in other age groups. In the case of the 50-59 and 60-69 years’ age groups, there were histological differences according to Lauren classification between males and females; however, the cancer stage did not exhibit significant differences. Because diffuse-type cancer is known to exhibit aggressive tendencies, rapid progression, and a higher recurrence rate [10], the need for cancer screening should be emphasized, especially in females of this age. In fact, the participation rate in nationwide screening for GC among Korean adults in their 40s was as high as 72% in 2018 [25]; nevertheless, more encouragement for females to undergo endoscopic screening is needed. No statistically significant differences were observed between the < 40 and > 80 age groups. This could be because the < 40 years’ age group had a high proportion of diffuse types in both sexes, whereas the > 80 years’ age group had a small number of subjects and short follow-up period, making it difficult to identify significant differences.

In the analysis according to disease stage, the difference between males and females was more pronounced in the stage IV group than in the other stage groups. Age at diagnosis was significantly lower than that of the total population, and the ratio of diffuse-type cancer was higher than that of the total population in both males and females. In addition, diffuse-type histology was correlated with advanced tumor stage (Pearson’s r=0.194, Spearman’s ρ=0.226, both p < 0.001). In summary, late diagnosis of diffuse-type cancer in young patients leads to poor prognosis. Currently, individuals < 40 years of age are not included in the nationwide cancer screening program in South Korea [25], and many recent studies have emphasized the risk for developing GC at a young age [26]. The results of this study also suggest the necessity of screening young adults, especially females of this age, for the early diagnosis of GC and improvement of prognosis.

Another survival-related factor was MSI status; patients with MSI-H tumors exhibited a significantly good prognosis. The Cancer Genome Atlas classifies gastric carcinomas into four molecular subtypes based on their underlying genetic mechanisms: Epstein-Barr virus–associated (9%), MSI (22%), genomically stable (20%), and chromosomal instability (50%) [27]. Among these, MSI refers to a condition of genetic hypermutability caused by defective DNA mismatch repair, and it is commonly observed in colorectal, gastric, and endometrial cancers. There have been efforts to use MSI as a predictive marker for prognosis and treatment response [28], that tumors with high levels of MSI (MSI-high) often exhibit a high mutation burden but may respond well to immune checkpoint inhibitors [27]. However, study results regarding the role of MSI as a prognostic marker in GC have remained inconsistent. In a pooled analysis, patients with MSI-H tumors exhibited better survival regardless of sex, whereas females exhibited better overall and GC-specific survival with MSS/MSI-L [15]. However, another meta-analysis reported poorer prognosis in males with MSI-H compared with their female counterparts, and that the prognostic value of MSI was limited only to females [29]. Another study reported that patients with MSI-H tumors had a better prognosis than those with MSS/MSI-L tumors, and females had a better prognosis than males, but there were some differences depending on the chemotherapy regimen used [30]. In the present study, the proportion of MSI-H tumors increased with age, especially in females and patients with intestinal-type cancers. Females with MSI-H tumors exhibited an advantage in overall survival, but there was no significant difference in GC-specific survival. In addition, a significant difference between sexes could not be revealed due to the limited number of patients in the chemotherapy group. Because sex hormones, such as estrogen, are involved in the mechanism of MSI [31], it is clear that there will be differences in prognosis according to sex and MSI status. However, other effects on prognosis, such as cancer stage and treatment methods, need to be considered. As such, further comprehensive research is required to confirm this hypothesis.

The present investigation had some limitations, the first of which were its retrospective, single-center design, and inherent risks for selection bias. However, in addition to clinical data warehouses and EMRs, we used surgical and medical cohorts built from hospital opening times. Second, it was not possible to confirm whether H. pylori infection or eradication treatment was due to the large number of patients with GC. In addition, specific regimens, treatment periods, and treatment responses could not be confirmed in patients who underwent chemotherapy. In this regard, a follow-up study is planned to analyze anticancer therapeutic histories and treatment responses according to oncogene mutations and DNA mismatch-repair deficiency profiles.

Nevertheless, this study was a large-scale investigation using data from approximately 14,739 patients with GC, including all patients who could be confirmed by a medical record search and a detailed study containing information such as cancer stage, histology, molecular characteristics, date of diagnosis and death, and exact cause of death. In addition, this study analyzed, in detail, overall and GC-specific survival according to patient age and sex, and disease stage, and histological cancer types and confirmed changes in survival tendencies according to age and differences according to stage between male and female patients with GC. In addition, the dates and causes of death of the enrolled patients were cross-reviewed with data from the NSO for verification. To the best of our knowledge, no studies have reported detailed results regarding sex differences in GC. Based on these results, efforts for the early diagnosis of GC at younger ages, especially among females, and efforts to establish a treatment policy considering molecular characteristics are needed in the future.

In conclusion, significant differences in survival between the sexes were observed with age and stage stratification, which should be considered in clinical practice in terms of designing tailored interventions and management strategies.

Electronic Supplementary Material

Supplementary materials are available at Cancer Research and Treatment website (https://www.e-crt.org).

crt-2025-149_S1_Table.pdf

crt-2025-149_S2_Fig.pdf

crt-2025-149_S3_Table.xlsx

crt-2025-149_S4_Fig.pdf

crt-2025-149_S5_Fig.pdf

NOTES

Ethical Statement

This study was reviewed and approved by the Institutional Review Board (IRB) of SNUBH (B-2006-618-004), and the initial prospective cohort was registered at clinicaltrials.gov (NCT04973631). Requirements for written informed consent were waived by the IRB. This study was carried out in accordance with the recommendations of the Declaration of Helsinki for biomedical research involving human subjects and the Guidelines for Good Clinical Practice.

Author Contributions

Conceived and designed the analysis: Kim N.

Collected the data: Choi Y, Kim N, Kim JH, Jo HH, Jun YK, Yoon H, Shin CM, Park YS (Young Soo Park), Lee DH, Kang SH, Park YS (Young Suk Park), Ahn SH, Suh YS, Park DJ, Kim HH, Kim JW (Ji-Won Kim), Kim JW (Jin Won Kim), Lee KW.

Contributed data or analysis tools: Choi Y, Kim JH, Jo HH, Oh HJ, Lee HS, Chang W, Lee YJ, Lee KH, Kim YH.

Performed the analysis: Choi Y, Kim JH.

Wrote the paper: Choi Y, Kim N, Jun YK, Yoon H, Shin CM, Park YS (Young Soo Park), Lee DH.

Writing - Review & Editing: Kim JW (Ji-Won Kim), Kim JW (Jin Won Kim), Lee KW, Chang W, Lee YJ, Lee KH, Kim YH.

Project administration: Kim N.

Supervision & Funding acquisition: Kim N, Lee DH.

Conflicts of Interest

Conflict of interest relevant to this article was not reported.

Funding

This work was supported by the National Research Foundation of Korea (NRF) grant (RS-2024-00337453) funded by the Korea government (MSIT) and by Seoul National University Bundang Hospital Research fund (02-2023-0012). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Fig. 1.

Histological type according to Lauren classification by age and sex: (A) male and (B) female.

Fig. 2.

Overall survival (A, C, E, G) and gastric cancer-specific survival (B, D, F, H) in the total population and subgroup analysis with age stratification.

Fig. 3.

Overall survival (A, C, E, G) and gastric cancer-specific survival (B, D, F, H) according to cancer stage.

Table 1.

Baseline characteristics of study participants

	Total (n=14,739)	Male (n=9,832)	Female (n=4,907)	p-value
Age (yr)	61.9±12.8	62.5±11.9	60.7±14.3	< 0.001
< 40	721 (4.9)	301 (3.1)	420 (8.6)	< 0.001
40-49	1,958 (13.3)	1,182 (12.0)	776 (15.8)
50-59	3,309 (22.5)	2,323 (23.6)	986 (20.1)
60-69	4,204 (28.5)	3,016 (30.7)	1,188 (24.2)
70-79	3,492 (23.7)	2,374 (24.1)	1,118 (22.8)
≥ 80	1,055 (7.2)	636 (6.5)	419 (8.5)
Location	13,898	9,313	4,585
Upper	2,677 (19.3)	1,834 (19.7)	843 (18.4)	< 0.001
Middle	3,642 (26.2)	2,267 (24.3)	1,375 (30.0)
Lower	7,579 (54.5)	5,212 (56.0)	2,367 (51.6)
Lauren type	13,118	8,806	4,312
Intestinal	7,901 (60.2)	5,952 (67.6)	1,949 (45.2)	< 0.001
Diffuse	4,799 (36.6)	2,566 (29.1)	2,233 (51.8)
Mixed	343 (2.6)	223 (2.5)	120 (2.8)
Indeterminate	75 (0.6)	65 (0.7)	10 (0.2)
WHO classification	14,163	9,486	4,677
ADC, WD	2,689 (19.0)	2,060 (21.7)	629 (13.4)	< 0.001
ADC, MD	4,363 (30.8)	3,280 (34.6)	1,083 (23.2)
ADC, PD	2,663 (18.8)	1,714 (18.1)	949 (20.3)
PCC, SRC	2,940 (20.8)	1,469 (15.5)	1,471 (31.5)
Mixed carcinoma	855 (6.0)	470 (5.0)	385 (8.2)
Mucinous ADC	107 (0.8)	82 (0.9)	25 (0.5)
Papillary ADC	165 (1.2)	119 (1.3)	46 (1.0)
Others	381 (2.7)	292 (3.1)	89 (1.9)
Cancer type	12,507	8,409	4,098
EGC	7,746 (61.9)	5,217 (62.0)	2,529 (61.7)	0.723
AGC	4,761 (38.1)	3,192 (38.0)	1,569 (38.3)
TNM stage	13,586	9,102	4,484
I	8,039 (59.2)	5,449 (59.9)	2,590 (57.8)	0.067
II	1,826 (13.4)	1,182 (13.0)	644 (14.4)
III	1,798 (13.2)	1,190 (13.1)	608 (13.6)
IV	1,923 (14.2)	1,281 (14.1)	642 (14.3)
p53 mutation	8,936	6,050	2,886
Negative	5,816 (65.1)	3,686 (60.9)	2,130 (73.8)	< 0.001
Positive	3,120 (34.9)	2,364 (39.1)	756 (26.2)
MSI	8,210	5,452	2,758
MSS, MSI-L	7,414 (90.3)	4,985 (91.4)	2,429 (88.1)	< 0.001
MSI-H	796 (9.7)	467 (8.6)	329 (11.9)
Smoking	12,717	8,544	4,173
Non-smoker	6,758 (53.1)	2,937 (34.4)	3,821 (91.6)	< 0.001
Smoker	5,959 (46.9)	5,607 (65.6)	352 (8.4)
Treatment
Endoscopic treatment	2,292 (15.5)	1,681 (17.1)	611 (12.4)	< 0.001
Surgery	9,217 (62.5)	6,039 (61.4)	3,178 (64.8)
Chemotherapy	1,467 (10.0)	1,018 (10.4)	449 (9.2)
Conservative treatment	1,763 (12.0)	1,094 (11.1)	669 (13.6)

Values are presented mean±SD or number (%). ADC, adenocarcinoma; AGC, advanced gastric cancer; EGC, early gastric cancer; MD, moderately differentiated; MSI, microsatellite instability; MSI-H, MSI-high; MSI-L, MSI-low; MSS, microsatellite stable; PCC, poorly cohesive carcinoma; PD, poorly differentiated; SD, standard deviation; SRC, signet ring cell carcinoma; WD, well differentiated; WHO, World Health Organization.

Table 2.

Risk factors for gastric cancer-related death

Variable	Univariate analyses		Multivariate analyses
Variable	HR (95% CI)	p-value	HR (95% CI)	p-value
Age	1.02 (1.02-1.03)	< 0.001	1.03 (1.02-1.03)	< 0.001
Sex
Male	Ref	0.255	-	-
Female	1.04 (0.97-1.12)		-
Lauren type
Intestinal	Ref	< 0.001	Ref	< 0.001
Diffuse	1.72 (1.60-1.86)		1.44 (1.27-1.65)
Mixed	0.99 (0.77-1.29)		1.05 (0.78-1.42)
Indeterminate	2.75 (1.85-4.09)		1.25 (0.73-2.14)
TNM staging
I	Ref	< 0.001	Ref	< 0.001
II	8.80 (7.47-10.37)		7.25 (5.78-9.10)
III	21.93 (18.90-25.45)		21.98 (17.87-27.02)
IV	85.99 (74.60-99.13)		50.34 (39.67-63.88)
p53 mutation
No	Ref	0.002	Ref	0.954
Yes	1.20 (1.07-1.34)		1.00 (0.89-1.14)
MSI
MSS, MSI-L	Ref	0.001	Ref	< 0.001
MSI-H	0.72 (0.59-0.87)		0.62 (0.49-0.78)

CI, confidence interval; HR, hazard ratio; MSI, microsatellite instability; MSI-H, MSI-high; MSI-L, MSI-low; MSS, microsatellite stable.

Table 3.

Subgroup analyses in stage IV patients

	Total (n=1,924)	Male (n=1,282)	Female (n=642)	p-value
Median survival (mo)	10	11	9	0.022
Age (yr)	61.59±14.25	62.41±13.23	59.96±15.97	0.001
Age (in diffuse-type patients) (yr)	54.55±14.71	56.43±14.29	52.26±14.91	0.001
Lauren classification
Intestinal	554 (48.0)	438 (56.7)	116 (30.4)	< 0.001
Diffuse	574 (49.7)	315 (40.7)	259 (68.0)
Mixed/Indeterminate	26 (2.3)	20 (2.6)	6 (1.6)

Values are presented mean±standard deviation or number (%) unless otherwise indicated.

REFERENCES

1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68:394–424. Article PubMed PDF
2. Park SH, Kang MJ, Yun EH, Jung KW. Epidemiology of gastric cancer in Korea: trends in incidence and survival based on Korea Central Cancer Registry data (1999-2019). J Gastric Cancer. 2022;22:160–8. Article PubMed PMC PDF
3. Kelley JR, Duggan JM. Gastric cancer epidemiology and risk factors. J Clin Epidemiol. 2003;56:1–9. Article PubMed
4. Lee TY, Wang CB, Chen TT, Kuo KN, Wu MS, Lin JT, et al. A tool to predict risk for gastric cancer in patients with peptic ulcer disease on the basis of a nationwide cohort. Clin Gastroenterol Hepatol. 2015;13:287–93. Article PubMed
5. Chandanos E, Rubio CA, Lindblad M, Jia C, Tsolakis AV, Warner M, et al. Endogenous estrogen exposure in relation to distribution of histological type and estrogen receptors in gastric adenocarcinoma. Gastric Cancer. 2008;11:168–74. Article PubMed PDF
6. Recent trends in SEER relative survival rates, 2000-2020 [Internet]. National Cancer Institute; 2025. [cited 2025 Mar 10]. Available from: https://seer.cancer.gov/statistics-network/explorer/application.html?site=18&data_type=4&graph_type=2&compareBy=sex&chk_sex_1=1&chk_sex_3=3&chk_sex_2=2&relative_survival_interval=5&race=1&age_range=1&stage=101&advopt_precision=1&advopt_show_ci=on&hdn_view=0&advopt_show_apc=on&advopt_display=2#resultsRegion0
7. Xing Y, Hosaka H, Moki F, Tomaru S, Itoi Y, Sato K, et al. Gender differences in patients with gastric adenocarcinoma. J Clin Med. 2024;13:2524.Article PubMed PMC
8. Korean Central Cancer Registry, 1993-2020 [Internet]. Statistics Korea; 2024. [cited 2025 Mar 10]. Available from: https://kosis.kr/statHtml/statHtml.do?orgId=101&tblId=DT_1B34E01&vw_cd=MT_ZTITLE&list_id=F_27&scrId=&seqNo=&lang_mode=ko&obj_var_id=&itm_id=&conn_path=MT_ZTITLE&path=%252FstatisticsList%252FstatisticsListIndex.do
9. Choi Y, Kim N, Kim KW, Jo HH, Park J, Yoon H, et al. Sex-based differences in histology, staging, and prognosis among 2983 gastric cancer surgery patients. World J Gastroenterol. 2022;28:933–47. Article PubMed PMC
10. Chen YC, Fang WL, Wang RF, Liu CA, Yang MH, Lo SS, et al. Clinicopathological variation of Lauren classification in gastric cancer. Pathol Oncol Res. 2016;22:197–202. Article PubMed PDF
11. Giroux V, Rustgi AK. Metaplasia: tissue injury adaptation and a precursor to the dysplasia-cancer sequence. Nat Rev Cancer. 2017;17:594–604. Article PubMed PMC PDF
12. Lauren P. The two histological main types of gastric carcinoma: diffuse and so-called intestinal-type carcinoma. An attempt at a histo-clinical classification. Acta Pathol Microbiol Scand. 1965;64:31–49. PubMed
13. Nagtegaal ID, Odze RD, Klimstra D, Paradis V, Rugge M, Schirmacher P, et al. The 2019 WHO classification of tumours of the digestive system. Histopathology. 2020;76:182–8. Article PubMed PMC PDF
14. Kang JM, Kim N, Yoo JY, Park YS, Lee DH, Kim HY, et al. The role of serum pepsinogen and gastrin test for the detection of gastric cancer in Korea. Helicobacter. 2008;13:146–56. Article PubMed
15. Yang X, Zhang T, Zhang H, Sang S, Chen H, Zuo X. Temporal trend of gastric cancer burden along with its risk factors in China from 1990 to 2019, and projections until 2030: comparison with Japan, South Korea, and Mongolia. Biomark Res. 2021;9:84.Article PubMed PMC PDF
16. Farinati F, Pelizzaro F. Gastric cancer screening in Western countries: a call to action. Dig Liver Dis. 2024;56:1653–62. Article PubMed
17. Raimondi A, Kim YW, Kang WK, Langley RE, Choi YY, Kim KM, et al. Prognostic and predictive impact of sex in locally advanced microsatellite instability high gastric or gastroesophageal junction cancer: an individual patient data pooled analysis of randomized clinical trials. Eur J Cancer. 2024;203:114043.Article PubMed
18. The general rules for the gastric cancer study in surgery and pathology. Part II. Histological classification of gastric cancer. Jpn J Surg. 1981;11:140–5. PubMed
19. Kim HW, Kim JH, Lim BJ, Kim H, Kim H, Park JJ, et al. Sex disparity in gastric cancer: female sex is a poor prognostic factor for advanced gastric cancer. Ann Surg Oncol. 2016;23:4344–51. Article PubMed PDF
20. Kang S, Park M, Cho JY, Ahn SJ, Yoon C, Kim SG, et al. Tumorigenic mechanisms of estrogen and Helicobacter pylori cytotoxin-associated gene A in estrogen receptor alpha-positive diffuse-type gastric adenocarcinoma. Gastric Cancer. 2022;25:678–96. Article PubMed PDF
21. Yi JH, Do IG, Jang J, Kim ST, Kim KM, Park SH, et al. Anti-tumor efficacy of fulvestrant in estrogen receptor positive gastric cancer. Sci Rep. 2014;4:7592.Article PubMed PMC PDF
22. Wang M, Pan JY, Song GR, Chen HB, An LJ, Qu SX. Altered expression of estrogen receptor alpha and beta in advanced gastric adenocarcinoma: correlation with prothymosin alpha and clinicopathological parameters. Eur J Surg Oncol. 2007;33:195–201. Article PubMed
23. Tang W, Liu R, Yan Y, Pan X, Wang M, Han X, et al. Expression of estrogen receptors and androgen receptor and their clinical significance in gastric cancer. Oncotarget. 2017;8:40765–77. Article PubMed PMC
24. Jung YJ, Kim HJ, Park CH, Park SJ, Kim N. Effects of reproductive factors on Lauren intestinal-type gastric cancers in females: a multicenter retrospective study in South Korea. Gut Liver. 2022;16:706–15. Article PubMed PMC
25. Kim YI, Choi IJ. Current status of the gastric cancer screening program in Korea. J Korean Med Assoc. 2022;65:250–7. Article PDF
26. Ugai T, Sasamoto N, Lee HY, Ando M, Song M, Tamimi RM, et al. Is early-onset cancer an emerging global epidemic? Current evidence and future implications. Nat Rev Clin Oncol. 2022;19:656–73. Article PubMed PMC PDF
27. Rodriquenz MG, Roviello G, D’Angelo A, Lavacchi D, Roviello F, Polom K. MSI and EBV positive gastric cancer’s subgroups and their link with novel immunotherapy. J Clin Med. 2020;9:1427.Article PubMed PMC
28. Sato Y, Okamoto K, Kawano Y, Kasai A, Kawaguchi T, Sagawa T, et al. Novel biomarkers of gastric cancer: current research and future perspectives. J Clin Med. 2023;12:4646.Article PubMed PMC
29. Quaas A, Biesma HD, Wagner AD, Verheij M, van Berge Henegouwen MI, Schoemig-Markiefka B, et al. Microsatellite instability and sex differences in resectable gastric cancer: a pooled analysis of three European cohorts. Eur J Cancer. 2022;173:95–104. Article PubMed
30. Hiltner T, Kohlruss M, Herz AL, Lorenzen S, Novotny A, Hapfelmeier A, et al. Microsatellite instability and sex-specific differences of survival in gastric cancer after neoadjuvant chemotherapy without and with taxane: an observational study in real world patients. J Cancer Res Clin Oncol. 2023;149:7651–62. Article PubMed PMC PDF
31. Choi Y, Kim N. Sex difference of colon adenoma pathway and colorectal carcinogenesis. World J Mens Health. 2024;42:256–82. Article PubMed PMC PDF

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REFERENCES

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Survival Rates of Patients with Gastric Cancer According to Age and Sex: A Large-Scale Study Using Data from 14,739 Patients

Cancer Res Treat. 2026;58(1):252-263. Published online April 16, 2025

DOI: https://doi.org/10.4143/crt.2025.149

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Abstract
Introduction
Materials and Methods
Results
Discussion
Electronic Supplementary Material
NOTES
REFERENCES

Survival Rates of Patients with Gastric Cancer According to Age and Sex: A Large-Scale Study Using Data from 14,739 Patients

Fig. 1. Histological type according to Lauren classification by age and sex: (A) male and (B) female.

Fig. 2. Overall survival (A, C, E, G) and gastric cancer-specific survival (B, D, F, H) in the total population and subgroup analysis with age stratification.

Fig. 3. Overall survival (A, C, E, G) and gastric cancer-specific survival (B, D, F, H) according to cancer stage.

Fig. 1.

Fig. 2.

Fig. 3.

Survival Rates of Patients with Gastric Cancer According to Age and Sex: A Large-Scale Study Using Data from 14,739 Patients

	Total (n=14,739)	Male (n=9,832)	Female (n=4,907)	p-value
Age (yr)	61.9±12.8	62.5±11.9	60.7±14.3	< 0.001
< 40	721 (4.9)	301 (3.1)	420 (8.6)	< 0.001
40-49	1,958 (13.3)	1,182 (12.0)	776 (15.8)
50-59	3,309 (22.5)	2,323 (23.6)	986 (20.1)
60-69	4,204 (28.5)	3,016 (30.7)	1,188 (24.2)
70-79	3,492 (23.7)	2,374 (24.1)	1,118 (22.8)
≥ 80	1,055 (7.2)	636 (6.5)	419 (8.5)
Location	13,898	9,313	4,585
Upper	2,677 (19.3)	1,834 (19.7)	843 (18.4)	< 0.001
Middle	3,642 (26.2)	2,267 (24.3)	1,375 (30.0)
Lower	7,579 (54.5)	5,212 (56.0)	2,367 (51.6)
Lauren type	13,118	8,806	4,312
Intestinal	7,901 (60.2)	5,952 (67.6)	1,949 (45.2)	< 0.001
Diffuse	4,799 (36.6)	2,566 (29.1)	2,233 (51.8)
Mixed	343 (2.6)	223 (2.5)	120 (2.8)
Indeterminate	75 (0.6)	65 (0.7)	10 (0.2)
WHO classification	14,163	9,486	4,677
ADC, WD	2,689 (19.0)	2,060 (21.7)	629 (13.4)	< 0.001
ADC, MD	4,363 (30.8)	3,280 (34.6)	1,083 (23.2)
ADC, PD	2,663 (18.8)	1,714 (18.1)	949 (20.3)
PCC, SRC	2,940 (20.8)	1,469 (15.5)	1,471 (31.5)
Mixed carcinoma	855 (6.0)	470 (5.0)	385 (8.2)
Mucinous ADC	107 (0.8)	82 (0.9)	25 (0.5)
Papillary ADC	165 (1.2)	119 (1.3)	46 (1.0)
Others	381 (2.7)	292 (3.1)	89 (1.9)
Cancer type	12,507	8,409	4,098
EGC	7,746 (61.9)	5,217 (62.0)	2,529 (61.7)	0.723
AGC	4,761 (38.1)	3,192 (38.0)	1,569 (38.3)
TNM stage	13,586	9,102	4,484
I	8,039 (59.2)	5,449 (59.9)	2,590 (57.8)	0.067
II	1,826 (13.4)	1,182 (13.0)	644 (14.4)
III	1,798 (13.2)	1,190 (13.1)	608 (13.6)
IV	1,923 (14.2)	1,281 (14.1)	642 (14.3)
p53 mutation	8,936	6,050	2,886
Negative	5,816 (65.1)	3,686 (60.9)	2,130 (73.8)	< 0.001
Positive	3,120 (34.9)	2,364 (39.1)	756 (26.2)
MSI	8,210	5,452	2,758
MSS, MSI-L	7,414 (90.3)	4,985 (91.4)	2,429 (88.1)	< 0.001
MSI-H	796 (9.7)	467 (8.6)	329 (11.9)
Smoking	12,717	8,544	4,173
Non-smoker	6,758 (53.1)	2,937 (34.4)	3,821 (91.6)	< 0.001
Smoker	5,959 (46.9)	5,607 (65.6)	352 (8.4)
Treatment
Endoscopic treatment	2,292 (15.5)	1,681 (17.1)	611 (12.4)	< 0.001
Surgery	9,217 (62.5)	6,039 (61.4)	3,178 (64.8)
Chemotherapy	1,467 (10.0)	1,018 (10.4)	449 (9.2)
Conservative treatment	1,763 (12.0)	1,094 (11.1)	669 (13.6)

Variable	Univariate analyses		Multivariate analyses
Variable	HR (95% CI)	p-value	HR (95% CI)	p-value
Age	1.02 (1.02-1.03)	< 0.001	1.03 (1.02-1.03)	< 0.001
Sex
Male	Ref	0.255	-	-
Female	1.04 (0.97-1.12)		-
Lauren type
Intestinal	Ref	< 0.001	Ref	< 0.001
Diffuse	1.72 (1.60-1.86)		1.44 (1.27-1.65)
Mixed	0.99 (0.77-1.29)		1.05 (0.78-1.42)
Indeterminate	2.75 (1.85-4.09)		1.25 (0.73-2.14)
TNM staging
I	Ref	< 0.001	Ref	< 0.001
II	8.80 (7.47-10.37)		7.25 (5.78-9.10)
III	21.93 (18.90-25.45)		21.98 (17.87-27.02)
IV	85.99 (74.60-99.13)		50.34 (39.67-63.88)
p53 mutation
No	Ref	0.002	Ref	0.954
Yes	1.20 (1.07-1.34)		1.00 (0.89-1.14)
MSI
MSS, MSI-L	Ref	0.001	Ref	< 0.001
MSI-H	0.72 (0.59-0.87)		0.62 (0.49-0.78)

	Total (n=1,924)	Male (n=1,282)	Female (n=642)	p-value
Median survival (mo)	10	11	9	0.022
Age (yr)	61.59±14.25	62.41±13.23	59.96±15.97	0.001
Age (in diffuse-type patients) (yr)	54.55±14.71	56.43±14.29	52.26±14.91	0.001
Lauren classification
Intestinal	554 (48.0)	438 (56.7)	116 (30.4)	< 0.001
Diffuse	574 (49.7)	315 (40.7)	259 (68.0)
Mixed/Indeterminate	26 (2.3)	20 (2.6)	6 (1.6)

Table 1. Baseline characteristics of study participants

Table 2. Risk factors for gastric cancer-related death

CI, confidence interval; HR, hazard ratio; MSI, microsatellite instability; MSI-H, MSI-high; MSI-L, MSI-low; MSS, microsatellite stable.

Table 3. Subgroup analyses in stage IV patients

Values are presented mean±standard deviation or number (%) unless otherwise indicated.