Short- and long-term outcomes after perioperative EOX therapy versus upfront surgery for gastric cancer: a single-centre propensity score–matched cohort study

Introduction: Despite radical surgery, gastric cancer (GC) survival rates remain low in Western countries. Randomised trials suggest that perioperative chemotherapy downstages disease, improving long-term survival without increasing complications. We compared outcomes for upfront surgery (US) versus surgery combined with perioperative EOX (epirubicin, oxaliplatin, capecitabine) therapy for short- and long-term survival. Methods: We analysed 310 patients who underwent curative intent gastrectomy for GC at a single tertiary centre from 2006 to 2017. Patients were assigned to the EOX group (n = 105) or the US group (n = 205). Propensity score matching (PSM) was utilised to balance baseline characteristics, clinical stage, surgery type, and histology. Short-term outcomes included the Comprehensive Complication Index (CCI) and 30-day mortality, while long-term outcomes were overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS). Results: After PSM, 102 patients remained in each group. The EOX group exhibited significantly lower preoperative haemoglobin levels compared to the US group, but other baseline characteristics were comparable. Tumour-related outcomes favoured the EOX group, with significantly smaller tumours (P < 0.001), fewer metastatic lymph nodes (P = 0.004), and lower tumour stages overall. Splenectomy was more common in the US group (40.2% versus 23.5%, P = 0.011). Postoperative complications were similar between groups, although ICU admissions were more frequent in the EOX group (16.7% versus 6.9%, P = 0.030). Thirty-day mortality rates were low and comparable (1.0% in the EOX group versus 2.0% in the US group, P = 1.000). Long-term outcomes, including overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS), showed no significant differences between the groups. Conclusions: Perioperative EOX therapy is as safe as upfront surgery and significantly reduces metastatic lymph nodes and tumour size, suggesting its role in downstaging the disease. However, despite these promising oncological responses, this benefit does not translate into improved long-term survival. © The Author(s) 2025.