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Kirkegård J, Ladekarl M, Johannsen IR, Mortensen F. Effect of adjuvant chemotherapy after pancreatectomy in patients with node-negative pancreatic cancer: target trial emulation. Br J Surg 2024; 111:znad398. [PMID: 38006324 DOI: 10.1093/bjs/znad398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/07/2023] [Accepted: 11/09/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND The effect of adjuvant therapy in node-negative pancreatic cancer is uncertain. The aim of this study was to estimate the effect of adjuvant chemotherapy on survival after surgery for pancreatic cancer in patients with node-negative (pN0) and node-positive (pN+) disease using target trial emulation. METHODS This was an observational cohort study emulating a hypothetical RCT by the clone-censor-weight approach using population-based Danish healthcare registries. The study included Danish patients undergoing curative-intent surgery for pancreatic cancer during 2008-2021, who were discharged alive no more than 4 weeks after surgery. At the time of discharge after surgery, the data for each patient were duplicated; one copy was assigned to the adjuvant chemotherapy strategy and the other to the no adjuvant chemotherapy strategy of the hypothetical trial. Copies were censored when the assigned treatment was no longer compatible with the observed treatment. To account for informative censoring, uncensored patients were weighted according to measured confounders. The primary outcomes were absolute difference in 2-year survival and median overall survival, comparing adjuvant with no adjuvant chemotherapy. RESULTS Some 424 patients with pN0 and 953 with pN+ disease were included. Of these, 62.0 and 74.6% respectively initiated adjuvant chemotherapy within the 8-week grace period. Among patients with pN0 tumours, the difference in 2-year survival between those with and without adjuvant therapy was -2.2 (95% c.i. -11.8 to 7.4)%. In those with pN+ disease, the difference in 2-year survival was 9.9 (1.6 to 18.1)%. Median overall survival was 24.9 (i.q.r. 12.8-49.4) and 15.0 (8.0-34.0) months for patients having adjuvant and no adjuvant therapy respectively. CONCLUSION In a target trial emulation using observational data, adjuvant chemotherapy did not improve survival after surgery for node-negative pancreatic cancer.
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Affiliation(s)
- Jakob Kirkegård
- Department of Surgery, Hepatopancreatobiliary Section, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Morten Ladekarl
- Department of Oncology and Clinical Cancer Research Centre, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Frank Mortensen
- Department of Surgery, Hepatopancreatobiliary Section, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Ni X, Li D, Dai S, Pan H, Sun H, Ao J, Chen L, Kong H. Development and Evaluation of Nomograms to Predict the Cancer-Specific Mortality and Overall Mortality of Patients with Hepatocellular Carcinoma. BIOMED RESEARCH INTERNATIONAL 2021; 2021:1658403. [PMID: 33860031 PMCID: PMC8024067 DOI: 10.1155/2021/1658403] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 01/11/2021] [Accepted: 03/22/2021] [Indexed: 01/10/2023]
Abstract
Hepatocellular carcinoma (HCC) is the most common type among primary liver cancers (PLC). With its poor prognosis and survival rate, it is necessary for HCC patients to have a long-term follow-up. We believe that there are currently no relevant reports or literature about nomograms for predicting the cancer-specific mortality of HCC patients. Therefore, the primary goal of this study was to develop and evaluate nomograms to predict cancer-specific mortality and overall mortality. Data of 45,158 cases of HCC patients were collected from the Surveillance, Epidemiology, and End Results (SEER) program database between 2004 and 2013, which were then utilized to develop the nomograms. Finally, the performance of the nomograms was evaluated by the concordance index (C-index) and the area under the time-dependent receiver operating characteristic (ROC) curve (td-AUC). The categories selected to develop a nomogram for predicting cancer-specific mortality included marriage, insurance, radiotherapy, surgery, distant metastasis, lymphatic metastasis, tumor size, grade, sex, and the American Joint Committee on Cancer (AJCC) stage; while the marriage, radiotherapy, surgery, AJCC stage, grade, race, sex, and age were selected to develop a nomogram for predicting overall mortality. The C-indices for predicted 1-, 3-, and 5-year cancer-specific mortality were 0.792, 0.776, and 0.774; the AUC values for 1-, 3-, and 5-year cancer-specific mortality were 0.830, 0.830, and 0.830. The C-indices for predicted 1-, 3-, and 5-year overall mortality were 0.770, 0.755, and 0.752; AUC values for predicted 1-, 3-, and 5-year overall mortality were 0.820, 0.820, and 0.830. The results showed that the nomograms possessed good agreement compared with the observed outcomes. It could provide clinicians with a personalized predicted risk of death information to evaluate the potential changes of the disease-specific condition so that clinicians can adjust therapy options when combined with the actual condition of the patient, which is beneficial to patients.
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Affiliation(s)
- Xiaofeng Ni
- Department of Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
- Key Laboratory of Diagnosis and Treatment of Severe Hepato-Pancreatic Diseases of Zhejiang Province, Zhejiang Provincial Top Key Discipline in Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Ding Li
- Key Laboratory of Diagnosis and Treatment of Severe Hepato-Pancreatic Diseases of Zhejiang Province, Zhejiang Provincial Top Key Discipline in Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Shengjie Dai
- Department of Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Hao Pan
- Department of Orthopaedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Hongwei Sun
- Department of Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Jianyang Ao
- Department of Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Lei Chen
- Department of Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
- Department of Orthopaedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Hongru Kong
- Department of Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
- Key Laboratory of Diagnosis and Treatment of Severe Hepato-Pancreatic Diseases of Zhejiang Province, Zhejiang Provincial Top Key Discipline in Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
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Winer LK, Cortez AR, Ahmad SA, Wima K, Olowokure O, Latif T, Kharofa J, Patel SH. Evaluating the Impact of ESPAC-1 on Shifting the Paradigm of Pancreatic Cancer Treatment. J Surg Res 2020; 259:442-450. [PMID: 33059910 DOI: 10.1016/j.jss.2020.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 08/09/2020] [Accepted: 09/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In 2004, the European Study Group for Pancreatic Cancer (ESPAC)-1 long-term data concluded that adjuvant chemotherapy provided a survival benefit for patients with pancreatic ductal adenocarcinoma (PDAC), whereas adjuvant chemoradiation was associated with worse overall survival. In this study, we investigated how long it took for US practice patterns to change following this trial. METHODS The National Cancer Database was used to identify patients with stage I-III PDAC who underwent R0 or R1 resection followed by adjuvant chemotherapy or chemoradiation between 1998 and 2015. A multivariate analysis was performed to determine predictors of receiving adjuvant chemoradiation in the post-ESPAC-1 era. RESULTS Between 1998 and 2015, adjuvant chemotherapy use increased from 2.9% to 51.6%, whereas adjuvant chemoradiation decreased from 49.5% to 22.9%. In 2010, adjuvant chemotherapy utilization surpassed that of chemoradiation. For patients diagnosed in the post-ESPAC-1 era, adjuvant chemotherapy (n = 7733) and chemoradiation (n = 6969) groups were compared. Patients who underwent adjuvant chemoradiation were younger, had private insurance, underwent surgery at nonacademic centers, and had more pathologically advanced cancers (all P < 0.01). After 2010, R1 resection was the strongest independent predictor of adjuvant chemoradiation use by multivariate analysis (OR 2.05, CI 1.8-2.3, P < 0.01). CONCLUSIONS Adjuvant chemotherapy use exceeded that of adjuvant chemoradiation 6 y after the final publication of ESPAC-1 in 2004, highlighting the challenges of disseminating and adopting clinical data. After 2010, R1 disease was the most significant predictor of receiving adjuvant chemoradiation. Prospective studies are underway to definitively address the role of adjuvant chemoradiation in PDAC.
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Affiliation(s)
- Leah K Winer
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexander R Cortez
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Syed A Ahmad
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, Ohio; Department of Surgery, Section of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Koffi Wima
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Olubenga Olowokure
- Department of Hematology & Oncology, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Tahir Latif
- Department of Hematology & Oncology, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Jordan Kharofa
- Department of Radiation Oncology, University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Sameer H Patel
- Department of Surgery, Cincinnati Research on Outcomes and Safety in Surgery (CROSS), University of Cincinnati College of Medicine, Cincinnati, Ohio; Department of Surgery, Section of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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Raoof M, Blakely AM, Melstrom LG, Lee B, Warner SG, Chung V, Singh G, Chen Y, Fong Y. Adjuvant chemotherapy versus chemoradiation in high-risk pancreatic adenocarcinoma: A propensity score-matched analysis. Cancer Med 2019; 8:5881-5890. [PMID: 31414566 PMCID: PMC6792522 DOI: 10.1002/cam4.2491] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 12/26/2022] Open
Abstract
PURPOSE The American Society of Clinical Oncology guidelines recommend adjuvant chemoradiation (ACR) for margin-positive (R1) and/or node-positive (N+) pancreatic cancers. Our goal was to investigate if there is evidence of superiority of adjuvant chemoradiation (ACR) over adjuvant chemotherapy (AC). METHODS We utilized data from the National Cancer Database (NCDB) for N+ and/or R1 pancreatic adenocarcinoma patients diagnosed from 2004 to 2012 who underwent ACR or AC. Patients who received neoadjuvant radiation, no adjuvant treatment, or adjuvant radiation alone were excluded. Propensity score nearest-neighbor 1:1 matching (PSM) was performed between ACR and AC groups based on age, sex, race, insurance, year of diagnosis, comorbidities, tumor site and size, T-stage, nodal status, margin status, grade, and treatment facility. Primary outcome was overall survival (OS). RESULTS A total of 8297 patients were eligible. After PSM, two well-balanced groups of 3244 patients each were analyzed. ACR resulted in superior OS compared with AC alone (Hazard ratio [HR] 0.83, 95% CI 0.79-0.87; median OS 22 vs 19 months, P < .0001). Subset analyses demonstrated OS benefit of ACR compared with AC in N+, R0 patients (HR: 0.82, 95% CI 0.77-0.88; Median OS 24 vs 20 months, P < .001) as well as N+, R1 patients (HR: 0.77, 95% CI 0.68-0.87; Median OS 17 vs 15 months, P < .001); but not in node-negative, R1 patients (HR: 1.12, 95% CI 0.84-1.48; Median OS 18 vs 22 months, P = .63). CONCLUSION The addition of radiation to AC was associated with a clinically small but meaningful increase in survival of patients undergoing curative-intent pancreatic resections. This association was not evident in patients with microscopically positive margins but node-negative disease and larger studies will be needed.
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Affiliation(s)
- Mustafa Raoof
- Department of SurgeryCity of Hope National Medical CenterDuarteCalifornia
| | - Andrew M. Blakely
- Department of SurgeryCity of Hope National Medical CenterDuarteCalifornia
| | - Laleh G. Melstrom
- Department of SurgeryCity of Hope National Medical CenterDuarteCalifornia
| | - Byrne Lee
- Department of SurgeryCity of Hope National Medical CenterDuarteCalifornia
| | - Susanne G. Warner
- Department of SurgeryCity of Hope National Medical CenterDuarteCalifornia
| | - Vincent Chung
- Department of Medical OncologyCity of Hope National Medical CenterDuarteCalifornia
| | - Gagandeep Singh
- Department of SurgeryCity of Hope National Medical CenterDuarteCalifornia
| | - Yi‐Jen Chen
- Department of Radiation OncologyCity of Hope National Medical CenterDuarteCalifornia
| | - Yuman Fong
- Department of SurgeryCity of Hope National Medical CenterDuarteCalifornia
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