Real-world prognostic factors for survival among treated patients with metastatic pancreatic ductal adenocarcinoma

Real-world clinical outcomes and economic burden of metastatic pancreatic ductal adenocarcinoma: a systematic review

AIMS

This systematic review summarizes real-world clinical outcomes and economic burden of first-line FOLFIRINOX (FFX)/modified FFX (mFFX) and nab-paclitaxel plus gemcitabine (GnP) in metastatic pancreatic ductal adenocarcinoma in the US.

METHODS

Embase and MEDLINE were searched for materials published since 2014; citations were reviewed in a two-step process. Included studies were qualitatively synthesized.

RESULTS

Searches yielded 2,528 citations; 29 were included (17 clinical studies/12 economic studies). In 9/17 clinical studies, median overall survival (mOS) ranged from 4.7 months to 11.4 months for FFX/mFFX, with the unweighted median of the estimates within this range being 9.2 months; for GnP mOS ranged from 3.6 to 9.8 months, and the unweighted median of the estimates was 6.9 months. In 8/17 studies, grade 3/4 anemia, neutropenia, and thrombocytopenia were the most commonly reported adverse events. Across economic burden studies, total costs were similar between the 2 groups. Outpatient, supportive care, and granulocyte colony-stimulating factor costs were higher for the FFX generic regimen, and chemotherapy costs were higher for the GnP branded regimen.

CONCLUSIONS

Real-world OS in FFX- and GnP-treated populations was shorter than that in clinical trials, and total costs of FFX and GnP were similar, but with differences in cost components.

A study of pharmacists-joint total parenteral nutrition in haematopoietic cell transplantation in accord with diagnosis related groups: A retrospective clinical research

Background

Within Diagnosis Related Groups, based on service capability, efficiency, and quality safety assessment, clinical pharmacists contribute to promoting rational drug utilisation in healthcare institutions. However, a deficiency of pharmacist involvement has been observed in the total parenteral nutrition support to patients following haematopoietic cell transplantation (HCT) within DRGs.

Methods

This study involved 146 patients who underwent HCT at the Department of Haematology, the Second Affiliated Hospital of Dalian Medical University, spanning from January 2020 to December 2022.

Results

Patients were allocated equally, with 73 in the control group and 73 in the pharmacist-involved group: baseline characteristics showed no statistics significance, including age, body mass index, nutrition risk screening-2002 score, liver and kidney function, etc. Albumin levels, prealbumin levels were significantly improved after a 7-day TPN support (34.92 ± 4.24 vs 36.25 ± 3.65, P = 0.044; 251.30 ± 95.72 vs 284.73 ± 83.15, P = 0.026). The body weight was increased after a 7-day support and before discharge (58.77 ± 12.47 vs 63.82 ± 11.70, P = 0.013; 57.61 ± 11.85 vs 64.92 ± 11.71, P < 0.001). The length of hospital stay, costs and the rate of re-admissions were significantly shortened (51.10 ± 1.42 vs 46.41 ± 1.86, P = 0.048; 360,162.67 ± 91,831.34 vs 324,070.16 ± 112,315.51, P = 0.035; 61.64% vs 43.84%, P = 0.046).

Conclusions

Pharmacist-joint TPN support enhances the service efficiency score of medical units, ensuring the fulfilment of orders and rational medication.

Integration of liposomal irinotecan in the first-line treatment of metastatic pancreatic cancer: try to do not think about the white bear

The approval of novel therapeutic agents remains widely reliant on evidence derived from large phase III randomized controlled trials. Liposomal irinotecan (ONIVYDE®) stands out as the only drug that has demonstrated improved survival both as a first-line therapy in combination with oxaliplatin and 5-fluorouracil/leucovorin (5FU/LV) (NALIRIFOX) compared to the standard gemcitabine plus nab-paclitaxel in the NAPOLI3 trial, and as a second-line treatment in combination with 5FU/LV compared to the standard 5FU/LV in the NAPOLI1 trial. However, just as the white bear of the Dostoevsky's paradox, the judgment of these results is invariably distracted by the intrusive thought of how different they might be if compared to similar regimens containing standard-free irinotecan as FOLFIRINOX or FOLFIRI, respectively. Here, we present and thoroughly discuss the evidence encompassing the pharmacologic, preclinical, and clinical development of liposomal irinotecan that can dispel any intrusive thoughts and foster a rational and well-considered judgment of this agent and its potential integration into the therapeutic strategies for pancreatic ductal adenocarcinoma.

Systemic Chemotherapy With or Without Hepatic Arterial Infusion Chemotherapy for Liver Metastases From Pancreatic Cancer: A Propensity Score Matching Analysis

BACKGROUND

The significance of systemic chemotherapy (SCT) combined with hepatic arterial infusion (HAI) chemotherapy in the treatment of pancreatic ductal adenocarcinoma with liver metastases (PACLM) remains unclear. Based on previous studies, this single-center propensity score matching (PSM) study aimed to explore the efficacy of SCT with or without HAI for PACLM.

PATIENT AND METHODS

The PSM method was used to screen 661 cases of PACLM who received SCT at Tianjin Medical University Cancer Institute and Hospital from 2001 to 2020. According to the 1:6 ratio with PSM, 385 patients were divided into the SCT+HAI group (n = 55) and the SCT group (n = 330). After a median follow-up of 49 (range 7-153) months, overall survival (OS) and survival-related prognostic factors were analyzed.

RESULTS

The main baseline characteristics of the SCT+HAI group and the SCT alone group were matched appropriately (P > .05). After PSM, the median OS for patients in the 2 groups was 10.6 and 7.6 months, respectively (P = .02). Multivariate analysis revealed that peritoneal metastases (P = .03), CA199 ≥ 500U/mL (P = .03), and lactate dehydrogenase (LDH) ≥ 250U/L (P = .03) were prognostic factors of poor survival, modern SCT plus HAI (P = .04) was a protective factor.

CONCLUSION

Our findings indicated that adequate cycles of SCT+HAI result in better survival than SCT alone in patients with PACLM. Patients with peritoneal metastases, markedly elevated CA19-9 and LDH have a poorer prognosis. The conclusion has yet to be validated in randomized controlled clinical trials.

Is lung involvement a favorable prognostic factor for pancreatic ductal adenocarcinoma with synchronous liver metastases?-A propensity score analysis

BACKGROUND

For advanced pancreatic cancer, pulmonary metastases (PM) have been considered favorable factors compared to metastases of other sites, but it remains unknown whether the prognosis of patients with synchronous liver and lung metastases is better than that of non-PM.

METHODS

Data was derived from a two-decade cohort and included 932 cases of pancreatic adenocarcinoma with synchronous liver metastases (PACLM). Propensity score matching (PSM) was applied to balance 360 selected cases, grouped into PM (n = 90) and non-PM (n = 270). Overall survival (OS) and survival-related factors were analyzed.

RESULTS

In PSM-adjusted data, the median OS was 7.3 and 5.8 months, for PM and non-PM, respectively (p = 0.16). Multivariate analysis revealed that male gender, poor performance status, higher hepatic tumor burden, ascites, elevated carbohydrate antigen 19-9, and lactate dehydrogenase were factors of poor survival (p < 0.05). Chemotherapy was the only independent significant factor of favorable prognosis (p < 0.05).

CONCLUSION

Although lung involvement was indicated to be a favorable prognostic factor for patients with PACLM in the whole cohort, PM were not associated with better survivals in the subset of cases subjected to PSM adjustment.

A novel preoperative MRI-based radiomics nomogram outperforms traditional models for prognostic prediction in pancreatic ductal adenocarcinoma

To develop an efficient prognostic model based on preoperative magnetic resonance imaging (MRI) radiomics for patients with pancreatic ductal adenocarcinoma (PDAC), the preoperative MRI data of PDAC patients in two independent centers (defined as development cohort and validation cohort, respectively) were collected retrospectively, and the radiomics features of tumors were then extracted. Based on the optimal radiomics features which were significantly related to overall survival (OS) and progression-free survival (PFS), the score of radiomics signature (Rad-score) was calculated, and its predictive efficiency was evaluated according to the area under receiver operator characteristic curve (AUC). Subsequently, the clinical-radiomics nomogram which incorporated the Rad-score and clinical parameters was developed, and its discrimination, consistency and application value were tested by calibration curve, concordance index (C-index) and decision curve analysis (DCA). Moreover, the predictive value of the clinical-radiomics nomogram was compared with traditional prognostic models. A total of 196 eligible PDAC patients were enrolled in this study. The AUC value of Rad-score for OS and PFS in development cohort was 0.724 and 0.781, respectively, and the value of Rad-score was negatively correlated with PDAC's prognosis. Moreover, the developed clinical-radiomics nomogram showed great consistency with the C-index for OS and PFS in development cohort was 0.814 and 0.767, respectively. In addition, the DCA demonstrated that the developed nomogram displayed better clinical predictive usefulness than traditional prognostic models. We concluded that the preoperative MRI-based radiomics signature was significantly related to the poor prognosis of PDAC patients, and the developed clinical-radiomics nomogram showed better predictive ability, it might be used for individualized prognostic assessment of preoperative patients with PDAC.

Pharmacist-led standardization of total parenteral nutrition improves postoperative nutritional status in colorectal cancer patients

Background

Total parenteral nutrition (TPN) is an essential treatment for patients who undergo abdominal surgery. Due to the gap of knowledge background between clinicians and pharmacists, the participation of the latter may improve TPN standardization. However, the impact on clinical outcome is unknown. In this study, we evaluated the impact of appropriacy and efficacy of TPN prescription, after a pharmacist-led TPN standardization program introduced.

Methods

A pharmacist-led TPN standardization program was introduced in the Zhejiang Cancer Hospital and the clinical outcomes were assessed. The TPN standardization program includes a pre-established standard multidisciplinary evaluation standard, a computerized TPN management system and regular evaluations of TPN prescription performed by pharmacists. Any concerns were identified and improved via discussed with doctors. To evaluate the effect of pharmacists’ intervention in nutritional status and postoperative complications, an observational before-and-after cohort study was performed. All patients admitted in hospital with colorectal cancer (CRC) and receiving abdominal surgery in June 2019 (pre-intervention cohort) and June 2020 (post-intervention cohort) were retrospectively analyzed. Nutritional status of patients was evaluated using the levels of postoperative serum albumin, prealbumin, total protein, and their decrease extent. Surgical or TPN-related complications and recovery time were collated as the clinical outcomes.

Results

There were no significant differences in the basic clinical information of the two cohorts, suggesting that the two groups are comparable. The average postoperative prealbumin levels were elevated in 2020 compared to 2019 (192.3±5.5 mg/L for 2019 and 229.5±4.8 mg/L for 2020, P<0.001). In addition, the post-intervention cohort showed a lower postoperative infection rate (11.6% vs. 18.2%), shorter duration of infection (9.4±1.4 vs. 7.7±1.0 days), lower incidence of postoperative albumin decrease (25.2% vs. 76.7%), prealbumin decrease (71.5% vs. 78.9%), and total protein decrease (25.2% vs. 72.2%), and lower incidence of TPN-related hypoglycemia (5.4% vs. 15.3%).

Conclusions

Pharmacist-led TPN standardization improved the postoperative clinical outcomes in patients with colorectal cancer (CRC).

Real-world prognostic factors for survival among treated patients with metastatic pancreatic ductal adenocarcinoma

Background

Many real‐world studies of patients with metastatic pancreatic ductal adenocarcinoma (mPDAC) are restricted to single centers, limiting the generalizability of their insights. This study aimed to identify important population‐based predictors for survival in patients diagnosed with mPDAC in a broader setting.

Methods

Data between 1 January 2017 and 31 December 2019 were extracted from the Flatiron Health EHR database. Treatment‐specific predictive models were generated for patients treated with first‐line gemcitabine+nab­paclitaxel (GNP), FOLFIRINOX, gemcitabine monotherapy (gem‐mono), and second‐line liposomal irinotecan‐based regimens. The holdout method was used for cross‐validation. Age at diagnosis, sex, BMI, smoking status, and ECOG performance score were included in all models with additional demographic, clinical characteristics, and hematological function assessed for inclusion.

Results

Of the 3625 patients, 43% received GNP, 26% received FOLFIRINOX, 7% received gem‐mono, and 23% received other regimens; 40% (n = 1448) advanced to the second line. Among all first‐line patients, the following were included in the final model: prior surgery, white blood cell (WBC) counts, serum albumin (SA), liver function tests (LFTs), serum bilirubin, serum carbohydrate antigen 19–9, and ascites. Models for patients receiving specific therapies differed from the overall model, GNP (ascites removed), FOLFIRINOX (stage at initial diagnosis added), and gem‐mono (LFTs omitted). Alkaline phosphatase (ALP), SA, and WBC counts were important predictors of survival among patients treated with second‐line liposomal irinotecan. Across all regimens, the strongest predictors of survival were ECOG score, SA, and ALP.

Conclusions

In this real‐world study of patients with mPDAC, important population prognostic factors of survival were identified in a large cohort of patients receiving systemic treatment.