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Safyan RA, Kim E, Dekker E, Homs M, Aguirre AJ, Koerkamp BG, Chiorean EG. Multidisciplinary Standards and Evolving Therapies for Patients With Pancreatic Cancer. Am Soc Clin Oncol Educ Book 2024; 44:e438598. [PMID: 38781541 DOI: 10.1200/edbk_438598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Pancreatic ductal adenocarcinoma (PDA) is a challenging disease that presents at an advanced stage and results in many symptoms that negatively influence patients' quality of life and reduce their ability to receive effective treatment. Early implementation of expert multidisciplinary care with nutritional support, exercise, and palliative care for both early-stage and advanced disease promises to maintain or improve the patients' physical, social, and psychological well-being, decrease aggressive interventions at the end of life, and ultimately improve survival. Moreover, advances in treatment strategies in the neoadjuvant and metastatic setting combined with novel therapeutic agents targeting the key drivers of the disease are leading to improvements in the care of patients with pancreatic cancer. Here, we emphasize the multidisciplinary supportive and therapeutic care of patients with PDA, review current guidelines and new developments of neoadjuvant and perioperative treatments for localized disease, as well as the treatment standards and the evolving field of precision oncology and immunotherapies for advanced PDA.
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Affiliation(s)
- Rachael A Safyan
- University of Washington School of Medicine, Department of Medicine, Division of Hematology-Oncology, Seattle, WA
- Fred Hutchinson Cancer Center, Clinical Research Division, Seattle, WA
| | - Eejung Kim
- Dana-Farber Cancer Center, Department of Medical Oncology, Boston, MA
- Harvard Medical School, Boston, MA
| | - Emmelie Dekker
- Erasmus MC Cancer Institute, Department of Surgery, Rotterdam, the Netherlands
| | - Marjolein Homs
- Erasmus MC Cancer Institute, Department of Medical Oncology, Rotterdam, the Netherlands
| | - Andrew J Aguirre
- Dana-Farber Cancer Center, Department of Medical Oncology, Boston, MA
- Harvard Medical School, Boston, MA
| | - Bas Groot Koerkamp
- Erasmus MC Cancer Institute, Department of Surgery, Rotterdam, the Netherlands
| | - E Gabriela Chiorean
- University of Washington School of Medicine, Department of Medicine, Division of Hematology-Oncology, Seattle, WA
- Fred Hutchinson Cancer Center, Clinical Research Division, Seattle, WA
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Paiella S, Malleo G, Casciani F, Salvia R. ASO Author Reflections: Adjuvant Therapy for Resectable Pancreatic Cancer in the Real World-Not as Common as One Might Think. Ann Surg Oncol 2024; 31:2959-2960. [PMID: 38349565 DOI: 10.1245/s10434-024-15014-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 04/10/2024]
Affiliation(s)
- Salvatore Paiella
- Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
| | - Giuseppe Malleo
- Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Fabio Casciani
- Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Jung HS, Han Y, Yun WG, Cho YJ, Lee M, Lee DH, Kwon W, Jang JY. Examining neoadjuvant treatment candidates in resectable pancreatic cancer based on tumor-vessel interactions and CA 19-9 levels: a retrospective cohort study. Int J Surg 2024; 110:2883-2893. [PMID: 38376856 PMCID: PMC11093487 DOI: 10.1097/js9.0000000000001184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/29/2024] [Indexed: 02/21/2024]
Abstract
INTRODUCTION The applicability of neoadjuvant treatment (NAT) for resectable pancreatic ductal adenocarcinoma (PDAC) has arisen, however, high-level evidence is lacking. This study aimed to explore patient subgroups with high-risk resectable PDAC for selecting candidates who may benefit from NAT. METHODS The 1132 patients with resectable or borderline resectable PDAC who underwent surgery between 2007 and 2021 were retrospectively reviewed. Patients with resectable PDAC without contact of major vessels (R-no contact) ( n =651), with contact of portal vein or superior mesenteric vein (PV/SMV) ≤180° (R-contact) ( n =306), and borderline resectable PDAC without arterial involvement (BR-V) ( n =175) were analyzed. RESULTS The mean age was 64.3±9.8 years, and 647 patients (57.2%) were male. The median follow-up was 26 months in the entire cohort. Patients with resectable PDAC without vascular contact had the most improved overall survival (OS) (median; 31.5 months). OS did not significantly differ between NAT and upfront surgery in the entire resectable PDAC cohort. However, in R-contact group, NAT showed significantly improved OS compared to upfront surgery (33 vs. 23 months). Neoadjuvant FOLFIRINOX was showed a better OS than gemcitabine-based regimens in patients who underwent NAT (34 vs. 24 months). NAT was associated with a better survival in the patients with CA 19-9 level ≥150 U/ml, only when the tumor has PV/SMV contact in resectable disease (40 vs. 19 months, P =0.001). CONCLUSIONS NAT can be considered as an effective treatment in patients with resectable PDAC, particularly when the tumor is in contact with PV/SMV and CA 19-9 ≥150 U/ml.
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Affiliation(s)
- Hye-Sol Jung
- Department of Surgery and Cancer Research Institute
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute
| | - Won-Gun Yun
- Department of Surgery and Cancer Research Institute
| | | | - Mirang Lee
- Department of Surgery and Cancer Research Institute
| | - Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute
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Paiella S, Malleo G, Lionetto G, Cattelani A, Casciani F, Secchettin E, De Pastena M, Bassi C, Salvia R. Adjuvant Therapy After Upfront Resection of Resectable Pancreatic Cancer: Patterns of Omission and Use-A Prospective Real-Life Study. Ann Surg Oncol 2024; 31:2892-2901. [PMID: 38286884 PMCID: PMC10997715 DOI: 10.1245/s10434-024-14951-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 01/05/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND Little is known about adjuvant therapy (AT) omission and use outside of randomized trials. We aimed to assess the patterns of AT omission and use in a cohort of upfront resected pancreatic cancer patients in a real-life scenario. METHODS From January 2019 to July 2022, 317 patients with resected pancreatic cancer and operated upfront were prospectively enrolled in this prospective observational trial according to the previously calculated sample size. The association between perioperative variables and the risk of AT omission and AT delay was analyzed using multivariable logistic regression. RESULTS Eighty patients (25.2%) did not receive AT. The main reasons for AT omission were postoperative complications (38.8%), oncologist's choice (21.2%), baseline comorbidities (20%), patient's choice (10%), and early recurrence (10%). At the multivariable analysis, the odds of not receiving AT increased significantly for older patients (odds ratio [OR] 1.1, p < 0.001), those having an American Society of Anesthesiologists score ≥II (OR 2.03, p = 0.015), or developing postoperative pancreatic fistula (OR 2.5, p = 0.019). The likelihood of not receiving FOLFIRINOX as AT increased for older patients (OR 1.1, p < 0.001), in the presence of early-stage disease (stage I-IIa vs. IIb-III, OR 2.82, p =0.031; N0 vs. N+, OR 3, p = 0.03), and for patients who experienced postoperative major complications (OR 4.7, p = 0.009). A twofold increased likelihood of delay in AT was found in patients experiencing postoperative complications (OR 3.86, p = 0.011). CONCLUSIONS AT is not delivered in about one-quarter of upfront resected pancreatic cancer patients. Age, comorbidities, and postoperative complications are the main drivers of AT omission and mFOLFIRINOX non-use. CLINICALTRIALS REGISTRATION NCT03788382.
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Affiliation(s)
- Salvatore Paiella
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy.
| | - Giuseppe Malleo
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Gabriella Lionetto
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Alice Cattelani
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Fabio Casciani
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Erica Secchettin
- Department of Surgical Sciences, University of Verona, Verona, Italy
| | - Matteo De Pastena
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Verona, Italy.
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Rashid Z, Munir MM, Woldesenbet S, Khan MMM, Khalil M, Endo Y, Tsilimigras DI, Dillhoff M, Ejaz A, Pawlik TM. Association between social determinants of health and delayed postoperative adjuvant therapy among patients undergoing resection of pancreatic cancer. J Surg Oncol 2024; 129:850-859. [PMID: 38151795 DOI: 10.1002/jso.27571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/07/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND AND OBJECTIVES Pancreatic cancer (PDAC) requires a multimodality approach. We sought to define the association between social determinants of health (SDOH) and delayed or nonreceipt of adjuvant chemotherapy (aCT) among patients undergoing PDAC resection. METHODS Data on patients who underwent PDAC resection between 2014 and 2020 were identified from Medicare Standard Analytic Files and merged with the county-level social vulnerability index (SVI). Mediation analysis defined the association between SVI subthemes and aCT receipt. RESULTS Among 24 078 patients, 47.7% received timely aCT, 17.7% received delayed aCT, and 34.6% did not receive any aCT. High SVI was associated with delay (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.10-1.34) and nonreceipt of aCT (OR 1.30, 95% CI 1.20-1.41) (both p < 0.05). 73.1% of the variation in timely aCT receipt was directly attributable to SVI, whereas 26.9% of the effect was due to indirect mediators including hospital volume (6.4%), length-of-stay (7.9%) and postoperative complications (12.6%). Socioeconomic status (delayed aCT: OR 1.25, 95% CI 1.13-1.38; nonreceipt aCT: OR 1.25, 95% CI 1.15-1.36) and household composition and disability (delayed aCT: OR 1.30, 95% CI 1.17-1.43; nonreceipt aCT: OR 1.19, 95% CI 1.09-1.29) were associated with receipt of aCT (both p < 0.001). CONCLUSIONS Most of the disparities in receipt of aCT after PDAC surgery are driven by underlying SDOH such as SVI.
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Affiliation(s)
- Zayed Rashid
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Muhammad M Munir
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Muhammad M M Khan
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mujtaba Khalil
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
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Henault D, Westphalen CB, O'Kane GM. The neoadjuvant approach in resectable pancreatic ductal adenocarcinoma: lessons learned. Lancet Gastroenterol Hepatol 2024; 9:186-188. [PMID: 38237623 DOI: 10.1016/s2468-1253(23)00451-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/15/2023] [Indexed: 02/12/2024]
Affiliation(s)
- David Henault
- Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplant, Centre Hospitalier de l'Université de Montréal, QC, Canada; Princess Margaret Cancer Centre and Ontario Institute for Cancer Research, Toronto, ON Canada
| | - C Benedikt Westphalen
- Department of Medicine III, University Hospital, Comprehensive Cancer Center, LMU Munich, Germany; German Cancer Consortium, Partner Site Munich, Munich, Germany
| | - Grainne M O'Kane
- Princess Margaret Cancer Centre and Ontario Institute for Cancer Research, Toronto, ON Canada; Department of Medical Oncology, Trinity St James's Cancer Institute, Dublin, Ireland. grainne.o'
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Okui N, Tsunematsu M, Furukawa K, Shirai Y, Haruki K, Sakamoto T, Uwagawa T, Onda S, Gocho T, Ikegami T. The prognosis-based classification model in resectable pancreatic cancer. Surg Oncol 2024; 52:102035. [PMID: 38198986 DOI: 10.1016/j.suronc.2024.102035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/07/2023] [Accepted: 01/04/2024] [Indexed: 01/12/2024]
Abstract
AIM Pancreatic ductal adenocarcinoma treatment is mainly based on the anatomical resectability classification. However, prognosis-based classification may be more reasonable. In this study, we stratified resectable pancreatic ductal adenocarcinoma according to preoperative factors and reconsidered treatment strategies. METHODS We retrospectively evaluated 131 patients who underwent upfront surgery for resectable pancreatic ductal adenocarcinoma between 2007 and 2019. Recurrence within 1 year after surgery was defined as early recurrence, and the risk factors for early recurrence were identified using preoperative factors. Subsequently, we calculated the scores and stratified the participant groups. RESULTS Fifty-five (42 %) patients who relapsed within 1 year showed significantly poorer survival than those without recurrence (median overall survival, 14.0 vs. 80.6 months; p < 0.01). Multivariate analysis revealed that a tumor diameter of ≥24 mm (p < 0.01) and preoperative serum carbohydrate antigen 19-9 level of ≥380 U/mL (p = 0.04) were the independent risk factors for early recurrence. Early recurrence score was created using these factors, stratifying the participant group into three groups of 0-2 points, and the prognosis was significantly different (median overall survival, 49.3 vs. 31.2 vs. 16.0 months; p < 0.01). CONCLUSION We stratified the upfront surgical cases of resectable pancreatic ductal adenocarcinoma. The group with a score of 0 had a good prognosis, and upfront surgery was possibly not futile on patients in poor general condition. The group with a score of 2 had a poor prognosis and may require stronger preoperative treatment.
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Affiliation(s)
- Norimitsu Okui
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Masashi Tsunematsu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenei Furukawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshihiiro Shirai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Koichiro Haruki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Taro Sakamoto
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Tadashi Uwagawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shinji Onda
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takeshi Gocho
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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van Eijck CWF, Mustafa DAM, Vadgama D, de Miranda NFCC, Groot Koerkamp B, van Tienhoven G, van der Burg SH, Malats N, van Eijck CHJ. Enhanced antitumour immunity following neoadjuvant chemoradiotherapy mediates a favourable prognosis in women with resected pancreatic cancer. Gut 2024; 73:311-324. [PMID: 37709493 PMCID: PMC10850691 DOI: 10.1136/gutjnl-2023-330480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/01/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND This study investigates sex disparities in clinical outcomes and tumour immune profiles in patients with pancreatic ductal adenocarcinoma (PDAC) who underwent upfront resection or resection preceded by gemcitabine-based neoadjuvant chemoradiotherapy (nCRT). METHODS Patients originated from the PREOPANC randomised controlled trial. Upfront surgery was performed in 82 patients, and 66 received nCRT before resection. The impact of sex on overall survival (OS) was investigated using Cox proportional hazards models. The immunological landscape within the tumour microenvironment (TME) was mapped using transcriptomic and spatial proteomic profiling. RESULTS The 5-year OS rate differed between the sexes following resection preceded by nCRT, with 43% for women compared with 22% for men. In multivariate analysis, the female sex was a favourable independent prognostic factor for OS only in the nCRT group (HR 0.19; 95% CI 0.07 to 0.52). Multivariate heterogeneous treatment effects analysis revealed a significant interaction between sex and treatment, implying increased nCRT efficacy among women with resected PDAC. The TME of women contained fewer protumoural CD163+MRC1+M2 macrophages than that of men after nCRT, as indicated by transcriptomic and validated using spatial proteomic profiling. CONCLUSION PDAC tumours of women are more sensitive to gemcitabine-based nCRT, resulting in longer OS after resection compared with men. This may be due to enhanced immunity impeding the infiltration of protumoral M2 macrophages into the TME. Our findings highlight the importance of considering sex disparities and mitigating immunosuppressive macrophage polarisation for personalised PDAC treatment.
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Affiliation(s)
- Casper W F van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
- Genetic and Molecular Epidemiology Group, Spanish National Cancer Research Centre, and CIBERONC, Madrid, Spain
| | - Dana A M Mustafa
- Department of Pathology, Tumour-Immuno Pathology Laboratory, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Disha Vadgama
- Department of Pathology, Tumour-Immuno Pathology Laboratory, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Sjoerd H van der Burg
- Department of Medical Oncology, Oncode Institute, Leiden University Medical Center, Leiden, The Netherlands
| | - Núria Malats
- Genetic and Molecular Epidemiology Group, Spanish National Cancer Research Centre, and CIBERONC, Madrid, Spain
| | - Casper H J van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
- Genetic and Molecular Epidemiology Group, Spanish National Cancer Research Centre, and CIBERONC, Madrid, Spain
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Park BK, Seo JH, Han JH, Lee KJ, Son KJ, Choi JK. Trends in treatment patterns and survival outcomes in pancreatic cancer: A nationwide population-based study in Korea. Eur J Cancer 2023; 189:112932. [PMID: 37352643 DOI: 10.1016/j.ejca.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 05/19/2023] [Accepted: 05/26/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND The treatment of pancreatic cancer has evolved; however, real-world data on treatment trends remain scarce. This study investigated treatment patterns for pancreatic cancer and patient survival using a nationwide population-based study in Korea. METHODS Using the National Health Insurance database, data from 78,920 patients diagnosed with pancreatic cancer in Korea between 2006 and 2019 were extracted. Treatment patterns and survival by age group and year of diagnosis were examined. RESULTS Primary treatment was delivered as follows: 16,562 patients (21.0%) underwent surgery, 20,998 patients (26.6%) received chemotherapy, 1332 patients (1.7%) received chemoradiotherapy, and 40,040 patients (50.7%) received supportive care only. The proportion of patients undergoing surgery or chemotherapy increased gradually in all age groups over time. The commonly used anti-cancer drugs have changed from gemcitabine±erlotinib to gemcitabine+nab-paclitaxel and FOLFIRINOX. Survival improved mainly in patients who underwent surgery or chemotherapy. Median overall survival for all patients improved from 5.5 months in 2006-2008 to 9.8 months in 2018-2019, with greater improvement observed in younger age groups: 8.8-18.8 months, age ≤59 years, 6.8-14.6 months, age 60-69 years, 4.2-8.3 months, age 70-79 years and 2.4-3.4 months, age ≥80 years (all p < 0.0001). CONCLUSIONS An increase in the rates of surgery and chemotherapy for pancreatic cancer was observed. Survival rates for pancreatic cancer have generally improved over the past decade and are greater in patients undergoing surgery or chemotherapy and in younger age groups.
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Affiliation(s)
- Byung Kyu Park
- Division of Gastroenterology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea.
| | - Jeong Hun Seo
- Division of Gastroenterology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Joung-Ho Han
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Kyong Joo Lee
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Kang Ju Son
- Department of Policy Research Affairs, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jung Kyu Choi
- Health Insurance Research Institute, National Health Insurance Service, Wonju, Korea
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Hajibandeh S, Hajibandeh S, Intrator C, Hassan K, Sehmbhi M, Shah J, Mazumdar E, Kausar A, Satyadas T. Neoadjuvant chemoradiotherapy versus immediate surgery for resectable and borderline resectable pancreatic cancer: Meta-analysis and trial sequential analysis of randomized controlled trials. Ann Hepatobiliary Pancreat Surg 2023; 27:28-39. [PMID: 36536501 PMCID: PMC9947376 DOI: 10.14701/ahbps.22-052] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/07/2022] [Indexed: 12/24/2022] Open
Abstract
We aimed to compare resection and survival outcomes of neoadjuvant chemoradiotherapy (CRT) and immediate surgery in patients with resectable pancreatic cancer (RPC) or borderline resectable pancreatic cancer (BRPC). In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards, a systematic review of randomized controlled trials (RCTs) was conducted. Random effects modeling was applied to calculate pooled outcome data. Likelihood of type 1 or 2 errors in the meta-analysis model was assessed by trial sequential analysis. A total of 400 patients from four RCTs were included. When RPC and BRPC were analyzed together, neoadjuvant CRT resulted in a higher R0 resection rate (risk ratio [RR]: 1.55, p = 0.004), longer overall survival (mean difference [MD]: 3.75 years, p = 0.009) but lower overall resection rate (RR: 0.83, p = 0.008) compared with immediate surgery. When RPC and BRPC were analyzed separately, neoadjuvant CRT improved R0 resection rate (RR: 3.72, p = 0.004) and overall survival (MD: 6.64, p = 0.004) of patients with BRPC. However, it did not improve R0 resection rate (RR: 1.18, p = 0.13) or overall survival (MD: 0.94, p = 0.57) of patients with RPC. Neoadjuvant CRT might be beneficial for patients with BRPC, but not for patients with RPC. Nevertheless, the best available evidence does not include contemporary chemotherapy regimens. Patients with RPC and those with BRPC should not be combined in the same cohort in future studies.
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Affiliation(s)
- Shahab Hajibandeh
- Department of General Surgery, University Hospital of Wales, Cardiff & Vale NHS Trust, Cardiff, United Kingdom,Corresponding author: Shahab Hajibandeh, MBChB, MRCS Department of General Surgery, University Hospital of Wales, Heath Park Way, Cardiff CF14 4XW, United Kingdom Tel: +44-7766106423, E-mail: ORCID: https://orcid.org/0000-0002-3294-4335
| | - Shahin Hajibandeh
- Hepatobiliary and Pancreatic Surgery and Liver transplant Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Christina Intrator
- Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, United Kingdom
| | - Karim Hassan
- Department of General Surgery, Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, Wrexham, United Kingdom
| | - Mantej Sehmbhi
- Department of Internal Medicine, Mount Sinai Morningside and West Hospitals, New York, NY, United States
| | - Jigar Shah
- Department of General Surgery, North Manchester General Hospital, North Manchester Care Organisation, Manchester, United Kingdom
| | - Eshan Mazumdar
- Department of General Surgery, University Hospital of Wales, Cardiff & Vale NHS Trust, Cardiff, United Kingdom
| | - Ambareen Kausar
- Department of Hepatobiliary and Pancreatic Surgery, Royal Blackburn Hospital, Blackburn, United Kingdom
| | - Thomas Satyadas
- Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, United Kingdom
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Villano AM, O’Halloran E, Goel N, Ruth K, Barrak D, Lefton M, Reddy SS. Total neoadjuvant therapy is associated with improved overall survival and pathologic response in pancreatic adenocarcinoma. J Surg Oncol 2022; 126:502-512. [PMID: 35476892 PMCID: PMC9340441 DOI: 10.1002/jso.26906] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/10/2022] [Accepted: 04/18/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Few studies have evaluated outcomes of total neoadjuvant therapy (TNT) compared with single modality neoadjuvant therapy (SMNT) or surgery first (SF) for pancreatic ductal adenocarcinoma (PDAC). METHODS A single-institution retrospective review of PDAC patients who underwent pancreatectomy was conducted (1993-2019). Overall survival (OS) estimates from diagnosis and from surgery were determined using Kaplan-Meier methods; Cox proportional hazards models adjusted for covariates. RESULTS Surgery was performed upfront (SF) in 168 (46.9%), while 111 (31.0%) had chemotherapy or chemoradiation before resection (SMNT), and 79 (22.1%) underwent TNT (chemotherapy and chemoradiation). Resection margins were more frequently R0 in the TNT group (86.1%) compared with SMNT (64.0%) and SF (72%) (p < 0.001). Complete pathologic response was more common in the TNT group (10.1%) compared with SMNT (3.6%) or SF (0.6%) (p = 0.001), resulting in prolonged survival (median OS = 100.2 months). TNT patients demonstrated longer median OS from surgery (33.6 months) compared with SF (19.1 months) and SMNT (17.4 months) (p = 0.010), which persisted after controlling for covariates. CONCLUSIONS TNT is associated with more frequent complete pathologic response, a higher rate of margin negative resection, and prolonged OS as compared with SF or SMNT. Additional studies to identify subgroups that derive the greatest benefit are warranted.
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Affiliation(s)
- Anthony M. Villano
- Division of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Eileen O’Halloran
- Division of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Neha Goel
- Division of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Karen Ruth
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, PA
| | - Dany Barrak
- Division of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Max Lefton
- Division of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Sanjay S. Reddy
- Division of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
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12
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Merz V, Mangiameli D, Zecchetto C, Quinzii A, Pietrobono S, Messina C, Casalino S, Gaule M, Pesoni C, Vitale P, Trentin C, Frisinghelli M, Caffo O, Melisi D. Predictive Biomarkers for a Personalized Approach in Resectable Pancreatic Cancer. Front Surg 2022; 9:866173. [PMID: 35599791 PMCID: PMC9114435 DOI: 10.3389/fsurg.2022.866173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/25/2022] [Indexed: 12/15/2022] Open
Abstract
The mainstay treatment for patients with immediate resectable pancreatic cancer remains upfront surgery, which represents the only potentially curative strategy. Nevertheless, the majority of patients surgically resected for pancreatic cancer experiences disease relapse, even when a combination adjuvant therapy is offered. Therefore, aiming at improving disease free survival and overall survival of these patients, there is an increasing interest in evaluating the activity and efficacy of neoadjuvant and perioperative treatments. In this view, it is of utmost importance to find biomarkers able to select patients who may benefit from a preoperative therapy rather than upfront surgical resection. Defined genomic alterations and a dynamic inflammatory microenvironment are the major culprits for disease recurrence and resistance to chemotherapeutic treatments in pancreatic cancer patients. Signal transduction pathways or tumor immune microenvironment could predict early recurrence and response to chemotherapy. In the last decade, distinct molecular subtypes of pancreatic cancer have been described, laying the bases to a tailored therapeutic approach, started firstly in the treatment of advanced disease. Patients with homologous repair deficiency, in particular with mutant germline BRCA genes, represent the first subgroup demonstrating to benefit from specific therapies. A fraction of patients with pancreatic cancer could take advantage of genome sequencing with the aim of identifying possible targetable mutations. These genomic driven strategies could be even more relevant in a potentially curative setting. In this review, we outline putative predictive markers that could help in the next future in tailoring the best therapeutic strategy for pancreatic cancer patients with a potentially curable disease.
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Affiliation(s)
- Valeria Merz
- Medical Oncology Unit, Santa Chiara Hospital, Trento, Italy
- Digestive Molecular Clinical Oncology Research Unit, Università degli Studi di Verona, Verona, Italy
| | - Domenico Mangiameli
- Digestive Molecular Clinical Oncology Research Unit, Università degli Studi di Verona, Verona, Italy
| | - Camilla Zecchetto
- Investigational Cancer Therapeutics Clinical Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Alberto Quinzii
- Investigational Cancer Therapeutics Clinical Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Silvia Pietrobono
- Digestive Molecular Clinical Oncology Research Unit, Università degli Studi di Verona, Verona, Italy
| | | | - Simona Casalino
- Investigational Cancer Therapeutics Clinical Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Marina Gaule
- Investigational Cancer Therapeutics Clinical Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Camilla Pesoni
- Investigational Cancer Therapeutics Clinical Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Chiara Trentin
- Medical Oncology Unit, Santa Chiara Hospital, Trento, Italy
| | | | - Orazio Caffo
- Medical Oncology Unit, Santa Chiara Hospital, Trento, Italy
| | - Davide Melisi
- Digestive Molecular Clinical Oncology Research Unit, Università degli Studi di Verona, Verona, Italy
- Investigational Cancer Therapeutics Clinical Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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13
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de Jong EJM, Mommers I, Fariña Sarasqueta A, van der Geest LG, Heij L, de Hingh IHJT, Homs MYV, Tjan-Heijnen VCG, Valkenburg-van Iersel LBJ, Wilmink JW, Geurts SME, de Vos-Geelen J. Adjuvant and first-line palliative chemotherapy regimens in patients diagnosed with periampullary cancer: a short report from a nationwide registry. Acta Oncol 2022; 61:591-596. [PMID: 35382678 DOI: 10.1080/0284186x.2022.2053199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Evelien J. M. de Jong
- Department of Internal Medicine, Division of Medical Oncology, Maastricht University Medical Center, GROW, Maastricht University, Maastricht, the Netherlands
| | - Irene Mommers
- Department of Internal Medicine, Division of Medical Oncology, Maastricht University Medical Center, GROW, Maastricht University, Maastricht, the Netherlands
| | - Arantza Fariña Sarasqueta
- Department of Pathology, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Lydia G. van der Geest
- Department of Research and Innovation, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - Lara Heij
- Department of Surgery, School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of General, Gastrointestinal, Hepatobiliary and Transplant Surgery, RWTH Aachen University Hospital, Aachen, Germany
- Institute of Pathology, RWTH Aachen University, Aachen, Germany
| | - Ignace H. J. T. de Hingh
- Department of Surgery, Catharina Cancer Institute, Eindhoven, the Netherlands
- GROW, Maastricht University, Maastricht, the Netherlands
| | - Marjolein Y. V. Homs
- Department of Medical Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Vivianne C. G. Tjan-Heijnen
- Department of Internal Medicine, Division of Medical Oncology, Maastricht University Medical Center, GROW, Maastricht University, Maastricht, the Netherlands
| | - Liselot B. J. Valkenburg-van Iersel
- Department of Internal Medicine, Division of Medical Oncology, Maastricht University Medical Center, GROW, Maastricht University, Maastricht, the Netherlands
| | - Johanna W. Wilmink
- Department of Medical Oncology, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Sandra M. E. Geurts
- Department of Internal Medicine, Division of Medical Oncology, Maastricht University Medical Center, GROW, Maastricht University, Maastricht, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, Maastricht University Medical Center, GROW, Maastricht University, Maastricht, the Netherlands
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14
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Chaudhari VA, Mitra A, Gupta V, Ostwal V, Ramaswamy A, Engineer R, Sirohi B, Shetty N, Bal M, DeSouza A, Bhandare MS, Shrikhande SV. Neoadjuvant therapy in borderline resectable pancreatic cancer: Outcomes in the era of changing practices and evolving evidence. Surgery 2022; 171:1388-1395. [PMID: 34922745 DOI: 10.1016/j.surg.2021.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 09/01/2021] [Accepted: 10/07/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Neoadjuvant therapy (NAT) is increasingly being used in the management of borderline resectable pancreatic cancer (BRPC). We compared the outcomes of patients with BRPC treated either with upfront surgery (UPS) or NAT to assess whether increased use of NAT has helped improve perioperative and long-term outcomes. METHODS Prospectively maintained database of 201 consecutive patients with BRPC treated at Tata Memorial Center, India, from 2007-2019 was analyzed. RESULTS NAT was offered to 148 patients and 53 were planned for UPS. Progression on NAT was seen in 47 (31.8%) patients. Resection was performed in 103 patients (51.24%). The resection rate was significantly lower after NAT as compared with upfront explorations (42.56% vs 75.47%, P = .00) however, R0 resection rate after NAT was significantly better (74.6% vs 42.5%, P = .001). NAT group showed a significant decrease in the pT stage (P = .004), node positivity (60%-31.7%, P = .005%), and perineural invasion (70%-41.6% P = .026). There was no significant difference in the median overall survival (OS) of patients offered NAT versus UPS on an intention-to-treat basis (15 vs 18 months P = .431). However, OS (22 vs 19 months, P = .205) and disease-free survival (DFS) (16 vs 11 months, P = .135) were higher for resected patients in the NAT group and OS was significantly superior in patients completing the course of treatment (34 vs 22 months, P = .010) CONCLUSION: The progression rate with NAT in patients with BPRC was 31.8%. NAT was associated with significant pathologic downstaging, improvement in R0 resection rate, and survival in resected patients.
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Affiliation(s)
- Vikram A Chaudhari
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Center, Mumbai, India. https://www.twitter.com/DrVAChaudhari
| | - Abhishek Mitra
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Center, Mumbai, India; Department of Surgical Gastroenterology and Gastrointestinal Oncology, Dharamshila Narayana Super Speciality Hospital, New Delhi, India
| | - Vikas Gupta
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Center, Mumbai, India. https://www.twitter.com/docvikasgupta
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Center, Mumbai, India. https://www.twitter.com/vikasO
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Center, Mumbai, India. https://www.twitter.com/AnantRamaswamy
| | - Reena Engineer
- Department of Radiotherapy, Tata Memorial Center, Mumbai, India
| | - Bhawna Sirohi
- Department of Medical Oncology, Tata Memorial Center, Mumbai, India; Department of Medical Oncology, Apollo Proton Cancer Center, Chennai, India. https://www.twitter.com/SirohiBhawna
| | - Nitin Shetty
- Interventional Radiology, Department of Radiology, Tata Memorial Center, Mumbai, India
| | - Munita Bal
- Department of Pathology, Tata Memorial Center, Mumbai, India. https://www.twitter.com/mun_mm
| | - Ashwin DeSouza
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Center, Mumbai, India
| | - Manish S Bhandare
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Center, Mumbai, India. https://www.twitter.com/Manishbhandare4
| | - Shailesh V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Center, Mumbai, India.
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15
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Versteijne E, van Dam JL, Suker M, Janssen QP, Groothuis K, Akkermans-Vogelaar JM, Besselink MG, Bonsing BA, Buijsen J, Busch OR, Creemers GJM, van Dam RM, Eskens FALM, Festen S, de Groot JWB, Groot Koerkamp B, de Hingh IH, Homs MYV, van Hooft JE, Kerver ED, Luelmo SAC, Neelis KJ, Nuyttens J, Paardekooper GMRM, Patijn GA, van der Sangen MJC, de Vos-Geelen J, Wilmink JW, Zwinderman AH, Punt CJ, van Tienhoven G, van Eijck CHJ. Neoadjuvant Chemoradiotherapy Versus Upfront Surgery for Resectable and Borderline Resectable Pancreatic Cancer: Long-Term Results of the Dutch Randomized PREOPANC Trial. J Clin Oncol 2022; 40:1220-1230. [PMID: 35084987 DOI: 10.1200/jco.21.02233] [Citation(s) in RCA: 285] [Impact Index Per Article: 142.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/28/2021] [Accepted: 12/22/2021] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The benefit of neoadjuvant chemoradiotherapy in resectable and borderline resectable pancreatic cancer remains controversial. Initial results of the PREOPANC trial failed to demonstrate a statistically significant overall survival (OS) benefit. The long-term results are reported. METHODS In this multicenter, phase III trial, patients with resectable and borderline resectable pancreatic cancer were randomly assigned (1:1) to neoadjuvant chemoradiotherapy or upfront surgery in 16 Dutch centers. Neoadjuvant chemoradiotherapy consisted of three cycles of gemcitabine combined with 36 Gy radiotherapy in 15 fractions during the second cycle. After restaging, patients underwent surgery followed by four cycles of adjuvant gemcitabine. Patients in the upfront surgery group underwent surgery followed by six cycles of adjuvant gemcitabine. The primary outcome was OS by intention-to-treat. No safety data were collected beyond the initial report of the trial. RESULTS Between April 24, 2013, and July 25, 2017, 246 eligible patients were randomly assigned to neoadjuvant chemoradiotherapy (n = 119) and upfront surgery (n = 127). At a median follow-up of 59 months, the OS was better in the neoadjuvant chemoradiotherapy group than in the upfront surgery group (hazard ratio, 0.73; 95% CI, 0.56 to 0.96; P = .025). Although the difference in median survival was only 1.4 months (15.7 months v 14.3 months), the 5-year OS rate was 20.5% (95% CI, 14.2 to 29.8) with neoadjuvant chemoradiotherapy and 6.5% (95% CI, 3.1 to 13.7) with upfront surgery. The effect of neoadjuvant chemoradiotherapy was consistent across the prespecified subgroups, including resectable and borderline resectable pancreatic cancer. CONCLUSION Neoadjuvant gemcitabine-based chemoradiotherapy followed by surgery and adjuvant gemcitabine improves OS compared with upfront surgery and adjuvant gemcitabine in resectable and borderline resectable pancreatic cancer.
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Affiliation(s)
- Eva Versteijne
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jacob L van Dam
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Mustafa Suker
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Quisette P Janssen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Karin Groothuis
- Clinical Research Department, Comprehensive Cancer Organisation the Netherlands (IKNL) Nijmegen, the Netherlands
| | - Janine M Akkermans-Vogelaar
- Clinical Research Department, Comprehensive Cancer Organisation the Netherlands (IKNL) Nijmegen, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen Buijsen
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
- GROW - School for Oncology and Developmental Biology, Maastricht University, the Netherlands
| | - Ferry A L M Eskens
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Marjolein Y V Homs
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Emile D Kerver
- Department of Medical Oncology, OLVG, Amsterdam, the Netherlands
| | - Saskia A C Luelmo
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Karen J Neelis
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Joost Nuyttens
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | - Gijs A Patijn
- Department of Surgery, Isala Oncology Center, Zwolle, the Netherlands
| | | | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW-School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Cornelis J Punt
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Centre, Utrecht University, the Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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16
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Suto H, Okano K, Oshima M, Ando Y, Matsukawa H, Takahashi S, Shibata T, Kamada H, Kobara H, Tsuji A, Masaki T, Suzuki Y. Efficacy and Safety of Neoadjuvant Chemoradiation Therapy Administered for 5 Versus 2 Weeks for Resectable and Borderline Resectable Pancreatic Cancer. Pancreas 2022; 51:269-277. [PMID: 35584385 DOI: 10.1097/mpa.0000000000002011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Indications of preoperative treatment for resectable (R-) or borderline resectable (BR-) pancreatic ductal adenocarcinoma (PDAC) are unclear, and the protocol remains to be standardized. METHODS Included 65 patients with R- and BR-PDAC with venous involvement (V-) received neoadjuvant chemoradiotherapy with S-1 and 50 Gy of radiation as the 5-week regimen. The outcomes of this group were compared with those of 52 patients who underwent S-1 and 30 Gy of radiation as the 2-week regimen, previously collected as our prospective phase II study. RESULTS Compared with the 2-week regimen, there were no significant differences in the rate of protocol completion, adverse events, mortality and morbidity, or R0 resection in the 5-week regimen. In subgroup analyses of R-PDAC, there were no significant differences in overall survival and recurrence-free survival between the groups. In contrast, the 5-week regimen had significantly better overall survival and recurrence-free survival than the 2-week regimen for BRV-PDAC. Similar results were observed after propensity score matching analysis. CONCLUSIONS The 5-week regimen of neoadjuvant chemoradiotherapy has good clinical efficacy and safety for R- and BRV-PDAC. The 5-week regimen could achieve better outcomes than the 2-week regimen for BRV-PDAC. In contrast, both regimens achieved similar outcomes for R-PDAC.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Akihito Tsuji
- Clinical Oncology, Faculty of Medicine, Kagawa University, Kagawa, Japan
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17
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A Randomized Placebo-Controlled Phase 2 Study of Gemcitabine and Capecitabine with or without T-ChOS as Adjuvant Therapy in Patients with Resected Pancreatic Cancer (CHIPAC). Pharmaceutics 2022; 14:pharmaceutics14030509. [PMID: 35335885 PMCID: PMC8955369 DOI: 10.3390/pharmaceutics14030509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 02/07/2023] Open
Abstract
The antitumor activity of chitooligosaccharides has been suggested. This phase 2 trial evaluated the efficacy and safety of T-ChOS™, in addition to adjuvant chemotherapy, in patients after resection of pancreatic ductal adenocarcinoma (PDAC). In this single-center, randomized, double-blind, placebo-controlled trial using patients ≥18 years of age after complete macroscopic resection for PDAC, patients were randomly assigned (1:1) to either a continuous oral T-ChOS group or a placebo group, in combination with gemcitabine (GEM) and oral capecitabine (CAP), for a maximum of six cycles. The primary endpoint was disease-free survival (DFS). Recruitment was stopped prematurely in July 2018, with 21 of planned 180 patients included, due to poor accrual and because modified FOLFIRINOX replaced GEM/CAP for the target population. Nine patients received T-ChOS and twelve received the placebo. The median DFS was 10.8 months (95% CI 5.9–15.7) for the T-ChOS arm and 8.4 months (95% CI 0–21.5) in the placebo arm. Overall, seven patients (78%) in the T-ChOS arm and eight patients (67%) in the placebo arm experienced at least one grade 3–4 treatment-related adverse event, most frequently neutropenia. Altogether, the addition of T-ChOS to chemotherapy in patients after resection of PDAC seems safe. However, the clinical benefit cannot be assessed due to the premature cessation of the trial.
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18
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Khan NN, Lewin T, Hatton A, Pilgrim C, Ioannou L, Te Marvelde L, Zalcberg J, Evans S. Systematic review of the predictors of health service use in pancreatic cancer. Am J Cancer Res 2022; 12:622-650. [PMID: 35261792 PMCID: PMC8900007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/21/2022] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Pancreatic cancer (PC) has a dismal prognosis, with identified disparities in survival outcomes based on demographic characteristics. These disparities may be ameliorated by equitable access to treatments and health services. This systematic review identifies patient and service-level characteristics associated with PC health service utilisation (HSU). METHODS Medline, Embase, CINAHL, PsycINFO and Scopus were systematically searched between 1st January, 2010 and 17 May, 2021 for population-based, PC studies which conducted univariable and/or multivariable regression analyses to identify patient and/or service-level characteristics associated with use of a treatment or health service. Direction of effect sizes were reported in an aggregate manner. RESULTS Sixty-two eligible studies were identified. Most (48/62) explored the predictors of surgery (n=25) and chemotherapy (n=23), and in populations predominantly based in the United States of America (n=50). Decreased HSU was observed among people belonging to older age groups, non-Caucasian ethnicities, lower socioeconomic status (SES) and lower education status. Non-metropolitan location of residence predicted decreased use of certain treatments, and was associated with reduced hospitalisations. People with comorbidities were less likely to use treatments and services, including specialist consultations and palliative care but were more likely to be hospitalised. A more recent year of diagnosis/year of death was generally associated with increased HSU. Academically affiliated and high-volume centres predicted increased treatment use and hospital readmissions. CONCLUSION Findings of this review may assist identification of vulnerable patient groups experiencing disparities in accessing and using treatments and therapies.
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Affiliation(s)
- Nadia N Khan
- Public Health and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - Tennille Lewin
- Public Health and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - Amy Hatton
- Public Health and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - Charles Pilgrim
- Public Health and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - Liane Ioannou
- Public Health and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - Luc Te Marvelde
- Public Health and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - John Zalcberg
- Public Health and Preventive Medicine, Monash University Melbourne, Victoria, Australia
| | - Sue Evans
- Public Health and Preventive Medicine, Monash University Melbourne, Victoria, Australia
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19
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Versteijne E, de Hingh IHJT, Homs MYV, Intven MPW, Klaase JM, van Santvoort HC, de Vos-Geelen J, Wilmink JW, van Tienhoven G. Neoadjuvant Treatment for Resectable and Borderline Resectable Pancreatic Cancer: Chemotherapy or Chemoradiotherapy? Front Oncol 2022; 11:744161. [PMID: 35237500 PMCID: PMC8882845 DOI: 10.3389/fonc.2021.744161] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 12/30/2021] [Indexed: 12/12/2022] Open
Abstract
Worldwide, there is a shifting paradigm from immediate surgery with adjuvant treatment to a neoadjuvant approach for patients with resectable or borderline resectable pancreatic cancer (RPC or BRPC). Comparison of neoadjuvant and adjuvant studies is extremely difficult because of a great difference in patient selection. The evidence from randomized studies shows that overall survival by intention-to-treat improves after neoadjuvant gemcitabine-based chemoradiotherapy or chemotherapy (various regimens), as compared to immediate surgery followed by adjuvant chemotherapy. Radiotherapy appears to play an important role in mediating locoregional effects. Yet, since more effective chemotherapy regimens are currently available, in particular FOLFIRINOX and Gemcitabine/Nab-paclitaxel, these chemotherapy regimens should be investigated in future randomized trials combined with (stereotactic) radiotherapy to further improve outcomes of RPC and BRPC.
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Affiliation(s)
- Eva Versteijne
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam University Medical Center (UMC), University of Amsterdam, Amsterdam, Netherlands
| | - Ignace H. J. T. de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven and GROW—School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
| | - Marjolein Y. V. Homs
- Department Medical Oncology, Erasmus Medical Center (MC) Cancer Institute, Rotterdam, Netherlands
| | - Martijn P. W. Intven
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Joost M. Klaase
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regionaal Academisch Kankercentrum Utrecht (RAKU), St Antonius Hospital, Nieuwegein, Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW—School for Oncology and Developmental Biology, Maastricht University Medical Center (UMC+), Maastricht, Netherlands
| | - Johanna W. Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Center (UMC), University of Amsterdam, Amsterdam, Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam University Medical Center (UMC), University of Amsterdam, Amsterdam, Netherlands
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20
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Neoadjuvant therapy or upfront surgery for resectable and borderline resectable pancreatic cancer: A meta-analysis of randomised controlled trials. Eur J Cancer 2021; 160:140-149. [PMID: 34838371 DOI: 10.1016/j.ejca.2021.10.023] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 10/06/2021] [Accepted: 10/20/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Neoadjuvant therapy may improve survival compared with upfront surgery in patients with resectable and borderline resectable pancreatic cancer, but high-quality evidence is lacking. METHODS We systematically searched for randomised trials comparing neoadjuvant therapy with upfront surgery for resectable and borderline resectable pancreatic cancer published since database inception until December 2020. The primary outcome was overall survival (OS) by intention-to-treat with subgroup analyses for resectability status. Meta-analyses using a random-effects model were performed. Certainty of evidence was assessed using the GRADE approach. RESULTS Seven trials with 938 patients were included. All trials included a neoadjuvant gemcitabine-based chemo(radio)therapy arm. None of the studies used adjuvant FOLFIRINOX. Neoadjuvant therapy improved OS (hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.52-0.85; P = 0.001; I2 = 46%) compared with upfront surgery. This represents an increase in median OS from 19 to 29 months. In the subgroup of resectable pancreatic cancer (i.e., venous contact ≤180°, no arterial contact), no statistically significant difference in OS was observed (HR 0.77, 95% CI 0.53-1.12; P = 0.18; I2 = 20%). In the subgroup of borderline resectable pancreatic cancer (i.e. venous contact >180°, any arterial contact), neoadjuvant therapy improved OS (HR 0.61, 95% CI 0.44-0.85; P = 0.004; I2 = 59%). The GRADE certainty of evidence was high for the outcome of OS. CONCLUSIONS Neoadjuvant therapy improves OS compared with upfront surgery in patients with borderline resectable pancreatic cancer. More evidence is required on whether neoadjuvant therapy improves survival for patients with resectable pancreatic cancer.
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Crippa S, Belfiori G, Bissolati M, Partelli S, Pagnanelli M, Tamburrino D, Gasparini G, Rubini C, Zamboni G, Falconi M. Recurrence after surgical resection of pancreatic cancer: the importance of postoperative complications beyond tumor biology. HPB (Oxford) 2021; 23:1666-1673. [PMID: 33934960 DOI: 10.1016/j.hpb.2021.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 01/07/2021] [Accepted: 04/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Current treatment of potentially resectable pancreatic ductal adenocarcinoma (PDAC) includes pancreatic resection followed by adjuvant therapy. Aim of this study is to identify factors that are related with overall and early recurrence after pancreatectomy for PDAC. METHODS Retrospective analysis of patients with histologically confirmed PDAC who underwent pancreatectomy between September 2009 and December 2014. Early relapse was defined as recurrence within 12 months after surgery. Univariate/multivariate analysis was performed to identify prognostic factors for recurrence. RESULTS 261 patients were included (54% males, mean age 67 years). Neoadjuvant and adjuvant treatments were performed in 55 (21%) and 243 (93%) patients. Overall morbidity was 56% with a rate of grade 3-4 Clavien-Dindo complications of 25%. Median disease-free survival was 18 months. Multivariate analysis identified nodal metastases (OR: 3.6) and perineural invasion (OR: 2.14) as independent predictors of disease recurrence in the entire cohort. 76 patients (29%) had an early recurrence. Poorly differentiated tumors (OR: 3.019) and grade 3-4 Clavien-Dindo complications (OR: 3.05) were independent risk factors for early recurrence. CONCLUSION Although overall recurrence is associated with tumor-related factors, severe postoperative complications represent an independent predictor of early recurrence. Patients at increased risk of severe postoperative complications may benefit from neoadjuvant therapy.
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Affiliation(s)
- Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimiliano Bissolati
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Pagnanelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Tamburrino
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Gasparini
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Corrado Rubini
- Department of Pathology, Università Politecnica Delle Marche, Ospedali Riuniti, Ancona, Italy
| | - Giuseppe Zamboni
- Department of Pathology, Ospedale Sacro Cuore-Don Calabria, Negrar, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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Systematic review and meta-analysis of diagnostic performance of CT imaging for assessing resectability of pancreatic ductal adenocarcinoma after neoadjuvant therapy: importance of CT criteria. Abdom Radiol (NY) 2021; 46:5201-5217. [PMID: 34331549 DOI: 10.1007/s00261-021-03198-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/23/2021] [Accepted: 06/26/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To assess the CT diagnostic performance for evaluating resectability of pancreatic ductal adenocarcinoma (PDAC) after neoadjuvant therapy and identify the factor(s) that affect(s) diagnostic performance. METHODS Databases were searched to identify studies published from January 1, 2000, to November 5, 2019 that evaluated the CT diagnostic performance for assessing resectability of post-neoadjuvant PDAC. Two reviewers independently extracted data and assessed the study quality. A meta-analysis was performed to obtain summary sensitivity and specificity values using a bivariate random-effects model, and heterogeneity across studies was assessed. Univariable meta-regression analysis was performed with eight variables, including the different CT criteria for resectability, conventional National Comprehensive Cancer Network (NCCN) criteria for upfront surgery, and modified criteria for post-neoadjuvant surgery. RESULTS Ten studies were included and analyzed. The summary sensitivity and specificity for resectability were 78% (95% CI 68-86%) and 60% (95% CI 44-74%), respectively. No significant heterogeneity was identified (bivariate correlation coefficient ρ = - 1, p-value for hierarchical summary receiver operating characteristics model β = 0.667). The two different CT criteria showed different diagnostic performance (p < 0.01), with higher sensitivity (81% [95% CI 73-90%] vs. 28% [95% CI 15-42%], p < 0.01) and lower specificity (57% [95% CI 41-73%] vs. 90% [95% CI 80-100%], p < 0.01) for the modified criteria. No other variables affected the diagnostic performance. CONCLUSION CT criteria were the factors that affected the diagnostic performance. Modification of the conventional criteria improved sensitivity but lowered specificity. Further modifications are required to improve specificity and uniformity.
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Neoadjuvant Treatment Strategies in Resectable Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13184724. [PMID: 34572951 PMCID: PMC8469083 DOI: 10.3390/cancers13184724] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Only 10–20% of patients with newly diagnosed resectable pancreatic adenocarcinoma have potentially resectable disease. Upfront surgery is the gold standard, but it is rarely curative. After surgical extirpation of tumors, up to 80% of patients will develop cancer recurrence, and the initial relapse is metastatic in 50–70% of these patients. Adjuvant chemotherapy offers the best strategy to date to improve overall survival but faces real challenges; some patients will experience rapid disease progression within 3 months of surgery and patients who do not receive all planned cycles of chemotherapy have unfavourable oncological outcomes. The neoadjuvant approach is therefore logical but requires further investigation. This approach shows favourable trends regarding disease-free survival and overall survival but, in the absence of rigorous published phase III trials, is not validated to date. Here, we intend to provide a comprehensive analysis of the literature to provide direction for future studies. Abstract Complete surgical resection is the cornerstone of curative therapy for resectable pancreatic adenocarcinoma. Upfront surgery is the gold standard, but it is rarely curative. Neoadjuvant treatment is a logical option, as it may overcome some of the limitations of adjuvant therapy and has already shown some encouraging results. The main concern regarding neoadjuvant therapy is the risk of disease progression during chemotherapy, meaning the opportunity to undergo the intended curative surgery is missed. We reviewed all recent literature in the following areas: major surveys, retrospective studies, meta-analyses, and randomized trials. We then selected the ongoing trials that we believe are of interest in this field and report here the results of a comprehensive review of the literature. Meta-analyses and randomized trials suggest that neoadjuvant treatment has a positive effect. However, no study to date can be considered practice changing. We considered design, endpoints, inclusion criteria and results of available randomized trials. Neoadjuvant treatment appears to be at least a feasible strategy for patients with resectable pancreatic cancer.
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Yoon MS, Lee HS, Kang CM, Lee WJ, Keum J, Sung MJ, Kim SS, Park MS, Jo JH, Chung MJ, Park JY, Park SW, Song SY, Hwang HK, Bang S. Response to Neoadjuvant Therapy and Prognosis in Patients with Resectable Pancreatic Cancer: A Propensity Score Matching Analysis. Gut Liver 2021; 16:118-128. [PMID: 34140428 PMCID: PMC8761915 DOI: 10.5009/gnl20301] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 11/18/2022] Open
Abstract
Background/Aims Controversy regarding the effectiveness of neoadjuvant therapy for resectable pancreatic ductal adenocarcinoma (PDAC) still exists. Here, we aimed to identify the potential benefits of neoadjuvant therapy followed by surgery for resectable PDAC. Methods We reviewed radiologically resectable PDAC patients who received resection with curative intent at a tertiary hospital in South Korea between January 2012 and August 2019. A total of 202 patients underwent curative resection for resectable PDAC 167 underwent surgical resection first during this period, and 35 received neoadjuvant chemotherapy/chemoradiation therapy followed by surgery. Resectable PDAC patients were subdivided, and 13 propensity score matching (PSM) was performed to reduce selection bias. Results Compared with the group that received surgery first, the group that received neoadjuvant treatment followed by surgery had significantly smaller tumors (22.0 mm vs 27.0 mm, p=0.004), a smaller proportion of patients with postoperative pathologic T stage (p=0.026), a smaller proportion of patients with lymphovascular invasion (20.0% vs 40.7%, p=0.022), and a larger proportion of patients with negative resection margins (74.3% vs 51.5%, p=0.049). After PSM, the group that received neoadjuvant therapy had a significantly longer progression-free survival than those in the group that underwent surgery first (29.6 months vs 15.1 months, p=0.002). Overall survival was not significantly different between the two groups after PSM analysis. Conclusions We observed significantly better surgical outcomes and progression-free survival with the addition of neoadjuvant therapy to the management of resectable PDAC. However, despite PSM, there was still selection bias due to the use of different regimens between the groups receiving surgery first and neoadjuvant therapy. Large homogeneous samples are needed in the future prospective studies.
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Affiliation(s)
- Min Sung Yoon
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Seung Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Moo Kang
- Division of Gastroenterology, Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Woo Jung Lee
- Division of Gastroenterology, Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jiyoung Keum
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Min Je Sung
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung-Seob Kim
- Division of Gastroenterology, Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Mi-Suk Park
- Division of Gastroenterology, Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Hyun Jo
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Moon Jae Chung
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong Youp Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Si Young Song
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ho Kyoung Hwang
- Division of Gastroenterology, Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seungmin Bang
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Achieving 'Marginal Gains' to Optimise Outcomes in Resectable Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13071669. [PMID: 33916294 PMCID: PMC8037133 DOI: 10.3390/cancers13071669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 12/21/2022] Open
Abstract
Simple Summary Improving outcomes in pancreatic cancer is achievable through the accumulation of marginal gains. There exists evidence of variation and undertreatment in many areas of the care pathway. By fully realising the existing opportunities, there is the potential for immediate improvements in outcomes and quality of life. Abstract Improving outcomes among patients with resectable pancreatic cancer is one of the greatest challenges of modern medicine. Major improvements in survival will result from the development of novel therapies. However, optimising existing pathways, so that patients realise benefits of already proven treatments, presents a clear opportunity to improve outcomes in the short term. This narrative review will focus on treatments and interventions where there is a clear evidence base to improve outcomes in pancreatic cancer, and where there is also evidence of variation and under-treatment. Avoidance of preoperative biliary drainage, treatment of pancreatic exocrine insufficiency, prehabiliation and enhanced recovery after surgery, reducing perioperative complications, optimising opportunities for elderly patients to receive therapy, optimising adjuvant chemotherapy and regular surveillance after surgery are some of the strategies discussed. Each treatment or pathway change represents an opportunity for marginal gain. Accumulation of marginal gains can result in considerable benefit to patients. Given that these interventions already have evidence base, they can be realised quickly and economically.
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Rieser CJ, Zenati M, Narayanan S, Bahary N, Lee KK, Paniccia A, Bartlett DL, Zureikat AH. Optimal Management of Resectable Pancreatic Head Cancer in the Elderly Patient: Does Neoadjuvant Therapy Offer a Survival Benefit? Ann Surg Oncol 2021; 28:6264-6272. [PMID: 33748894 DOI: 10.1245/s10434-021-09822-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 02/22/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Neoadjuvant therapy (NAT) is a growing strategy for patients with resectable pancreatic ductal adenocarcinoma (PDAC). Elderly patients are at increased risk of treatment withdrawal due to functional decline, and the benefit of NAT in this cohort remains to be studied. OBJECTIVE The objective of this study was to compare outcomes of elderly patients with resectable head PDAC who underwent NAT or a surgery-first (SF) approach. METHODS All patients 75 years of age and older with radiographically resectable (National Comprehensive Cancer Network criteria) PDAC who underwent pancreaticoduodenectomy at a single institution from 2008 to 2017 were analyzed. Baseline characteristics and perioperative outcomes were compared between the SF and NAT cohorts. Recurrence-free survival and overall survival (OS) were analyzed by treatment strategy. RESULTS Overall, 158 patients were identified: SF cohort = 90 (57%) and NAT cohort = 68 (43%). Patients in the SF cohort were older (80 vs. 78 years; p = 0.01) but there were no differences in preoperative comorbidities or frailty indices. SF patients had a trend toward higher rates of major complications (38% vs. 24%; p = 0.06) with higher Comprehensive Complication Index totals (20.9 vs. 20; p = 0.03). There were similar rates of adjuvant therapy. NAT was associated with significantly longer OS (24.6 vs. 17.6 months; p = 0.01) in both the intent-to-treat and resected cohorts. On multivariable analysis (MVA), NAT remained an independent predictor of OS (hazard ratio 0.60; p = 0.02). CONCLUSION NAT is safe and effective for elderly patients with PDAC. This study suggests NAT is associated with fewer complications after surgery, equal rates of adjuvant therapy receipt, and increased OS over a surgery-first approach.
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Affiliation(s)
- Caroline J Rieser
- Division of GI Surgical Oncology, Department of Surgery, Pancreatic Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mazen Zenati
- Department of Surgery and Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sowmya Narayanan
- Division of GI Surgical Oncology, Department of Surgery, Pancreatic Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nathan Bahary
- Department of Medical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kenneth K Lee
- Division of GI Surgical Oncology, Department of Surgery, Pancreatic Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alessandro Paniccia
- Division of GI Surgical Oncology, Department of Surgery, Pancreatic Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - David L Bartlett
- AHN Cancer Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of GI Surgical Oncology, Department of Surgery, Pancreatic Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA.
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Krell RW, McNeil LR, Yanala UR, Are C, Reames BN. Neoadjuvant Therapy for Pancreatic Ductal Adenocarcinoma: Propensity-Matched Analysis of Postoperative Complications Using ACS-NSQIP. Ann Surg Oncol 2021; 28:3810-3822. [PMID: 33386542 DOI: 10.1245/s10434-020-09460-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 11/23/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND The use of neoadjuvant therapy (NAT) for pancreatic ductal adenocarcinoma (PDAC) is increasing. While there is an association between NAT and improved post-pancreatectomy complication rates in limited patient populations, the strength of the relationship and its applicability to a broader and modern pancreatectomy cohort remains unclear. METHODS We used the 2014-2018 American College of Surgeons National Surgical Quality Improvement Project to evaluate NAT use for PDAC patients undergoing pancreatectomy. We also used propensity score matching techniques to compare 30-day postoperative outcomes, including clinically relevant postoperative pancreatic fistula (CR-POPF) and delayed gastric emptying (DGE), between patients selected for NAT versus upfront surgery. RESULTS Patients receiving NAT were more likely to undergo vascular resections (33% vs. 16%, p < 0.001), have perioperative transfusions (18% vs. 12%, p < 0.001), and undergo longer procedures. Rates of CR-POPF (6%, vs. 10%, p < 0.001), DGE (11% vs. 13%, p = 0.016), postoperative percutaneous drainage (9% vs. 12%, p < 0.001), and SSI (15% vs. 18%, p < 0.001) were lower for patients selected for NAT. The association of NAT with CR-POPF remained statistically significant (adjusted odds ratio 0.52, 95% CI 0.42-0.66) after adjustment for operative technique, gland texture, and need for vascular resection for patients undergoing pancreaticoduodenectomy, but not for patients undergoing distal pancreatectomy. CONCLUSIONS Among PDAC patients undergoing resection, selection for NAT is associated with fewer CR-POPFs, postoperative procedural interventions, and infectious complications, particularly for patients undergoing pancreaticoduodenectomy. These associations should be considered in discussions of multidisciplinary treatment sequencing for patients with PDAC.
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Affiliation(s)
- Robert W Krell
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Logan R McNeil
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ujwal R Yanala
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Chandrakanth Are
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Bradley N Reames
- Division of Surgical Oncology, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA.
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Mackay TM, Latenstein AEJ, Bonsing BA, Bruno MJ, van Eijck CHJ, Groot Koerkamp B, de Hingh IHJT, Homs MYV, van Hooft JE, van Laarhoven HW, Molenaar IQ, van Santvoort HC, Stommel MWJ, de Vos-Geelen J, Wilmink JW, Busch OR, van der Geest LG, Besselink MG. Nationwide compliance with a multidisciplinary guideline on pancreatic cancer during 6-year follow-up. Pancreatology 2020; 20:1723-1731. [PMID: 33069583 DOI: 10.1016/j.pan.2020.10.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/27/2020] [Accepted: 10/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Compliance with national guidelines on pancreatic cancer management could improve patient outcomes. Early compliance with the Dutch guideline was poor. The aim was to assess compliance with this guideline during six years after publication. MATERIALS AND METHODS Nationwide guideline compliance was investigated for three subsequent time periods (2012-2013 vs. 2014-2015 vs. 2016-2017) in patients with pancreatic cancer using five quality indicators in the Netherlands Cancer Registry: 1) discussion in multidisciplinary team meeting (MDT), 2) maximum 3-week interval from final MDT to start of treatment, 3) preoperative biliary drainage when bilirubin >250 μmol/L, 4) use of adjuvant chemotherapy, and 5) chemotherapy for inoperable disease (non-metastatic and metastatic). RESULTS In total, 14 491 patients were included of whom 2290 (15.8%) underwent resection and 4561 (31.5%) received chemotherapy. Most quality indicators did not change over time: overall, 88.8% of patients treated with curative intent were discussed in a MDT, 42.7% were treated with curative intent within the 3-week interval, 62.7% with a resectable head tumor and bilirubin >250 μmol/L underwent preoperative biliary drainage, 57.2% received chemotherapy after resection, and 36.6% with metastatic disease received chemotherapy. Only use of chemotherapy for non-metastatic, non-resected disease improved over time (23.4% vs. 25.6% vs. 29.7%). CONCLUSION Nationwide compliance to five quality indicators for the guideline on pancreatic cancer management showed little to no improvement during six years after publication. Besides critical review of the current quality indicators, these outcomes may suggest that a nationwide implementation program is required to increase compliance to guideline recommendations.
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Affiliation(s)
- Tara M Mackay
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Anouk E J Latenstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bert A Bonsing
- Deparment of Surgery, Leids University Medical Center, Leiden, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Marjolein Y V Homs
- Department of Medical Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hanneke W van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lydia G van der Geest
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
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Turner MC, Masoud SJ, Cerullo M, Adam MA, Shah KN, Blazer DG, Abbruzzese JL, Zani S. Improved overall survival is still observed in patients receiving delayed adjuvant chemotherapy after pancreaticoduodenectomy for pancreatic adenocarcinoma. HPB (Oxford) 2020; 22:1542-1548. [PMID: 32299656 DOI: 10.1016/j.hpb.2020.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/01/2020] [Accepted: 03/08/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Adjuvant chemotherapy (AC) is associated with improved survival following resection of pancreatic adenocarcinoma but is frequently delayed or deferred due to perioperative complications or patient deconditioning. The aim of this study was to assess impact of delayed AC on overall survival after pancreaticoduodenectomy for pancreatic head adenocarcinoma. METHODS Patients with stage I-III pancreatic head adenocarcinoma in the 2006-2015 National Cancer Database were grouped by timing of AC (<6-weeks, 6-12-weeks, and 12-24-weeks). Overall survival was compared using Cox proportional hazard models adjusting for patient, tumor, and hospital factors. Subgroup analyses were conducted to assess the impact of comorbidities, readmission or extended hospital stay, and receipt of single- versus multi-agent chemotherapy. RESULTS Of 13438 patients, 4552 (33.9%) received no AC, 2112 (15.7%) received AC <6-weeks following resection, 5580 (41.5%) within 6-12 weeks, and 1194 (8.9%) within 12-24 weeks. AC was associated with improved overall survival (adjusted hazard ratio [HR] <6-weeks: 0.765, 6-12-weeks: 0.744, and 12-24-weeks: 0.736 (p < 0.001)). This survival advantage persisted for patients with comorbidities, those with postoperative complications, and in those receiving single- or multi-agent regimens. CONCLUSIONS For patients with stage I-III pancreatic adenocarcinoma, receipt of AC is associated with improved overall survival, even if delayed up to 24-weeks.
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Affiliation(s)
- Megan C Turner
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Sabran J Masoud
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Marcelo Cerullo
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mohamed A Adam
- Department of Surgery, Duke University Medical Center, Durham, NC, USA; Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kevin N Shah
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Dan G Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Kalisvaart M, Broadhurst D, Marcon F, Pande R, Schlegel A, Sutcliffe R, Marudanayagam R, Mirza D, Chatzizacharias N, Abradelo M, Muiesan P, Isaac J, Ma YT, McConville C, Roberts K. Recurrence patterns of pancreatic cancer after pancreatoduodenectomy: systematic review and a single-centre retrospective study. HPB (Oxford) 2020; 22:1240-1249. [PMID: 32046922 DOI: 10.1016/j.hpb.2020.01.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 11/29/2019] [Accepted: 01/06/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Positive margins in pancreatoduodenectomy (PD) for pancreatic cancer, specifically the superior mesenteric artery (SMA) margin, are associated with worse outcomes. Local therapies targeting these margins could impact on recurrence. This study analysed recurrence-patterns to identify whether strategies to control local disease could have a meaningful impact. METHODS (I) Systematic review to define recurrence patterns and resection margin status. (II) Additional retrospective study of PD performed at our centre. RESULTS In the systematic review, 23/617 evaluated studies were included (n = 3815). Local recurrence was observed in 7-69%. SMA margin (6 studies) was positive in 15-35%. In the retrospective study (n = 204), local recurrence was more frequently observed with a positive SMA margin (66 vs.45%; p = 0.005). Furthermore, in a multivariate cox-proportional hazard model, only a positive SMA margin was associated with disease recurrence (HR 1.615; 95%CI 1.127-2.315; p = 0.009). Interestingly, median overall survival was 20 months and similar for patients who developed local only, metastases only or simultaneous recurrence (p = 0.124). CONCLUSION Local recurrence of pancreatic cancer is common and associated with similar mortality rates as those who present with simultaneous or metastatic recurrence. Involvement of the SMA margin is an independent predictor for disease progression and should be the target of future adjuvant local therapies.
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Affiliation(s)
- Marit Kalisvaart
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Damian Broadhurst
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Francesca Marcon
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Rupaly Pande
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Andrea Schlegel
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Robert Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Ravi Marudanayagam
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Darius Mirza
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Nikolaos Chatzizacharias
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Manuel Abradelo
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Paolo Muiesan
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - John Isaac
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Yuk T Ma
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Christopher McConville
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Keith Roberts
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK; Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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31
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Mackay TM, Smits FJ, Latenstein AEJ, Bogte A, Bonsing BA, Bos H, Bosscha K, Brosens LAA, Hol L, Busch ORC, Creemers GJ, Curvers WL, den Dulk M, van Dieren S, van Driel LMJW, Festen S, van Geenen EJM, van der Geest LG, de Groot DJA, de Groot JWB, Haj Mohammad N, Haberkorn BCM, Haver JT, van der Harst E, Hemmink GJM, de Hingh IH, Hoge C, Homs MYV, van Huijgevoort NC, Jacobs MAJM, Kerver ED, Liem MSL, Los M, Lubbinge H, Luelmo SAC, de Meijer VE, Mekenkamp L, Molenaar IQ, van Oijen MGH, Patijn GA, Quispel R, van Rijssen LB, Römkens TEH, van Santvoort HC, Schreinemakers JMJ, Schut H, Seerden T, Stommel MWJ, Ten Tije AJ, Venneman NG, Verdonk RC, Verheij J, van Vilsteren FGI, de Vos-Geelen J, Vulink A, Wientjes C, Wit F, Wessels FJ, Zonderhuis B, van Werkhoven CH, van Hooft JE, van Eijck CHJ, Wilmink JW, van Laarhoven HWM, Besselink MG. Impact of nationwide enhanced implementation of best practices in pancreatic cancer care (PACAP-1): a multicenter stepped-wedge cluster randomized controlled trial. Trials 2020; 21:334. [PMID: 32299515 PMCID: PMC7161112 DOI: 10.1186/s13063-020-4180-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 02/18/2020] [Indexed: 01/05/2023] Open
Abstract
Background Pancreatic cancer has a very poor prognosis. Best practices for the use of chemotherapy, enzyme replacement therapy, and biliary drainage have been identified but their implementation in daily clinical practice is often suboptimal. We hypothesized that a nationwide program to enhance implementation of these best practices in pancreatic cancer care would improve survival and quality of life. Methods/design PACAP-1 is a nationwide multicenter stepped-wedge cluster randomized controlled superiority trial. In a per-center stepwise and randomized manner, best practices in pancreatic cancer care regarding the use of (neo)adjuvant and palliative chemotherapy, pancreatic enzyme replacement therapy, and metal biliary stents are implemented in all 17 Dutch pancreatic centers and their regional referral networks during a 6-week initiation period. Per pancreatic center, one multidisciplinary team functions as reference for the other centers in the network. Key best practices were identified from the literature, 3 years of data from existing nationwide registries within the Dutch Pancreatic Cancer Project (PACAP), and national expert meetings. The best practices follow the Dutch guideline on pancreatic cancer and the current state of the literature, and can be executed within daily clinical practice. The implementation process includes monitoring, return visits, and provider feedback in combination with education and reminders. Patient outcomes and compliance are monitored within the PACAP registries. Primary outcome is 1-year overall survival (for all disease stages). Secondary outcomes include quality of life, 3- and 5-year overall survival, and guideline compliance. An improvement of 10% in 1-year overall survival is considered clinically relevant. A 25-month study duration was chosen, which provides 80% statistical power for a mortality reduction of 10.0% in the 17 pancreatic cancer centers, with a required sample size of 2142 patients, corresponding to a 6.6% mortality reduction and 4769 patients nationwide. Discussion The PACAP-1 trial is designed to evaluate whether a nationwide program for enhanced implementation of best practices in pancreatic cancer care can improve 1-year overall survival and quality of life. Trial registration ClinicalTrials.gov, NCT03513705. Trial opened for accrual on 22th May 2018.
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Affiliation(s)
- T M Mackay
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - F J Smits
- Department of surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - A E J Latenstein
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - A Bogte
- Department of gastroenterology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - B A Bonsing
- Department of surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - H Bos
- Department of medical oncology, Tjongerschans Hospital, Heerenveen, the Netherlands
| | - K Bosscha
- Department of surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - L A A Brosens
- Department of pathology, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of pathology, Radboud University, Nijmegen, the Netherlands
| | - L Hol
- Department of gastroenterology, Maasstad Hospital, Rotterdam, the Netherlands
| | - O R C Busch
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - G J Creemers
- Department of medical oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - W L Curvers
- Department of gastroenterology, Catharina Hospital, Eindhoven, the Netherlands
| | - M den Dulk
- Department of surgery, Maastricht UMC+, Maastricht, the Netherlands
| | - S van Dieren
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - L M J W van Driel
- Department of gastroenterology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - S Festen
- Department of surgery, OLVG, Amsterdam, the Netherlands
| | - E J M van Geenen
- Department of gastroenterology, Radboud UMC, Nijmegen, the Netherlands
| | - L G van der Geest
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - D J A de Groot
- Department of medical oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - J W B de Groot
- Department of medical oncology, Oncology Center Isala, Zwolle, the Netherlands
| | - N Haj Mohammad
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - B C M Haberkorn
- Department of medical oncology, Maasstad Hospital, Rotterdam, the Netherlands
| | - J T Haver
- Department of nutrition and dietetics, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - E van der Harst
- Department of surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - G J M Hemmink
- Department of gastroenterology, Oncology Center Isala, Zwolle, the Netherlands
| | - I H de Hingh
- Department of surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - C Hoge
- Department of gastroenterology, Maastricht UMC+, Maastricht, the Netherlands
| | - M Y V Homs
- Department of medical oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - N C van Huijgevoort
- Department of gastroenterology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M A J M Jacobs
- Department of gastroenterology, Cancer Center Amsterdam, Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - E D Kerver
- Department of medical oncology, OLVG, Amsterdam, the Netherlands
| | - M S L Liem
- Department of surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - M Los
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - H Lubbinge
- Department of gastroenterology, Tjongerschans Hospital, Heerenveen, the Netherlands
| | - S A C Luelmo
- Department of medical oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - V E de Meijer
- Department of surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - L Mekenkamp
- Department of medical oncology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - I Q Molenaar
- Department of surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - M G H van Oijen
- Department of medical oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - G A Patijn
- Department of surgery, Oncology Center Isala, Zwolle, the Netherlands
| | - R Quispel
- Department of gastroenterology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - L B van Rijssen
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands
| | - T E H Römkens
- Department of gastroenterology, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - H C van Santvoort
- Department of surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - H Schut
- Department of medical oncology, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - T Seerden
- Department of gastroenterology, Amphia Hospital, Breda, the Netherlands
| | - M W J Stommel
- Department of surgery, Radboud UMC, Nijmegen, the Netherlands
| | - A J Ten Tije
- Department of medical oncology, Amphia Hospital, Breda, the Netherlands
| | - N G Venneman
- Department of gastroenterology and hepatology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - R C Verdonk
- Department of gastroenterology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - J Verheij
- Department of pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - F G I van Vilsteren
- Department of gastroenterology, University Medical Center Groningen, Groningen, the Netherlands
| | - J de Vos-Geelen
- Department of medical oncology, Maastricht UMC+, Maastricht, the Netherlands
| | - A Vulink
- Department of medical oncology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - C Wientjes
- Department of gastroenterology, OLVG, Amsterdam, the Netherlands
| | - F Wit
- Department of surgery, Tjongerschans Hospital, Heerenveen, the Netherlands
| | - F J Wessels
- Department of radiology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St. Antonius Hospital, Nieuwegein, the Netherlands
| | - B Zonderhuis
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - C H van Werkhoven
- Julius Center for Health Sciences and primary care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - J E van Hooft
- Department of gastroenterology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - C H J van Eijck
- Department of surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - J W Wilmink
- Department of medical oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - H W M van Laarhoven
- Department of medical oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - M G Besselink
- Department of surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, PO Box 22660, 1100 DD, Amsterdam, the Netherlands.
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Pranger BK, Tseng DSJ, Ubels S, van Santvoort HC, Nieuwenhuijs VB, de Jong KP, Patijn G, Molenaar IQ, Erdmann JI, de Meijer VE. How to Approach Para-Aortic Lymph Node Metastases During Exploration for Suspected Periampullary Carcinoma: Resection or Bypass? Ann Surg Oncol 2020; 27:2949-2958. [PMID: 32157526 PMCID: PMC7334266 DOI: 10.1245/s10434-020-08304-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Indexed: 01/08/2023]
Abstract
Background Intraoperative para-aortic lymph node (PALN) sampling during surgical exploration in patients with suspected pancreatic head cancer remains controversial. Objective The aim of this study was to assess the value of routine PALN sampling and the consequences of different treatment strategies on overall patient survival. Methods A retrospective, multicenter cohort study was performed in patients who underwent surgical exploration for suspected pancreatic head cancer. In cohort A, the treatment strategy was to avoid pancreatoduodenectomy and to perform a double bypass procedure when PALN metastases were found during exploration. In cohort B, routinely harvested PALNs were not examined intraoperatively and pancreatoduodenectomy was performed regardless. PALNs were examined with the final resection specimen. Clinicopathological data, survival data and complication data were compared between study groups. Results Median overall survival for patients with PALN metastases who underwent a double bypass procedure was 7.0 months (95% confidence interval [CI] 5.5–8.5), versus 11 months (95% CI 8.8–13) in the pancreatoduodenectomy group (p = 0.049). Patients with PALN metastases who underwent pancreatoduodenectomy had significantly increased postoperative morbidity compared with patients who underwent a double bypass procedure (p < 0.001). In multivariable analysis, severe comorbidity (ASA grade 2 or higher) was an independent predictor for decreased survival in patients with PALN involvement (hazard ratio 3.607, 95% CI 1.678–7.751; p = 0.001). Conclusion In patients with PALN metastases, pancreatoduodenectomy was associated with significant survival benefit compared with a double bypass procedure, but with increased risk of complications. It is important to weigh the advantages of resection versus bypass against factors such as comorbidities and clinical performance when positive intraoperative PALNs are found. Electronic supplementary material The online version of this article (10.1245/s10434-020-08304-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bobby K Pranger
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Dorine S J Tseng
- Department of Hepatopancreatobiliary Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein and University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sander Ubels
- Department of Surgery, Isala Clinics Zwolle, Zwolle, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Hepatopancreatobiliary Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein and University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Koert P de Jong
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gijs Patijn
- Department of Surgery, Isala Clinics Zwolle, Zwolle, The Netherlands
| | - I Quintus Molenaar
- Department of Hepatopancreatobiliary Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joris I Erdmann
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Vincent E de Meijer
- Department of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Versteijne E, Suker M, Groothuis K, Akkermans-Vogelaar JM, Besselink MG, Bonsing BA, Buijsen J, Busch OR, Creemers GJM, van Dam RM, Eskens FALM, Festen S, de Groot JWB, Groot Koerkamp B, de Hingh IH, Homs MYV, van Hooft JE, Kerver ED, Luelmo SAC, Neelis KJ, Nuyttens J, Paardekooper GMRM, Patijn GA, van der Sangen MJC, de Vos-Geelen J, Wilmink JW, Zwinderman AH, Punt CJ, van Eijck CH, van Tienhoven G. Preoperative Chemoradiotherapy Versus Immediate Surgery for Resectable and Borderline Resectable Pancreatic Cancer: Results of the Dutch Randomized Phase III PREOPANC Trial. J Clin Oncol 2020; 38:1763-1773. [PMID: 32105518 PMCID: PMC8265386 DOI: 10.1200/jco.19.02274] [Citation(s) in RCA: 621] [Impact Index Per Article: 155.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Preoperative chemoradiotherapy may improve the radical resection rate for resectable or borderline resectable pancreatic cancer, but the overall benefit is unproven. PATIENTS AND METHODS In this randomized phase III trial in 16 centers, patients with resectable or borderline resectable pancreatic cancer were randomly assigned to receive preoperative chemoradiotherapy, which consisted of 3 courses of gemcitabine, the second combined with 15 × 2.4 Gy radiotherapy, followed by surgery and 4 courses of adjuvant gemcitabine or to immediate surgery and 6 courses of adjuvant gemcitabine. The primary end point was overall survival by intention to treat. RESULTS Between April 2013 and July 2017, 246 eligible patients were randomly assigned; 119 were assigned to preoperative chemoradiotherapy and 127 to immediate surgery. Median overall survival by intention to treat was 16.0 months with preoperative chemoradiotherapy and 14.3 months with immediate surgery (hazard ratio, 0.78; 95% CI, 0.58 to 1.05; P = .096). The resection rate was 61% and 72% (P = .058). The R0 resection rate was 71% (51 of 72) in patients who received preoperative chemoradiotherapy and 40% (37 of 92) in patients assigned to immediate surgery (P < .001). Preoperative chemoradiotherapy was associated with significantly better disease-free survival and locoregional failure-free interval as well as with significantly lower rates of pathologic lymph nodes, perineural invasion, and venous invasion. Survival analysis of patients who underwent tumor resection and started adjuvant chemotherapy showed improved survival with preoperative chemoradiotherapy (35.2 v 19.8 months; P = .029). The proportion of patients who suffered serious adverse events was 52% versus 41% (P = .096). CONCLUSION Preoperative chemoradiotherapy for resectable or borderline resectable pancreatic cancer did not show a significant overall survival benefit. Although the outcomes of the secondary end points and predefined subgroup analyses suggest an advantage of the neoadjuvant approach, additional evidence is required.
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Affiliation(s)
- Eva Versteijne
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Mustafa Suker
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Karin Groothuis
- Clinical Research Department, Comprehensive Cancer Organisation the Netherlands (IKNL), Nijmegen, the Netherlands
| | - Janine M Akkermans-Vogelaar
- Clinical Research Department, Comprehensive Cancer Organisation the Netherlands (IKNL), Nijmegen, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen Buijsen
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Ronald M van Dam
- Department of Surgery, Division of Hepato-Pancreato-Biliary & Oncology, European Surgery Center Aachen Maastricht, Maastricht UMC+, Maastricht, the Netherlands
| | - Ferry A L M Eskens
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Marjolein Y V Homs
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Emile D Kerver
- Department of Medical Oncology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Saskia A C Luelmo
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Karen J Neelis
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Joost Nuyttens
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | | | - Gijs A Patijn
- Department of Surgery, Isala Oncology Center, Zwolle, the Netherlands
| | | | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Aeilko H Zwinderman
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Cornelis J Punt
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Mackay TM, Smits FJ, Roos D, Bonsing BA, Bosscha K, Busch OR, Creemers GJ, van Dam RM, van Eijck CHJ, Gerhards MF, de Groot JWB, Groot Koerkamp B, Haj Mohammad N, van der Harst E, de Hingh IHJT, Homs MYV, Kazemier G, Liem MSL, de Meijer VE, Molenaar IQ, Nieuwenhuijs VB, van Santvoort HC, van der Schelling GP, Stommel MWJ, Ten Tije AJ, de Vos-Geelen J, Wit F, Wilmink JW, van Laarhoven HWM, Besselink MG. The risk of not receiving adjuvant chemotherapy after resection of pancreatic ductal adenocarcinoma: a nationwide analysis. HPB (Oxford) 2020; 22:233-240. [PMID: 31439478 DOI: 10.1016/j.hpb.2019.06.019] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/24/2019] [Accepted: 06/28/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The relation between type of postoperative complication and not receiving chemotherapy after resection of pancreatic ductal adenocarcinoma (PDAC) is unclear. The aim was to investigate which patient factors and postoperative complications were associated with not receiving adjuvant chemotherapy. METHODS Patients who underwent resection (2014-2017) for PDAC were identified from the nationwide mandatory Dutch Pancreatic Cancer Audit. The association between patient-, tumor-, center-, treatment characteristics, and the risk of not receiving adjuvant chemotherapy was analyzed with multivariable logistic regression. RESULTS Overall, of 1306 patients, 24% (n = 312) developed postoperative Clavien Dindo ≥3 complications. In-hospital mortality was 3.5% (n = 46). Some 433 patients (33%) did not receive adjuvant chemotherapy. Independent predictors (all p < 0.050) for not receiving adjuvant chemotherapy were older age (odds ratio (OR) 0.96), higher ECOG performance status (OR 0.57), postoperative complications (OR 0.32), especially grade B/C pancreatic fistula (OR 0.51) and post-pancreatectomy hemorrhage (OR 0.36), poor tumor differentiation grade (OR 0.62), and annual center volume of <40 pancreatoduodenectomies (OR 0.51). CONCLUSIONS This study demonstrated that a third of patients do not receive chemotherapy after resection of PDAC. Next to higher age, worse performance status and lower annual surgical volume, this is mostly related to surgical complications, especially postoperative pancreatic fistula and post-pancreatectomy hemorrhage.
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Affiliation(s)
- Tara M Mackay
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - F Jasmijn Smits
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Group, Delft, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Geert-Jan Creemers
- Department of Medical Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht UMC+, Maastricht, the Netherlands
| | | | | | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | | | - Marjolein Y V Homs
- Department of Medical Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, VU Medical Center, Amsterdam, the Netherlands
| | - Mike S L Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - I Quintus Molenaar
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | - Hjalmar C van Santvoort
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, the Netherlands
| | | | | | | | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans, Heerenveen, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
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Goel N, Nadler A, Reddy S, Hoffman JP, Pitt HA. Biliary microbiome in pancreatic cancer: alterations with neoadjuvant therapy. HPB (Oxford) 2019; 21:1753-1760. [PMID: 31101398 DOI: 10.1016/j.hpb.2019.04.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/14/2019] [Accepted: 04/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neoadjuvant therapy for pancreatic cancer is being employed more commonly. Most of these patients undergo biliary stenting which results in bacterial colonization and more surgical site infections (SSIs). However, the influence of neoadjuvant therapy on the biliary microbiome has not been studied. METHODS From 2007 to 2017, patients at our institution who underwent pancreatoduodenectomy (PD) and had operative bile cultures were studied. Patient demographics, stent placement, bile cultures, bacterial sensitivities, SSIs and clinically-relevant postoperative pancreatic fistulas (CR-POPF) were analyzed. Patients who underwent neoadjuvant therapy were compared to those who went directly to surgery. Standard statistical analyses were performed. RESULTS Eighty-three patients received neoadjuvant therapy while 89 underwent surgery alone. Patients who received neoadjuvant therapy were more likely to have enterococci (45 vs 22%, p < 0.01), and Klebsiella (37 vs 19%, p < 0.01) in their bile. Resistance to cephalosporins was more common in those who received neoadjuvant therapy (76 vs 60%, p < 0.05). Neoadjuvant therapy did not affect the incidence of SSIs or CR-POPFs. CONCLUSION The biliary microbiome is altered in patients undergoing pancreatoduodenectomy (PD) after neoadjuvant therapy. Most patients undergoing PD with a biliary stent have microorganisms resistant to cephalosporins. Antibiotic prophylaxis in these patients should cover enterococci and gram-negative bacteria.
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Affiliation(s)
- Neha Goel
- Department of Surgery, Fox Chase Cancer Center, USA
| | | | - Sanjay Reddy
- Department of Surgery, Fox Chase Cancer Center, USA
| | | | - Henry A Pitt
- Temple University Health System, USA; Lewis Katz School of Medicine at Temple University, USA.
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van Veldhuisen E, Walma MS, van Rijssen LB, Busch OR, Bruijnen RCG, van Delden OM, Mohammad NH, de Hingh IH, Yo LS, van Laarhoven HW, van Leeuwen MS, Nio CY, van Santvoort HC, de Vries J, Wessels FJ, Wilmink JW, Molenaar IQ, Besselink MG, van Lienden KP. Added value of intra-operative ultrasound to determine the resectability of locally advanced pancreatic cancer following FOLFIRINOX chemotherapy (IMAGE): a prospective multicenter study. HPB (Oxford) 2019; 21:1385-1392. [PMID: 31010633 DOI: 10.1016/j.hpb.2019.02.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 02/11/2019] [Accepted: 02/25/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Determining the resectability of locally advanced pancreatic cancer (LAPC) after FOLFIRINOX chemotherapy is challenging because CT-scans cannot reliably assess vascular involvement. This study evaluates the added value of intra-operative ultrasound (IOUS) in LAPC following FOLFIRINOX induction chemotherapy. METHODS Prospective multicenter study in patients with LAPC who underwent explorative laparotomy with IOUS after FOLFIRINOX chemotherapy. Resectability was defined according to the National Comprehensive Cancer Network guidelines. IOUS findings were compared with preoperative CT-scans and pathology results. RESULTS CT-staging in 38 patients with LAPC after FOLFIRINOX chemotherapy defined 22 patients LAPC, 15 borderline resectable and one resectable. IOUS defined 19 patients LAPC, 13 borderline resectable and six resectable. In 12/38 patients, IOUS changed the resectability status including five patients from borderline resectable to resectable and five patients from LAPC to borderline resectable. Two patients were upstaged from borderline resectable to LAPC. Tumor diameters were significantly smaller upon IOUS (31.7 ± 9.5 mm versus 37.1 ± 10.0 mm, p = 0.001) and resectability varied significantly (p = 0.043). Ultimately, 20 patients underwent resection of whom 14 were evaluated as (borderline) resectable on CT-scan, and 17 on IOUS. DISCUSSION This prospective study demonstrates that IOUS may change the resectability status up to a third of patients with LAPC following FOLFIRINOX chemotherapy.
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Affiliation(s)
- Eran van Veldhuisen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marieke S Walma
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands; Department of Surgery, University Medical Center, Utrecht, the Netherlands
| | - L Bengt van Rijssen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Rutger C G Bruijnen
- Department of Radiology, University Medical Center, Utrecht, the Netherlands
| | - Otto M van Delden
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, University Medical Center, Utrecht, the Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Lonneke S Yo
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Hanneke W van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | | | - C Yung Nio
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St Antonius Hospital Nieuwegein, University Medical Center Utrecht Cancer Center, Regional Academic Cancer Center Utrecht, the Netherlands
| | - Jan de Vries
- Department of Radiology and Nuclear Medicine, Cancer Center Amsterdam, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Frank J Wessels
- Department of Radiology, University Medical Center, Utrecht, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, St Antonius Hospital Nieuwegein, University Medical Center Utrecht Cancer Center, Regional Academic Cancer Center Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
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Lambert A, Schwarz L, Borbath I, Henry A, Van Laethem JL, Malka D, Ducreux M, Conroy T. An update on treatment options for pancreatic adenocarcinoma. Ther Adv Med Oncol 2019; 11:1758835919875568. [PMID: 31598142 PMCID: PMC6763942 DOI: 10.1177/1758835919875568] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 08/19/2019] [Indexed: 12/24/2022] Open
Abstract
Pancreatic cancer is one of the most lethal solid organ tumors. Due to the rising incidence, late diagnosis, and limited treatment options, it is expected to be the second leading cause of cancer deaths in high income countries in the next decade. The multidisciplinary treatment of this disease depends on the stage of cancer at diagnosis (resectable, borderline, locally advanced, and metastatic disease), and combines surgery, chemotherapy, chemoradiotherapy, and supportive care. The landscape of multidisciplinary pancreatic cancer treatment is changing rapidly, especially in locally advanced disease, and the number of treatment options in metastatic disease, including personalized medicine, innovative targets, immunotherapy, therapeutic vaccines, adoptive T-cell transfer, or stemness inhibitors, will probably expand in the near future. This review summarizes the current literature and provides an overview of how new therapies or new therapeutic strategies (neoadjuvant therapies, conversion surgery) will guide multidisciplinary disease management, future clinical trials, and, hopefully, will increase overall survival.
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Affiliation(s)
- Aurélien Lambert
- Department of Medical Oncology, Institut de Cancérologie de Lorraine and Université de Lorraine, Nancy, France
| | - Lilian Schwarz
- Department of Digestive Surgery, Rouen University Hospital and Université de Rouen Normandie, France
| | - Ivan Borbath
- Department of Gastroenterology and Digestive Oncology, Cliniques Universitaires Saint-Luc and Université Catholique de Louvain, Brussels, Belgium
| | - Aline Henry
- Department of Supportive Care in Oncology, Institut de Cancérologie de Lorraine, Nancy, France
| | - Jean-Luc Van Laethem
- Department of Gastroenterology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Belgium
| | - David Malka
- Department of Medical Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Michel Ducreux
- Department of Medical Oncology, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Thierry Conroy
- Institut de Cancérologie de Lorraine, 6 avenue de Bourgogne, 50519 Vandoeuvre-lès-Nancy CEDEX, France
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Inoue Y, Saiura A, Oba A, Kawakatsu S, Ono Y, Sato T, Mise Y, Ishizawa T, Takahashi Y, Ito H. Optimal Extent of Superior Mesenteric Artery Dissection during Pancreaticoduodenectomy for Pancreatic Cancer: Balancing Surgical and Oncological Safety. J Gastrointest Surg 2019; 23:1373-1383. [PMID: 30306451 DOI: 10.1007/s11605-018-3995-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/23/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND We describe the short- and long-term outcomes for PDAC patients after tailored mesopancreas dissection using supracolic artery-first approach followed by adjuvant therapy. METHODS This study analyzed 233 consecutive patients who underwent artery-first pancreaticoduodenectomy for PDAC. Dissection extent for the superior mesenteric artery (SMA) was categorized into three levels: level 2 (LV2) including regional lymph nodes, level 3 (LV3) with hemicircumferential nerve plexus dissection, and extended-level 3 (E-LV3) including borderline resectable cases for the SMA. All clinical, pathological, and survival outcomes were reviewed. RESULTS LV2/3/E-LV3 dissection was performed in 77/115/41 patients. The short-term outcomes were similar among groups without mortality. Although postoperative diarrhea requiring opioids was significantly more frequent in the E-LV3 group (76%) than other groups (vs. LV2 (21%), P < .0001; vs. LV3 (34%), P < .0001; LV2 vs. LV3, P = 0.20), most cases of diarrhea were well controlled. Adjuvant chemotherapy was introduced similarly among groups (LV2, 76%; LV3, 81%; E-LV3, 88%, P = 0.29). The 3- and 5-year overall survival rates in the LV2/3/E-LV3 groups were 42/33/42% and 27/22/26%, respectively, showing no significant difference among groups. DISCUSSION Our tailored dissection and preemptive use of opioid antidiarrheal effectively prevents intractable diarrhea, increasing the success of adjuvant chemotherapy.
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Affiliation(s)
- Yosuke Inoue
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akio Saiura
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Atsushi Oba
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Shoji Kawakatsu
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yoshihiro Ono
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takafumi Sato
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yoshihiro Mise
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takeaki Ishizawa
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yu Takahashi
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Hiromichi Ito
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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Skau Rasmussen L, Vittrup B, Ladekarl M, Pfeiffer P, Karen Yilmaz M, Østergaard Poulsen L, Østerlind K, Palnæs Hansen C, Bau Mortensen M, Viborg Mortensen F, Sall M, Detlefsen S, Bøgsted M, Wilki Fristrup C. The effect of postoperative gemcitabine on overall survival in patients with resected pancreatic cancer: A nationwide population-based Danish register study. Acta Oncol 2019; 58:864-871. [PMID: 30905248 DOI: 10.1080/0284186x.2019.1581374] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: Adjuvant chemotherapy following curative resection is the standard treatment for pancreatic adenocarcinoma (PC). Randomized clinical trials using gemcitabine have shown a median overall survival (mOS) of 2 years and a 5-year survival rate of 15-20%. However, the effect of gemcitabine outside these trials is less clear. We examined the effect of postoperative gemcitabine on survival in an unselected cohort of patients receiving curative resection for PC in Denmark during a five-year period. Material and methods: From 1 May 2011 to 30 April 2016, 731 patients treated with curative resection were identified in the Danish Pancreatic Cancer Database (DPCD). Thirty patients died within 10 weeks postoperatively; 78 received other regimens or preoperative chemotherapy and were excluded. Of the remaining 623 patients, the chemotherapy (CT) group (n = 409, 66%) received gemcitabine within 10 weeks after resection, whereas the non-chemotherapy (NCT) group (n = 214, 34%) did not receive CT within 10 weeks. Results: CT patients were slightly younger than NCT patients but did not otherwise differ in baseline characteristics. The CT group showed a mOS of 24 months (95% CI; 21-27) and a 5-year survival rate of 22% (95% CI; 17-27); the NCT group had a mOS of 22 months (95% CI; 16-26, p = .27) and a 5-year survival rate of 26% (95% CI; 19-34, p = .66). Most patients (415/623) had lymph node metastases. Of these patients, those in the CT group (n = 280) had significantly longer mOS [20 months (95% CI; 18-24)] than those in the NCT group (n = 135) [14 months (95% CI; 11-17)]. Conclusions: In this national Danish cohort of PC patients undergoing resection between 2011 and 2016, the survival after postoperative gemcitabine was similar to that reported in previous clinical trials. However, the survival advantage of postoperative gemcitabine was limited to patients with lymph node metastases.
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Affiliation(s)
- Louise Skau Rasmussen
- Department of Oncology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Benny Vittrup
- Department of Oncology, University Hospital Herlev, Herlev, Denmark
| | - Morten Ladekarl
- Department of Oncology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Mette Karen Yilmaz
- Department of Oncology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Laurids Østergaard Poulsen
- Department of Oncology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Kell Østerlind
- Department of Oncology, North Sealand Hospital, Hillerød, Denmark
| | - Carsten Palnæs Hansen
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Michael Bau Mortensen
- Odense Pancreas Center (OPAC), Department of Surgery, Odense University Hospital, Odense, Denmark
| | | | - Mogens Sall
- Department of Surgical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Sönke Detlefsen
- Odense Pancreas Center (OPAC), Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Martin Bøgsted
- Department of Clinical Medicine, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- Department of Haematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Claus Wilki Fristrup
- Danish Pancreatic Cancer Database, Denmark
- Department of Surgery, Odense University Hospital, Odense, Denmark
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Djanani A, Schmiderer A, Niederreiter L, Niederreiter M, Tilg H. Management of ductal pancreatic cancer. Eur Surg 2019. [DOI: 10.1007/s10353-019-0583-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Ven Fong Z, Chang DC, Lillemoe KD, Nipp RD, Tanabe KK, Qadan M. Contemporary Opportunity for Prehabilitation as Part of an Enhanced Recovery after Surgery Pathway in Colorectal Surgery. Clin Colon Rectal Surg 2019; 32:95-101. [PMID: 30833857 DOI: 10.1055/s-0038-1676473] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The implementation of upfront, preoperative habilitation ("prehabilitation"), as opposed to postoperative habilitation (rehabilitation), provides a unique opportunity to optimize surgical outcomes, while ensuring that patients receive necessary conditioning that may otherwise be significantly delayed by postoperative complications. In this review, opportunities to design, implement, monitor, and evaluate a surgical prehabilitation program in colorectal surgery are discussed, and broken down to include emotional, physical, and nutritional aspects of care in the preoperative setting.
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Affiliation(s)
- Zhi Ven Fong
- Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - David C Chang
- Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ryan D Nipp
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kenneth K Tanabe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Fitzgerald TL, Hunter L, Mosquera C, Jindal C, Biswas T, Zervos E, Efird JT. A simple matrix to predict treatment success and long-term survival among patients undergoing pancreatectomy. HPB (Oxford) 2019; 21:204-211. [PMID: 30087052 DOI: 10.1016/j.hpb.2018.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 05/16/2018] [Accepted: 07/09/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND A more accurate measure of long-term survival among patients who have undergone a successful resection for pancreatic adenocarcinoma may be computed by accounting for time already survived during the initial treatment window. METHODS Patients diagnosed with pancreatic adenocarcinoma, from 2004 through 2013, were identified from the American College of Surgeons National Cancer Database (NCDB). A risk-stratification matrix was constructed including age, histopathologic factors and the use of adjuvant therapy, given successful treatment and survival at 3-month following diagnosis. RESULTS A total of 25,897 patients (50% male, 53% >65 years of age) presented with stage I-III pancreatic cancer. The majority of patients had tumors >2 cm size (82%), grade I/II (65%), lymphatic invasion (LI) (66%), and negative margins (76%). A survival advantage for adjuvant therapy was observed among all patients, independent of their risk-profile. For example, a patient ≤65 years of age, with early stage cancer (size ≤2 cm, grade I/II, -ve LI, -ve margins) who received adjuvant therapy had a 62% probability of being alive beyond three years (95%CI = 59%-66%). In contrast, the survival probability decreased to 53% (95%CI = 59%-66%) without adjuvant therapy. CONCLUSIONS These results provide surgeons and patients with more accurate information regarding long-term survival, as well as the benefit of opting for adjuvant therapy after successful pancreatic surgery.
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Affiliation(s)
| | - Lucas Hunter
- Department of Surgical Oncology, Brody School of Medicine, Greenville, NC, USA
| | - Catalina Mosquera
- Department of Surgical Oncology, Brody School of Medicine, Greenville, NC, USA; Vidant Cancer Care, Greenville, NC, USA
| | - Charulata Jindal
- Centre for Clinical Epidemiology and Biostatistics (CCEB), School of Medicine and Public Health, The University of Newcastle (UoN), Newcastle, 2308, Australia
| | - Tithi Biswas
- Department of Radiation Oncology, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
| | | | - Jimmy T Efird
- Centre for Clinical Epidemiology and Biostatistics (CCEB), School of Medicine and Public Health, The University of Newcastle (UoN), Newcastle, 2308, Australia.
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Ma SJ, Hermann GM, Prezzano KM, Serra LM, Iovoli AJ, Singh AK. Adjuvant chemotherapy followed by concurrent chemoradiation is associated with improved survival for resected stage I-II pancreatic cancer. Cancer Med 2019; 8:939-952. [PMID: 30652417 PMCID: PMC6434497 DOI: 10.1002/cam4.1967] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 12/12/2018] [Accepted: 12/18/2018] [Indexed: 01/02/2023] Open
Abstract
Background This National Cancer Database (NCDB) analysis evaluates the clinical outcomes of postoperative chemotherapy followed by concurrent chemoradiation (C + CRT) compared to concurrent chemoradiation (CRT) alone or adjuvant chemotherapy alone (C) for resected pancreatic cancer. Methods The NCDB was queried for primary stage I‐II, cT1‐3N0‐1M0, resected pancreatic adenocarcinoma treated with adjuvant C, CRT, or C + CRT (2004‐2015). Patients treated with C + CRT were compared with those treated with C (cohort C) and CRT (cohort CRT). Baseline patient, tumor, and treatment characteristics were examined. Kaplan‐Meier analysis, multivariable Cox proportional hazards method, forest plot, and propensity score matching were used. Results Among 5667 patients, median follow‐up was 34.7, 45.2, and 39.7 months for the C, CRT, and C + CRT cohorts, respectively. By multivariable analysis for all patients, C and CRT had worse OS compared to C + CRT. Treatment interactions were seen among pathologically node‐positive disease. C + CRT was favored in 1‐3 and 4+ positive lymph node diseases when compared to C or CRT alone, but none of the treatment options were significantly favored in node negative disease. Using propensity score matching, 2152 patients for cohort C and 1774 patients for cohort CRT were matched. C + CRT remained significant for improved OS for both cohort C (median OS 23.3 vs 20.0 months) and cohort CRT (median OS 23.4 vs 20.8 months). Conclusion This NCDB study using propensity score matched analysis suggests an OS benefit for C + CRT compared to C or CRT alone following surgical resection of pancreatic cancer, particularly for patients with pathologically positive lymph nodes.
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Affiliation(s)
- Sung Jun Ma
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Gregory M Hermann
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Kavitha M Prezzano
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Lucas M Serra
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York
| | - Austin J Iovoli
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York
| | - Anurag K Singh
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
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Tingstedt B, Andersson B, Jönsson C, Formichov V, Bratlie SO, Öhman M, Karlsson BM, Ansorge C, Segersvärd R, Gasslander T. First results from the Swedish National Pancreatic and Periampullary Cancer Registry. HPB (Oxford) 2019; 21:34-42. [PMID: 30097413 DOI: 10.1016/j.hpb.2018.06.1811] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 05/21/2018] [Accepted: 06/24/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite improvements in therapy regimens over the past decades, overall survival rates for pancreatic and periampullary cancer are poor. Specific cancer registries are set up in various nations to regional differences and to enable larger prospective trials. The aim of this study was to describe the Swedish register, including possibilities to improve diagnostic work-ups, treatment, and follow-up by means of the register. METHODS Since 2010, all patients with pancreatic and periampullary cancer (including also patients who have undergone pancreatic surgery due to premalignant or benign lesions) have been registered in the Swedish National Periampullary and Pancreatic Cancer registry. RESULTS In total 9887 patients are listed in the registry; 8207 of those have malignant periampullary cancer. Approximately one-third (3282 patients) have had resections performed, including benign/premalignant resections. 30-day and 90-day mortality after pancreatoduodenectomy is 1.5% and 3.5%, respectively. The overall 3-year survival for resected pancreatic ductal adenocarcinoma is 35%. Regional variations decreased over the studied period, but still exist. CONCLUSION Results from the Swedish National Registry are satisfactory and comparable to international standards. Trends over time show increasing resection rates and some improved results. Better collaboration and openness within pancreatic surgeons is an important side effect.
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Affiliation(s)
- Bobby Tingstedt
- Department of Surgery, Skåne University Hospital, Lund, Sweden.
| | - Bodil Andersson
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Claes Jönsson
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Svein-Olav Bratlie
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mikael Öhman
- Departments of Surgical and Perioperative Sciences, Umeå University Hospital, Sweden
| | | | - Christophe Ansorge
- Department of Surgical Gastroenterology, Karolinska University Hospital, Stockholm, Sweden
| | - Ralf Segersvärd
- Department of Surgical Gastroenterology, Karolinska University Hospital, Stockholm, Sweden
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Roberts KJ, Bannister CA, Schrem H. Enzyme replacement improves survival among patients with pancreatic cancer: Results of a population based study. Pancreatology 2019; 19:114-121. [PMID: 30385188 DOI: 10.1016/j.pan.2018.10.010] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic exocrine insufficiency (PEI) and malnutrition are prevalent among patients with pancreatic adenocarcinoma. Pancreatic enzyme replacement therapy (PERT) can correct PEI but its use among patients with pancreatic cancer is unclear as are effects upon survival. This population-based study sought to address these issues METHODS: Subjects with pancreatic adenocarcinoma were identified from the UK Clinical Practice Research Datalink (CPRD). Propensity score matching generated matched pairs of subjects who did and did not receive PERT. Progression to all-cause mortality was compared using parametric survival models that included a range of relevant co-variables RESULTS: PERT use among the whole cohort (987/4554) was 21.7%. Some 1614 subjects generated 807 matched pairs. This resulted in a total, censored follow-up period of 1643 years. There were 1403 deaths in total, representing unadjusted mortality rates of 748 and 994 deaths per 1000 person-years for PERT-treated cases and their matched non-PERT-treated controls, respectively. With reference to the observed survival in pancreatic adenocarcinoma patients, adjusted median survival time was 262% greater in PERT-treated cases (survival time ratio (STR) = 2.62, 95% CI 2.27-3.02) when compared with matched, non-PERT-treated controls. Survival remained significantly greater among subjects receiving PERT regardless of the studied subgroup with respect to use of surgery or chemotherapy CONCLUSIONS: This population based study observes that the majority of patients with pancreatic adenocarcinoma do not receive PERT. PERT is associated with increased survival among patients with pancreatic adenocarcinoma suggesting a lack of clinical awareness and potential benefit of addressing malnutrition among these patients.
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Affiliation(s)
- K J Roberts
- Honorary Reader and Consultant Surgeon, Institute of Immunology and Immunotherapy, University of Birmingham, UK.
| | | | - H Schrem
- Consultant Surgeon, Dept Visceral, General and Transplant Surgery, Hannover Medical School, Germany
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van Erning FN, Mackay TM, van der Geest LGM, Groot Koerkamp B, van Laarhoven HWM, Bonsing BA, Wilmink JW, van Santvoort HC, de Vos-Geelen J, van Eijck CHJ, Busch OR, Lemmens VE, Besselink MG. Association of the location of pancreatic ductal adenocarcinoma (head, body, tail) with tumor stage, treatment, and survival: a population-based analysis. Acta Oncol 2018; 57:1655-1662. [PMID: 30264642 DOI: 10.1080/0284186x.2018.1518593] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The association between pancreatic ductal adenocarcinoma (PDAC) location (head, body, tail) and tumor stage, treatment and overall survival (OS) is unclear. METHODS Patients with PDAC diagnosed between 2005 and 2015 were included from the population-based Netherlands Cancer Registry. Patient, tumor and treatment characteristics were compared with the tumor locations. Multivariable logistic and Cox regression analyses were used. RESULTS Overall, 19,023 patients were included. PDAC locations were 13,451 (71%) head, 2429 (13%) body and 3143 (16%) tail. Differences were found regarding metastasized disease (head 42%, body 69%, tail 84%, p < .001), size (>4 cm: 21%, 40%, 51%, p < .001) and resection rate (17%, 4%, 7%, p < .001). For patients without metastases, median OS did not differ between head, body, tail (after resection: 16.8, 15.0, 17.3 months, without resection: 5.2, 6.1, 4.6 months, respectively). For patients with metastases, median OS differed slightly (2.6, 2.4, 1.9 months, respectively, adjusted HR body versus head 1.17 (95%CI 1.10-1.23), tail versus head 1.35 (95%CI 1.29-1.41)). CONCLUSIONS PDAC locations in body and tail are larger, more often metastasized and less often resectable than in the pancreatic head. Whereas survival is similar after resection, survival in metastasized disease is somewhat less for PDAC in the pancreatic body and tail.
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Affiliation(s)
- Felice N. van Erning
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
| | - Tara M. Mackay
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | - B. Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Hanneke W. M. van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Johanna W. Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, the Netherlands
| | | | - Olivier R. Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Valery E. Lemmens
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Marc G. Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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David JM, Kim S, Placencio-Hickok VR, Torosian A, Hendifar A, Tuli R. Treatment strategies and clinical outcomes of locally advanced pancreatic cancer patients treated at high-volume facilities and academic centers. Adv Radiat Oncol 2018; 4:302-313. [PMID: 31011675 PMCID: PMC6460104 DOI: 10.1016/j.adro.2018.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 10/29/2018] [Indexed: 02/07/2023] Open
Abstract
Purpose Locally advanced pancreatic cancer (LAPC) treatment has varying practice patterns with poor outcomes. We investigated treatment using single-agent chemotherapy and multiagent chemotherapy (MAC) with or without radiation therapy (RT) at high-volume facilities (HVFs) and academic centers (ACs). Methods and Materials The National Cancer Database was used to obtain data on 10,139 patients with LAPC. HVF was defined as the top 5% of facilities per number of patients treated at each facility. Univariate and multivariable (MVA) analysis Cox regressions were performed to identify the impact of HVF, AC, MAC, and RT on overall survival (OS). Results The median age of patients was 66 years (range, 22-90); 50.1% were male and 49.9% female. Of the patients, 46.1% received MAC, 53.8% received single-agent chemotherapy, 45.7% received RT, 54.3% did not receive RT, and 5% underwent surgical resection. The median follow-up was 48.8 months. On MVA, treatment at HVFs and ACs remained significantly associated with improved OS, with a hazard ratio (HR) of 0.84 (P < .001) and 0.94 (P = .004), respectively. The median OS for HVF treatment compared with low-volume facilities was 14.3 versus 11.2 months, respectively (P < .001). The median OS for AC treatment versus non-AC was 12.1 versus 10.8 months, respectively (P < .001). Additionally, on MVA, receipt of RT and MAC remained significantly associated with improved OS (HR: 0.76; P < .001; and HR: 0.73; P < .001, respectively). MVA for receipt of surgery showed that MAC is a significant predictor for receiving surgery (odds ratio: 1.29; P = .009). Conclusions Our results build on a growing literature supporting RT and MAC in treating LAPC. Additionally, we believe that-in the absence of prospective data-this makes a strong case for considering MAC with RT at ACs and HVFs for treating LAPC.
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Affiliation(s)
- John M. David
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sungjin Kim
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Veronica R. Placencio-Hickok
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Arman Torosian
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrew Hendifar
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Hematology and Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Richard Tuli
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Corresponding author. Department of Radiation Oncology, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA 90048.
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Huang L, Jansen L, Balavarca Y, van der Geest L, Lemmens V, Van Eycken L, De Schutter H, Johannesen TB, Primic-Žakelj M, Zadnik V, Mägi M, Pulte D, Schrotz-King P, Brenner H. Nonsurgical therapies for resected and unresected pancreatic cancer in Europe and USA in 2003-2014: a large international population-based study. Int J Cancer 2018; 143:3227-3239. [DOI: 10.1002/ijc.31628] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 04/21/2018] [Accepted: 05/17/2018] [Indexed: 01/01/2023]
Affiliation(s)
- Lei Huang
- Division of Clinical Epidemiology and Aging Research; German Cancer Research Center (DKFZ); Heidelberg Germany
- Medical Faculty Heidelberg; Heidelberg University; Heidelberg Germany
| | - Lina Jansen
- Division of Clinical Epidemiology and Aging Research; German Cancer Research Center (DKFZ); Heidelberg Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ); Heidelberg Germany
| | - Yesilda Balavarca
- Division of Preventive Oncology; German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT); Heidelberg Germany
| | - Lydia van der Geest
- Netherlands Cancer Registry (NCR), The Netherlands Comprehensive Cancer Organization (IKNL); Utrecht The Netherlands
| | - Valery Lemmens
- Netherlands Cancer Registry (NCR), The Netherlands Comprehensive Cancer Organization (IKNL); Utrecht The Netherlands
| | | | | | - Tom B. Johannesen
- Registry Department; The Cancer Registry of Norway (CRN); Oslo Norway
| | - Maja Primic-Žakelj
- Epidemiology and Cancer Registry; Institute of Oncology Ljubljana; Ljubljana Slovenia
| | - Vesna Zadnik
- Epidemiology and Cancer Registry; Institute of Oncology Ljubljana; Ljubljana Slovenia
| | - Margit Mägi
- Estonian Cancer Registry; National Institute for Health Development; Tallinn Estonia
| | - Dianne Pulte
- Division of Clinical Epidemiology and Aging Research; German Cancer Research Center (DKFZ); Heidelberg Germany
| | - Petra Schrotz-King
- Division of Preventive Oncology; German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT); Heidelberg Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research; German Cancer Research Center (DKFZ); Heidelberg Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ); Heidelberg Germany
- Division of Preventive Oncology; German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT); Heidelberg Germany
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Weberpals J, Jansen L, Silversmit G, Verbeeck J, van der Geest L, Vissers PA, Zadnik V, Brenner H. Comparative performance of a modified landmark approach when no time of treatment data are available within oncological databases: exemplary cohort study among resected pancreatic cancer patients. Clin Epidemiol 2018; 10:1109-1125. [PMID: 30214315 PMCID: PMC6121745 DOI: 10.2147/clep.s160973] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Purpose The Mantel-Byar method is the gold standard analytical approach to avoid immortal time bias, but requires information on the time between start of follow-up and exposure initiation. Alternatively, a modified landmark approach might be used to mitigate the amount of immortal time bias, which assumes exposure initiation at a predefined landmark time. In the context of an expected positive association between adjuvant chemotherapy (ACT) and overall survival among resected pancreatic cancer (PCa) patients, this study aims to empirically assess the performance of this approach relative to the Mantel-Byar method. Patients and methods Data from resected PCa patients diagnosed between 2003 and 2014 and registered in the national cancer registries of Belgium, the Netherlands, and Slovenia were used to estimate the association between ACT and overall survival using a Cox proportional hazards model by country and overall. Results derived from the immortal time bias (misclassifying the time to ACT initiation), Mantel-Byar method, and conventional and modified landmark analyses with assumed cutoff times of ACT initiation at 9, 12 and 15 weeks post-diagnosis were compared. Results In total, 5,668 patients with a total of 10,921 person-years of follow-up were eligible. All analytical approaches showed a significant survival benefit for resected PCa patients who received ACT, but immortal time bias analyses led to strong overestimation of ACT benefits compared to the Mantel-Byar method (immortal time bias: overall HR [95% CI] 0.68 [0.62-0.75] vs Mantel-Byar method: 0.82 [0.71-0.93]), whereas the conventional landmark approach generally provided rather conservative estimates (0.86 [0.75-1.00], 15 weeks landmark). HRs derived from modified landmark analyses depended on the cutoff time, but were similar compared to the Mantel-Byar method at 15 weeks (0.81 [0.70-0.94]). Conclusion A modified landmark approach might be a valid alternative to the Mantel-Byar method if no time of treatment information is available. The performance depends on the chosen cutoff time.
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Affiliation(s)
- Janick Weberpals
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany,
| | - Lina Jansen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany,
| | | | | | - Lydia van der Geest
- Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - Pauline Aj Vissers
- Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - Vesna Zadnik
- Epidemiology and Cancer Registry, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany, .,Division of Preventive Oncology, National Center for Tumor Diseases (NCT) and German Cancer Research Center (DKFZ), Heidelberg, Germany, .,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany,
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50
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Versteijne E, Vogel JA, Besselink MG, Busch ORC, Wilmink JW, Daams JG, van Eijck CHJ, Groot Koerkamp B, Rasch CRN, van Tienhoven G. Meta-analysis comparing upfront surgery with neoadjuvant treatment in patients with resectable or borderline resectable pancreatic cancer. Br J Surg 2018; 105:946-958. [PMID: 29708592 PMCID: PMC6033157 DOI: 10.1002/bjs.10870] [Citation(s) in RCA: 340] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/14/2017] [Accepted: 03/07/2018] [Indexed: 12/11/2022]
Abstract
Background Studies comparing upfront surgery with neoadjuvant treatment in pancreatic cancer may report only patients who underwent resection and so survival will be skewed. The aim of this study was to report survival by intention to treat in a comparison of upfront surgery versus neoadjuvant treatment in resectable or borderline resectable pancreatic cancer. Methods MEDLINE, Embase and the Cochrane Library were searched for studies reporting median overall survival by intention to treat in patients with resectable or borderline resectable pancreatic cancer treated with or without neoadjuvant treatment. Secondary outcomes included overall and R0 resection rate, pathological lymph node rate, reasons for unresectability and toxicity of neoadjuvant treatment. Results In total, 38 studies were included with 3484 patients, of whom 1738 (49·9 per cent) had neoadjuvant treatment. The weighted median overall survival by intention to treat was 18·8 months for neoadjuvant treatment and 14·8 months for upfront surgery; the difference was larger among patients whose tumours were resected (26·1 versus 15·0 months respectively). The overall resection rate was lower with neoadjuvant treatment than with upfront surgery (66·0 versus 81·3 per cent; P < 0·001), but the R0 rate was higher (86·8 (95 per cent c.i. 84·6 to 88·7) versus 66·9 (64·2 to 69·6) per cent; P < 0·001). Reported by intention to treat, the R0 rates were 58·0 and 54·9 per cent respectively (P = 0·088). The pathological lymph node rate was 43·8 per cent after neoadjuvant therapy and 64·8 per cent in the upfront surgery group (P < 0·001). Toxicity of at least grade III was reported in up to 64 per cent of the patients. Conclusion Neoadjuvant treatment appears to improve overall survival by intention to treat, despite lower overall resection rates for resectable or borderline resectable pancreatic cancer. PROSPERO registration number: CRD42016049374. Improved survival with neoadjuvant treatment
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Affiliation(s)
- E Versteijne
- Department of Radiation Oncology, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - J A Vogel
- Department of Surgery, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - O R C Busch
- Department of Surgery, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - J W Wilmink
- Department of Medical Oncology, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - J G Daams
- Medical Library, Academic Medical Centre, Amsterdam, The Netherlands
| | - C H J van Eijck
- Department of Surgery, Erasmus Medical Centre, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Centre, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - C R N Rasch
- Department of Radiation Oncology, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - G van Tienhoven
- Department of Radiation Oncology, Cancer Centre Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
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