Quality of life in pancreatic cancer: analysis by stage and treatment

Have a vital end-user been overlooked? Developing a shared decision intervention for patients with potential pancreatic cancer regarding the choice of surgery

Objective

To develop a patient decision aid facilitating shared decision making for patients with potential pancreatic cancer deciding about no treatment, surgical or medical treatment.

Methods

Based on a user-centred design by Wittemann et al., we developed a shared decision making intervention in three phases: 1) Understanding decision needs 2) Development of a patient decision aid (PtDA) based on a generic template 3) Assessment of the intervention from interviews with patients (n = 11), relatives (n = 11), nurses (n = 4) and surgeons (n = 2) analysed with thematic analysis, and measuring patients' perceptions of choice of options with the Decisional Conflict Scale.

Results

Results showed varying experiences with the use of the PtDA, with surgeons not finding PtDA useful as it was impractical and constraining with patients' conversations. There was no difference in patients' perceptions in choosing options for those being presented vs those patients not being presented for the PtDA.

Conclusion

The format and structure of the PtDA was not feasible for the surgeons as fundamental users in the present clinic.

Innovation

This study highlights the urgent need to consider clinical context before introducing a predefined tool and shows the importance of a multistakeholder approach. Research should focus on finding means to successful implement shared decision making.

Quality of life following perioperative optimization with nutritional supplements in patients undergoing gastrointestinal surgery for cancer: A randomized, placebo-controlled feasibility clinical trial

BACKGROUND

Up to two thirds of patients presenting for abdominal cancer surgery are malnourished pre-operatively. Perioperative nutritional supplementation has been proposed to improve surgical outcomes, though its effect on quality of life (QoL) is not yet understood.

METHODS

A randomized controlled feasibility trial for perioperative nutrition among patients undergoing major abdominal cancer surgery was conducted. Participants in the intervention group received supplements for 30 days before surgery. Participants completed two QoL questionnaires (EORTC-QLQ-C-30 and FACT-G) at baseline, then 4 and 12 weeks postoperatively. Participants were compared between and within groups at baseline, Weeks 4, and 12 using t tests. Minimal clinically important differences (MCIDs) were considered as a 10-point worsening from baseline.

RESULTS

Sixty-six participants were available for analysis in this study, including 33 in the intervention and 30 in the control arms. Baseline demographics were balanced between groups except for different rates of pancreas cancer (36% intervention vs. 9% control) and colorectal cancer (19% intervention vs. 34% control). At baseline, participants in the intervention group had lower overall QoL (59% vs. 77%, p = 0.01), role functioning (72% vs 88%, p = 0.045), and cognitive functioning (79% vs 90%, p = 0.047). Following surgery, role and physical functioning worsened in the control group, without significant differences between groups. Role functioning was persistently worsened at 12 weeks in the control group. The rates of MCIDs were similar between both intervention and control groups.

DISCUSSION

Perioperative nutrition was associated with preservation of QoL in the postoperative period following major abdominal cancer surgery compared to placebo.

SUMMARY

Among patients undergoing surgery for cancer, the majority present at high risk for malnutrition. In this placebo-controlled randomized trial among patients undergoing major abdominal surgery for cancer, preoperative nutrition supplementation was associated with the preservation of QoL in the postoperative period.

Gemcitabine and Paclitaxel Versus Gemcitabine Alone After 5-Fluorouracil, Oxaliplatin, and Irinotecan in Metastatic Pancreatic Adenocarcinoma: A Randomized Phase III PRODIGE 65-UCGI 36-GEMPAX UNICANCER Study

PURPOSE

GEMPAX was an open-label, randomized phase III clinical trial designed to assess the efficacy and tolerability of gemcitabine plus paclitaxel versus gemcitabine alone as second-line treatment for patients with metastatic pancreatic ductal adenocarcinoma (mPDAC) who previously received 5-fluorouracil, oxaliplatin, and irinotecan.

METHODS

Patients with histologically or cytologically confirmed mPDAC were randomly assigned (2:1) to receive GEMPAX (paclitaxel 80 mg/m2 + gemcitabine 1,000 mg/m2; IV; once at day (D) 1, D8, and D15/arm A) or gemcitabine (arm B) alone once at D1, D8, and D15 every 28 days until progression, toxicity, or patient's decision. The primary end point was overall survival (OS). Secondary end points included progression-free survival (PFS), objective response rate (ORR), quality of life, and safety.

RESULTS

Overall, 211 patients (median age, 64 [30-86] years; 62% male) were included. After a median study follow-up for alive patients of 13.4 versus 13.8 months in arm A versus arm B, the median OS (95% CI) was 6.4 (5.2 to 7.4) versus 5.9 months (4.6 to 6.9; hazard ratio [HR], 0.87 [0.63 to 1.20]; P = 0.4095), the median PFS was 3.1 (2.2 to 4.3) versus 2.0 months (1.9 to 2.3; HR, 0.64 [0.47 to 0.89]; P = 0.0067), and the ORR was 17.1% (11.3 to 24.4) versus 4.2% (0.9 to 11.9; P = 0.008) in arm A versus arm B, respectively. Overall, 16.7% of patients in arm A and 2.9% in arm B discontinued their treatment because of adverse events (AEs). One grade 5 AE associated with both gemcitabine and paclitaxel was reported in arm A (acute respiratory distress), and 58.0% versus 27.1% of patients experienced grade ≥3 treatment-related AEs in arm A versus arm B, among which 15.2% versus 4.3% had anemia, 15.9% versus 15.7% had neutropenia, 19.6% versus 4.3% had thrombocytopenia, 10.1% versus 2.9% had asthenia and 12.3% versus 0.0% had neuropathy.

CONCLUSION

While GEMPAX did not meet the primary end point of OS versus gemcitabine alone in patients with mPDAC in the second-line setting, both PFS and ORR were significantly improved.

Patient-reported outcomes at three months after pancreatic surgery for benign and malignant diseases - A prospective observational study

BACKGROUND/OBJECTIVES

Pancreatic surgery may have a long-lasting effect on patients' health status and quality of life (QoL). We aim to evaluate patient-reported outcomes (PRO) 3 months after pancreatic surgery.

METHODS

Patients scheduled for pancreatic surgery were enrolled in a prospective trial at five German centers. Patients completed PRO questionnaires (EQ-5D-5L, EORTC QLQ-PAN26, patient-reported happiness, and HADS-D), we report the first follow-up 3 months after surgery as an interim analysis. Statistical testing was performed using R software.

RESULTS

From 2019 to 2022 203 patients were enrolled, a three-month follow-up questionnaire was available in 135 (65.5 %). 77 (57.9 %) underwent surgery for malignant disease. Patient-reported health status (EQ-5D-5L) was impaired in 4/5 dimensions (mobility, self-care, usual activities, pain, discomfort) for patients with malignant and 3/5 dimensions (mobility, self-care, usual activities) for patients with benign disease 3 months after surgery (p < 0.05). Patients with malignant disease reported an increase in depressive symptoms, patients with benign disease had a decrease in anxiety symptoms (HADS-D; depression: 5.00 vs 6.51, p = 0.002; anxiety: 8.04 vs. 6.34, p = 0.030). Regarding pancreatic-disease-specific symptoms (EORTC-QLQ-PAN26), patients with malignant disease reported increased problems with taste, weight loss, weakness in arms and legs, dry mouth, body image and troubling side effects at three months. Patients with benign disease indicated more weakness in arms and legs, troubling side effects but less future worries at three months.

CONCLUSION

Patient-reported outcomes of patients undergoing pancreatic surgery for benign vs. malignant disease show important differences. Patients with malignant tumors report more severely decreased quality of life 3 months postoperatively than patients with benign tumors.

Clinical outcomes after online adaptive MR-guided stereotactic body radiotherapy for pancreatic tumors on a 1.5 T MR-linac

Introduction

Online adaptive magnetic resonance-guided radiotherapy (MRgRT) is a promising treatment modality for pancreatic cancer and is being employed by an increasing number of centers worldwide. However, clinical outcomes have only been reported on a small scale, often from single institutes and in the context of clinical trials, in which strict patient selection might limit generalizability of outcomes. This study presents clinical outcomes of a large, international cohort of patients with (peri)pancreatic tumors treated with online adaptive MRgRT.

Methods

We evaluated clinical outcomes and treatment details of patients with (peri)pancreatic tumors treated on a 1.5 Tesla (T) MR-linac in two large-volume treatment centers participating in the prospective MOMENTUM cohort (NCT04075305). Treatments were evaluated through schematics, dosage, delivery strategies, and success rates. Acute toxicity was assessed until 3 months after MRgRT started, and late toxicity from 3-12 months of follow-up (FU). The EORTC QLQ-C30 questionnaire was used to evaluate the quality of life (QoL) at baseline and 3 months of FU. Furthermore, we used the Kaplan-Meier analysis to calculate the cumulative overall survival.

Results

A total of 80 patients were assessed with a median FU of 8 months (range 1-39 months). There were 34 patients who had an unresectable primary tumor or were medically inoperable, 29 who had an isolated local recurrence, and 17 who had an oligometastasis. A total of 357 of the 358 fractions from all hypofractionated schemes were delivered as planned. Grade 3-4 acute toxicity occurred in 3 of 59 patients (5%) with hypofractionated MRgRT and grade 3-4 late toxicity in 5 of 41 patients (12%). Six patients died within 3 months after MRgRT; in one of these patients, RT attribution could not be ruled out as cause of death. The QLQ-C30 global health status remained stable from baseline to 3 months FU (70.5 at baseline, median change of +2.7 [P = 0.5]). The 1-year cumulative overall survival for the entire cohort was 67%, and that for the primary tumor group was 66%.

Conclusion

Online adaptive MRgRT for (peri)pancreatic tumors on a 1.5 T MR-Linac could be delivered as planned, with low numbers of missed fractions. In addition, treatments were associated with limited grade 3-4 toxicity and a stable QoL at 3 months of FU.

Evaluation of post-operative surveillance strategies and surgeon perceptions and beliefs of surveillance for pancreatic ductal adenocarcinoma in the UK

BACKGROUND

Despite high rates of recurrence after surgery for pancreatic ductal adenocarcinoma (PDAC) there is lack of standardised surveillance practices. We aimed to identify UK surveillance practice and interrogate surgeon beliefs around surveillance.

METHODS

A web-based survey was sent to all UK pancreatic units to assess surveillance practice for resected PDAC, factors influencing surveillance protocols, and perceptions and beliefs surrounding on current postoperative surveillance.

RESULTS

There was wide variation in reported practice between 40 consultant surgeons from 28 pancreatic units (100% unit response rate). 26% had standardised surveillance compared to 18% with no standardised practice. 16% individualised surveillance to the patient, and 40% reported differing practices between surgeons within units despite local surveillance protocols. 66% felt surveillance should be tailored to patient factors, and 58% to patient preference. There was a broad belief regarding a lack of robust evidence supporting surveillance making a trial necessary. Thematic analysis identified surveillance barriers, considerations for trial design, necessity for patient engagement and potential benefits of surveillance.

DISCUSSION

Wide variation in surveillance practice exists within and between units. A surveillance trial was deemed beneficial, however identified barriers potentially preclude a trial. Future work should assess acceptability for patients including impact on anxiety and quality-of-life.

High-risk liver patients are not associated with adverse events following pancreaticoduodenectomy

INTRODUCTION

Pancreaticoduodenectomy performed with underlying hepatic disease has been reported to have increased adverse events postoperatively. This study aimed to further evaluate that association.

METHODS

Retrospective review of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) main and targeted pancreatectomy registries for 2014-2016. High-risk liver patients were defined by MELD scores, received neoadjuvant chemotherapy, and had hepatosteatosis; two separate subgroups of MELD ≥9 and ≥ 11. High-risk liver patients were then compared to control cases via propensity score matching.

RESULTS

There were 156 and 132 cases that met the high-risk liver criteria for the MELD cutoffs of ≥9 and ≥ 11 respectively. Propensity score matching left 2527 cases for final adjusted analysis. On both univariate and multivariate analysis high-risk liver patients were not associated with increased adverse events following Whipple resection. Lack of association with increased adverse events held for both the ≥9 and ≥ 11 MELD score cohorts.

CONCLUSION

High-risk liver patients defined by MELD scores, neoadjuvant chemotherapy utilization, and hepatosteatosis were not associated with any increased incidence of adverse events following pancreaticoduodenectomy. Patients with underlying high-risk liver disease in this study did not appear to pose as a contraindication for oncologic resection of pancreatic adenocarcinoma.

DNA methylation and miR-92a-3p-mediated repression of HIP1R promotes pancreatic cancer progression by activating the PI3K/AKT pathway

Pancreatic cancer (PAAD) is a highly malignant tumour characterized of high mortality and poor prognosis. Huntingtin-interacting protein 1-related (HIP1R) has been recognized as a tumour suppressor in gastric cancer, while its biological function in PAAD remains to be elucidated. In this study, we reported the downregulation of HIP1R in PAAD tissues and cell lines, and the overexpression of HIP1R suppressed the proliferation, migration and invasion of PAAD cells, while silencing HIP1R showed the opposite effects. DNA methylation analysis revealed that the promoter region of HIP1R was heavily methylated in PAAD cell lines when compared to the normal pancreatic duct epithelial cells. A DNA methylation inhibitor 5-AZA increased the expression of HIP1R in PAAD cells. 5-AZA treatment also inhibited the proliferation, migration and invasion, and induced apoptosis in PAAD cell lines, which could be attenuated by HIP1R silencing. We further demonstrated that HIP1R was negatively regulated by miR-92a-3p, which modulates the malignant phenotype of PAAD cells in vitro and the tumorigenesis in vivo. The miR-92a-3p/HIP1R axis could regulate PI3K/AKT pathway in PAAD cells. Taken together, our data suggest that targeting DNA methylation and miR-92a-3p-mediated repression of HIP1R could serve as novel therapeutic strategies for PAAD treatment.

Evaluating the relationship between patient activation and health-related quality of life (HRQOL) in patients with pancreatic cancer (PwPC)

PURPOSE

Advanced pancreatic cancer is synonymous with a high mortality rate, debilitating symptom profile, and minimal prolongation in overall survival. Therefore, health-related quality of life (HRQOL) is important in patients with pancreatic cancer (PwPC). In chronic conditions, patient activation is positively associated and higher HRQOL. However, no known study has evaluated patient activation, HRQOL, and their association in PwPC.

METHODS

A 43-item cross-sectional survey assessed patient activation and HRQOL of patients with locally advanced and metastatic pancreatic cancer undergoing chemotherapy. Variables were analyzed descriptively, and relationships were assessed using bivariate statistics (sig p < 0.05).

RESULTS

Fifty-six patients participating in the study had an average age of 69.5 ± 11.1 years, and the majority were females (51.8%), Caucasians (61.8%), married/partnered (64.3%), and had at least a college degree (59%). Almost half were at stage 4 (48.2%), and most were newly diagnosed (66.1%). Mean patient activation score was 63.5 ± 17.2 (scale range: 0-100), with most at higher activation levels of 3 or 4 (66.7%). Mean HRQOL score of 41.0 ± 12.7 (scale range: 0-72) was low. Patient activation levels, age, education level, and gender explained 21% of variation in overall HRQOL scores. Patients at activation level 4 had significantly higher overall HRQOL versus those at lower activation (level 1 or 2). Higher patient activation was significantly associated with having either private insurance only or multiple insurances and being partnered.

CONCLUSION

Patient activation significantly predicted HRQOL in PwPC despite the low sample size. Initiatives to increase patient activation should focus on patients of low socioeconomic status and those without partner support.

Health-Related Quality of Life of Patients with Metastatic Pancreatic Cancer: A Systematic Literature Review

Background

Metastatic pancreatic cancer (mPaC) has a poor prognosis and available treatments provide only moderate improvements in survival. Preserving or improving health-related quality of life (HRQoL) is therefore an important treatment outcome for patients with mPaC. This systematic review identified HRQoL data in patients with mPaC before and after treatment, compared these with data from the general population, and reported the effects of different mPaC treatments on HRQoL.

Methods

Searches were performed in Embase, PubMed, and the Cochrane Library from January 2008 to May 2021, and the articles identified were screened for HRQoL data in patients with mPaC. Abstracts from relevant congresses were also manually searched. Publications included were randomized controlled trials and observational studies written in English that reported HRQoL data for adult patients with non-resectable mPaC who were on or off treatment.

Results

Thirty relevant publications were identified and HRQoL scores were collected. Overall, baseline mean scores from the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30), 5-dimension EuroQol questionnaire (EQ-5D), and Functional Assessment of Cancer Therapy-General (FACT-G) for newly diagnosed and previously treated patients with mPaC were worse than those of the general population. Baseline scores were generally better for previously treated patients than for newly diagnosed patients, indicating that mPaC treatments preserve or improve HRQoL. Identified publications also reported changes in HRQoL following first- or subsequent-line chemotherapy. When reported, 10 studies found improvements in overall HRQoL compared with baseline scores, four reported no changes in overall HRQoL after treatment, and six found deteriorations in overall HRQoL.

Conclusion

Patients with mPaC had worse HRQoL than the general population. Available anti-cancer therapies can improve or preserve HRQoL.

Do-Not-Resuscitate Orders and Outcomes for Patients with Pancreatic Cancer

Background

The impact of the do-not-resuscitate (DNR) order on patients with pancreatic cancer remains uncertain. In this study, we evaluated whether DNR status was associated with in-hospital mortality and costs for inpatient stay among patients hospitalized with pancreatic cancer.

Methods

Data were obtained from the National Inpatient Sample, Healthcare Cost and Utilization Project, which represents ∼20% of all discharges from US community hospitals; 40,246 pancreatic cancer admissions between 2011 and 2016 were included. Mortality was modeled using a logistic regression model; costs for inpatient stay were modeled using a multivariable generalized linear regression model.

Results

The sample included 6041 (15%) patients with a documented DNR order. After controlling for covariates, patients with a DNR order had approximately six times greater odds of mortality compared with patients without a DNR order (odds ratio 5.90, p < 0.0001). Compared with patients who survived without a DNR order during the hospital stay, patients who had a DNR order and died during the hospital stay had significantly lower costs (-US$983; p = 0.0270), and patients who died without a DNR order during the hospital stay had significantly higher costs (US$5638; p < 0.0001). Patients who survived with a DNR order had costs that were not significantly different from patients who survived without a DNR order.

Conclusions

The presence of a DNR order among patients with pancreatic cancer was significantly associated with higher mortality risk as well as lower costs for patients who died during the hospital stay. However, DNR status was not significantly associated with costs for pancreatic cancer patients who were discharged alive.

Pilot trial of remote monitoring to prevent malnutrition after hepatopancreatobiliary surgery

Background

Patients undergoing hepatopancreatobiliary (HPB) surgery, such patients with pancreatic, periampullary, and liver cancer, are at high risk for malnutrition. Malnutrition increases surgical complications and reduces overall survival. Despite its severity, there are limited interventions addressing malnutrition after HPB surgery. The aim of this pilot trial was to examine feasibility, acceptability, usability, and preliminary efficacy of a remote nutrition monitoring intervention after HPB surgery.

Methods

Participants received tailored nutritional counseling before and after surgery at 2 and 4 weeks after hospital discharge. Participants also recorded nutritional intake daily for 30 days, and these data were reviewed remotely by registered dietitians before nutritional counseling visits. Descriptive statistics were used to describe study outcomes.

Results

All 26 patients approached to participate consented to the trial before HPB surgery. Seven were excluded after consent for failing to meet eligibility criteria (e.g., did not receive surgery). Nineteen participants (52.6% female, median age = 65 years) remained eligible for remote monitoring post-surgery. Nineteen used the mobile app food diary, 79% of participants recorded food intake for greater than 80% of study days, 95% met with the dietitian for all visits, and 89% were highly satisfied with the intervention. Among participants with complete data, the average percent caloric goal obtained was 82.4% (IQR: 21.7).

Conclusions

This intervention was feasible and acceptable to patients undergoing HPB surgery. Preliminary efficacy data showed most participants were able to meet calorie intake goals. Future studies should examine intervention efficacy in a larger, randomized controlled trial.

Trial registration

Clinicaltrials.gov. Registered 16 September 2019, https://clinicaltrials.gov/ct2/show/NCT04091165.

Quality of life of locally advanced pancreatic cancer patients after FOLFIRINOX treatment

Background

Quality of life in cancer patients might be affected by chemotherapy-induced toxicity. Especially in patients with pancreatic ductal adenocarcinoma (PDAC), with a short life expectancy, fear of poor quality of life is often a reason for both patients and medical oncologists to refrain from further treatment. In this study, we investigated quality of life (QoL), pain, sleep, and activity levels in locally advanced pancreatic cancer (LAPC) patients after FOLFIRINOX treatment.

Methods

A total of 41 LAPC patients with stable disease or partial response were included after completion of at least four cycles of FOLFIRINOX. QoL was measured with the EORTC QLQ-C30 and NRS pain scores. Patients completed the Richards-Campbell Sleep Questionnaire (RCSQ) for five consecutive nights and wore a GENEActiv tri-axial accelerometer (Actiwatch) for 7 days, registering sleep duration, efficiency, and activity.

Results

Mean EORTC QLQ-C30 score for global health status was 78.3 (± 17.3), higher than reference values for cancer patients (P < 0.001) and general population (P = 0.045). LAPC patients reported few disease-related symptoms. Two patients (5%) reported pain scores > 3. Mean sleep duration was 8 h/night (± 1.2 h) and sleep efficiency 70% (± 9%) with high patient-reported quality of sleep (mean RCSQ score 72.0 ± 11.4). Mean duration of moderate-vigorous activity was 37 min/week (± 103 min/week).

Conclusions

QoL is very good in most LAPC patients with disease control after FOLFIRINOX, measured with validated questionnaires and Actiwatch registration. The fear of clinical deterioration after FOLFIRINOX is not substantiated by this study and should not be a reason to refrain from treatment.

Trial registration

Dutch trial register NL7578.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06648-1.

Modulated Electro-Hyperthermic (mEHT) Treatment in the Therapy of Inoperable Pancreatic Cancer Patients-A Single-Center Case-Control Study

Our present oncological treatment arsenal has limited treatment options for pancreatic ductal adenocarcinoma (PDAC). Extended reviews have shown the benefits of hyperthermia for PDAC, supporting the perspectives with the improvements of the treatment possibilities. METHODS: A retrospective single-center case-control study was conducted with the inclusion of 78 inoperable PDAC patients. Age-, sex-, chemotherapy-, stage-, and ascites formation-matched patients were assigned to two equal groups based on the application of modulated electro-hyperthermia (mEHT). The EHY2030 mEHT device was used. RESULTS: A trend in favor of mEHT was found in overall survival (p = 0.1420). To further evaluate the potential beneficial effects of mEHT, the presence of distant metastasis or ascites in the patients’ oncological history was investigated. Of note, mEHT treatment had a favorable effect on patients’ overall survival in metastatic disease (p = 0.0154), while less abdominal fluid responded to the mEHT treatment in a more efficient way (p ≤ 0.0138). CONCLUSION: mEHT treatment was associated with improved overall survival in PDAC in our single-center retrospective case-control study. The outcome measures encourage us to design a randomized prospective clinical study to further confirm the efficiency of mEHT in this patient cohort.

Cost-effectiveness analysis of FOLFIRINOX vs gemcitabine with nab-paclitaxel as adjuvant treatment for resected pancreatic cancer in the United States based on PRODIGE-24 and APACT trials

BACKGROUND: Pancreatic cancer is associated with low median overall survival. Combination chemotherapy regimens FOLFIRINOX and gemcitabine with nab-paclitaxel (GemNab) are the new adjuvant treatment standards for resectable pancreatic cancer. PRODIGE-24 and APACT trials demonstrated superior clinical outcomes with FOLFIRINOX and GemNab, each vs gemcitabine monotherapy. OBJECTIVE: To evaluate the cost-effectiveness of FOLFIRINOX vs GemNab for resectable pancreatic cancer in adults from the U.S. payer perspective, in order to inform decision makers about which of these treatments is optimal. METHODS: A Markov model with 3 disease states (relapse free, progressive disease, and death) was developed. Cycle length was 1 month, and time horizon was 10 years. Transition probabilities were derived from PRODIGE-24 and APACT survival data. All cost and utility input parameters were obtained from published literature. Cost-effectiveness analysis was performed to obtain total costs, quality-adjusted life-years (QALYs), life-years (LYs), and incremental cost-effectiveness ratio (ICER). A 3% annual discount rate was applied to costs and outcomes. The effect of uncertainty on model parameters was assessed with 1-way and probabilistic sensitivity analysis (PSA). RESULTS: Our analysis estimated that the cost for FOLFIRINOX was $40,831 higher than GemNab ($99,669 vs. $58,837). Despite increased toxicity, FOLFIRINOX was associated with additional 0.18 QALYs and 0.25 LYs compared with GemNab (QALY: 1.65 vs. 1.47; LY: 2.09 vs. 1.84). The ICER for FOLFIRINOX vs GemNab was $226,841 per QALY and $163,325 per LY. FOLFIRINOX was not cost-effective at a willingness-to-pay (WTP) threshold of $200,000 per QALY, and this was confirmed by the PSA. CONCLUSIONS: Total monthly cost for FOLFIRINOX was approximately 1.7 times higher than GemNab. If the WTP threshold increases to or above $250,000 per QALY, FOLFIRINOX then becomes a cost-effective treatment option. DISCLOSURES: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors have no conflicts of interest to declare.

Neurolytic Splanchnic Nerve Block and Pain Relief, Survival, and Quality of Life in Unresectable Pancreatic Cancer: A Randomized Controlled Trial

BACKGROUND

Neurolytic splanchnic nerve block is used to manage pancreatic cancer pain. However, its impact on survival and quality of life remains controversial. The authors' primary hypothesis was that pain relief would be better with a nerve block. Secondarily, they hypothesized that analgesic use, survival, and quality of life might be affected.

METHODS

This randomized, double-blind, parallel-armed trial was conducted in five Chinese centers. Eligible patients suffering from moderate to severe pain conditions were randomly assigned to receive splanchnic nerve block with either absolute alcohol (neurolysis) or normal saline (control). The primary outcome was pain relief measured on a visual analogue scale. Opioid consumption, survival, quality of life, and adverse effects were also documented. Analgesics were managed using a protocol common to all centers. Patients were followed up for 8 months or until death.

RESULTS

Ninety-six patients (48 for each group) were included in the analysis. Pain relief with neurolysis was greater for the first 3 months (largest at the first month; mean difference, 0.7 [95% CI, 0.3 to 1.0]; adjusted P < 0.001) compared with placebo injection. Opioid consumption with neurolysis was lower for the first 5 months (largest at the first month; mean difference, 95.8 [95% CI, 67.4 to 124.1]; adjusted P < 0.001) compared with placebo injection. There was a significant difference in survival (hazard ratio, 1.56 [95% CI, 1.03 to 2.35]; P = 0.036) between groups. A significant reduction in survival in neurolysis was found for stage IV patients (hazard ratio, 1.94 [95% CI, 1.29 to 2.93]; P = 0.001), but not for stage III patients (hazard ratio, 1.08 [95% CI, 0.59 to 1.97]; P = 0.809). No differences in quality of life were observed.

CONCLUSIONS

Neurolytic splanchnic nerve block appears to be an effective option for controlling pain and reducing opioid requirements in patients with unresectable pancreatic cancer.

EDITOR’S PERSPECTIVE

Management problems in patients with pancreatic cancer from a surgeon's perspective

Pancreatic cancer is one of the most lethal gastrointestinal tumor entities. Surgery is the only chance for cure; however, only a minority of patients can be offered this option. Due to the anatomic location of the gland, tumor-related problems and complications affecting the surrounding structures are common, leading to biliary and gastric outlet obstruction as well as portal vein thrombosis. This review article summarizes the management of pancreatic cancer-related problems from a surgical point of view. We further describe surgical treatment options in unresectable, metastasized and recurring pancreatic cancer, highlighting potential resection of oligometastatic disease in selected settings.

Phase II clinical trial of nab-paclitaxel plus gemcitabine in elderly patients with previously untreated locally advanced or metastatic pancreatic adenocarcinoma: the BIBABRAX study

PURPOSE

To evaluate the health-related quality of life (HRQoL), global health status (GHS), and deterioration-free survival of an elderly population (> 70 years) with unresectable locally advanced (LAPC) or metastatic pancreatic cancer (mPC) treated with nab-paclitaxel in combination with gemcitabine.

METHODS

In this open-label, single-arm, multicenter, phase II trial, patients received 4-week cycles of intravenous (i.v.) nab-paclitaxel at a dose of 125 mg/m², followed by i.v. injections of gemcitabine at a dose of 1000 mg/m² on days 1, 8 and 15 until disease progression or unacceptable toxicity was observed. The primary outcome was the HRQoL (deterioration-free rate at 3 months as evaluated with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30.

RESULTS

Eighty patients (median age: 74.6 years) were enrolled (56 with mPC, 24 with LAPC). The percentage of patients who had not experienced deterioration at 3 months was 54.3% (95% CI 41.6-67.0%). The median (interquartile range) time until definite deterioration was 1.6 (1.1-3.7) months. The objective response rate and clinical benefit rate were achieved by 11 (13.8%, 95% CI 6.2-21.3%) and 54 patients (67.5%, 95% CI 57.2-77.8%), respectively. The median overall survival was 9.2 months (95% CI 6.9-11.5), and the median progression-free survival was 7.2 months (95% CI 5.8-8.5). Only fatigue and neutropenia demonstrated a grade 3-4 toxicity incidence > 20%.

CONCLUSIONS

Our study confirms the clinical benefit of the combination of nab-paclitaxel and gemcitabine in an elderly population with pancreatic cancer in terms of improved survival and clinical response. However, we were unable to confirm a benefit in terms of quality-of-life.

Nutritional assessment and surgical outcomes in very elderly patients undergoing pancreaticoduodenectomy: a retrospective study

PURPOSE

To evaluate and compare the nutritional factors and clinical outcomes of pancreaticoduodenectomy between elderly and non-elderly patients.

METHODS

This retrospective study evaluated 122 consecutive patients who underwent pancreaticoduodenectomy from April 2008 to April 2020. Preoperative and postoperative nutritional factors (prognostic nutritional index), complication rates, and survival rates were compared between the elderly (≥ 80 years) and non-elderly (< 80 years) patient groups. Changes in nutrition markers were evaluated before surgery to 1 year after surgery.

RESULTS

A total of 20 elderly patients (16.4%) and 102 non-elderly patients (83.6%) underwent pancreaticoduodenectomy. Elderly patients had a significantly lower preoperative prognostic nutritional index than did non-elderly patients. At 3 months postoperatively, elderly patients had a lower albumin level and prognostic nutritional index. The median length of hospital stay was significantly longer (39.9 vs. 27 days, P = 0.004), the rate of death due to other diseases was higher, and the overall survival rate was significantly lower (1-/3-/5 year overall survival rates: 78.1%/26.7%/13.3% vs. 87.1%/54.4%/46.7%; log-rank test, P = 0.003) in the elderly group than in the non-elderly group.

CONCLUSIONS

The results suggest that careful patient selection and optimal perioperative care are necessary to determine whether pancreaticoduodenectomy is indicated for elderly patients.

Quality of Life, Fatigue, and Sleep Problems in Pancreatic Cancer Patients—A Randomized Trial on the Effects of Exercise

BACKGROUND

Improving quality of life (QoL) is an important treatment goal in pancreatic cancer patients. Although the beneficial effects of exercise on QoL are well understood, few studies have investigated more aggressive cancers such as pancreatic cancer.

METHODS

Within a randomized trial, we assessed the efficacy of 6-month resistance training on physical functioning (primary outcome) and further QoL-related outcomes. 65 pancreatic cancer patients were assigned to home-based training, supervised training, or a usual care control group. Analysis-of-covariance models on changes from baseline to 6 and 3 months were ap- plied.

RESULTS

47 patients completed the intervention period. After 6 months, no effects of resistance training were observed. However, after 3 months, explorative analyses showed significant between-group mean differences (MD) in favor for resistance training for physical functioning (pooled group: MD=11.0; p=0.016; effect size[ES]=0.31), as well as for global QoL (MD=12.1; p=0.016; effect size=0.56), and other outcomes, such as sleep problems and fatigue. Multiple imputation analyses yielded similar results. Home-based and supervised training performed similarly.

CONCLUSION

This first randomized resistance training trial in pancreatic cancer patients indicated clinically relevant improve- ments in QoL after 3 but not after 6 months. Given the severity of pancreatic cancer, exercise recommendations may already commence at surgery.

Increased psychological symptom burden in patients with pancreatic cancer: A population-based cohort study

BACKGROUND/OBJECTIVE

To investigate the psychological symptom burden in patients with pancreatic cancer.

METHODS

We used Danish population-based registries to identify 10,793 pancreatic cancer patients and 109,238 age and gender matched cancer-free comparison persons between the years 2000-2016. The cohorts were followed up to five years for first prescription for antidepressants, anxiolytics or hypnotics as proxies for the psychological symptom burden of depression, anxiety or insomnia. Cumulated incidence proportions were analysed using the pseudo-value approach and hazards were estimated with Cox regression models adjusted for potential confounders.

RESULTS

The highest HR for first antidepressant use was seen in the first six months after diagnosis (HR 8.73 (95% CI: 7.57; 10.06)). Within the first two years the overall estimated cumulated probability of 12.9% (95% CI: 12%; 13.8%) in pancreatic cancer patients, and 4.6% (95% CI: 4.5%; 4.8%) in comparisons, and 20.4% and 31.4% patients received first prescription of anxiolytics or hypnotics, respectively. We found no difference in HRs of first antidepressant by gender, year of diagnosis, cohabitation, education or comorbidity in the patient cohort, however younger age (<59 years) was associated with depression.

CONCLUSIONS

Pancreatic cancer patients are at risk for first antidepressant, anxiolytic and hypnotic use up to five years after diagnosis. Patients younger than 59 years, newly diagnosed with advanced pancreatic cancer, and not treated with surgery were more likely to have first antidepressant use. The study calls for interventions to reduce the psychological burden in advanced pancreatic cancer patients which may improve quality of life and survival.

Population-Level Symptom Assessment Following Pancreaticoduodenectomy for Adenocarcinoma

Importance

Postoperative morbidity associated with pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA) remains as high as 70%. However, to our knowledge, few studies have examined quality of life in this patient population.

Objective

To identify symptom burden and trajectories and factors associated with high symptom burden following PD for PA.

Design, Setting, and Participants

This population-based cohort study of patients undergoing PD for PA diagnosed between 2009 and 2015 linked population-level administrative health care data to routinely prospectively collected Edmonton Symptom Assessment System (ESAS) scores from 2009 to 2015, with a data analysis undertaken in 2018.

Exposures

Baseline characteristics, including age, sex, income quintile, rurality, immigration status, and comorbidity burden, as well as treatment characteristics, including year of surgery and receipt of chemotherapy.

Main Outcome and Measures

The outcome of interest was moderate to severe symptoms (defined as ESAS ≥4) for anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and impaired well-being. The monthly prevalence of moderate to severe symptoms was presented graphically for each symptom. Multivariable regression models identified factors associated with the reporting of moderate to severe symptoms.

Results

We analyzed 6058 individual symptom assessments among 615 patients with PA who underwent resection (285 women [46.3%]) with ESAS data. Tiredness (443 [72%]), impaired well-being (418 [68%]), and lack of appetite (400 [65%]) were most commonly reported as moderate to severe. The proportion of patients with moderate to severe symptoms was highest immediately after surgery (range, 14%-66% per symptom) and decreased over time, stabilizing around 3 months (range, 8%-42% per symptom). Female sex, higher comorbidity, and lower income were associated with a higher risk of reporting moderate to severe symptoms. Receipt of adjuvant chemotherapy was not associated with the risk of moderate to severe symptoms.

Conclusions and Relevance

There is a high prevalence of symptoms following PD for PA, with improvement over the first 3 months following surgery. In what to our knowledge is the largest cohort reporting on symptom burden for this population, we have identified factors associated with symptom severity. These findings will aid in managing patients' perioperative expectations and designing strategies to improve targeted symptom management.

Impact of Patient Age on Morbidity and Survival Following Laparoscopic Pancreaticoduodenectomy

PURPOSES

To present preliminary perioperative and long-term outcomes in elderly patients compared with younger patients who underwent laparoscopic pancreaticoduodenectomy (LPD).

MATERIALS AND METHODS

A total of 199 patients who underwent LPD were included in this study. The primary data relating to these patients were collected and analyzed in our center from October 2010 to 2017.

RESULTS

The intraoperative and postoperative information, including the rate and severity of short-term complications, pathologic outcomes, and other surgical outcomes, showed no significant differences between the 2 groups. Furthermore, the median overall survival for 2 malignant diseases of the young patients was not significantly better than the elderly.

CONCLUSIONS

Our data suggest that patient age showed little influence on postoperative morbidity, mortality, and long-term survival in pancreatic adenocarcinoma and periampullary adenocarcinoma following LPD, whereas studies with larger sample sizes and longer follow-up are necessary before definitive conclusions can be made.

An update on treatment options for pancreatic adenocarcinoma

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.

Health-related quality of life and medical comorbidities in older patients with pancreatic adenocarcinoma: An analysis using the 1998-2011 surveillance, epidemiology, and end results-medicare health outcomes survey data

OBJECTIVES

This study compares health-related quality of life (HRQoL) of older patients with pancreatic ductal adenocarcinoma (PDAC) to controls without cancer, and examines the impact of medical comorbidities on HRQoL.

MATERIALS AND METHODS

We conducted a case-control study using the 1998-2011 Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey (SEER-MHOS) linked dataset. Cases were Medicare beneficiaries aged 65 and older diagnosed with PDAC (N = 128) and matched controls were without a history of cancer (N = 512). We used the Short Form 36 (SF-36) and Veterans-RAND-12 (VR-12) to examine HRQoL and calculated mental (MCS) and physical (PCS) component scores. Linear regression and mixed effects models were used to examine the impact of medical comorbidities on MCS and PCS for cases and controls, respectively.

RESULTS

Cases reported significantly poorer PCS (29.3 vs. 36.3) and MCS (44.8 vs. 49.9) compared to controls. Comorbidities were significantly associated with lower PCS and MCS in controls. However, neither total number of comorbidities or comorbidities grouped by organ systems (cardiopulmonary disease, musculoskeletal disease, diabetes) were significantly related to PCS or MCS for cases. Comparison of regression coefficients estimates did not indicate that lack of significance was due to differences in sample size.

CONCLUSIONS

The results of this study highlight the poor HRQoL reported by older patients with PDAC. HRQoL scores were very low in this population, particularly in physical health status, which were not explained by comorbidities.

Survival, Complications and Patient Reported Outcomes after Pancreatic Surgery

BACKGROUND

Long-term effects of complications in pancreatic surgery have not been systematically evaluated. The objectives were to assess potential effects of complications on survival and patient reported outcomes (PROs) as well as feasibility of PRO questionnaires in patients with periampullary and pancreatic tumors.

METHODS

From October 2008 to December 2011, 208 patients undergoing pancreatic surgery were included in a prospective observational study. ESAS, EORTC QLQ-C30 and QLQ-PAN26 questionnaires were completed at inclusion, then every third month. Complications were recorded according to the Clavien-Dindo (CD) classification and Comprehensive Complication Index (CCI).

RESULTS

148 complications were registered in 100 patients (48%), 36 patients (17%) had CD IIIa or above. 125 patients (60%) completed baseline questionnaires, 80 (39%) responded after three and 54 (28%) after six months. Complications were associated with reduced long-term survival in patients with pancreatic ductal adenocarcinoma (PDAC) (p = 0.049) and other malignant diseases. No significant relationship was found between complications and PROs, except for anxiety, which was significantly increased in patients with complications.

CONCLUSION

Postoperative complications led to increased anxiety at 3 months after surgery and were associated with reduced long-term survival in patients with malignancy. A short, patient derived, disease specific questionnaire is required in the clinical research context.

Performance of a Multidisciplinary Pancreatic Cancer Conference in Predicting and Managing Resectable Pancreatic Cancer

OBJECTIVES

Surgery is the curative treatment for pancreatic ductal adenocarcinoma (PDA). Guidelines recommend utilizing a multidisciplinary pancreatic cancer conference (MDPC) in treatment; however, data are limited. The objective of this study was to assess the accuracy of an MDPC.

METHODS

Patients with PDA presented at an MDPC were prospectively collected from April 2013 to August 2016. Patients were included if the MDPC predicted them to have resectable PDA and underwent upfront surgery. Secondary aims were to compare differences in tumor characteristics, time to surgery, and resection rates with patients prior to MDPC implementation (pre-MDPC).

RESULTS

A total of 278 patients were presented at the MDPC. After excluding borderline and nonresectable cases, 91 patients were predicted as resectable on evaluation, and 70 were fit for surgery. The MDPC predicted resection in 91.4%. The MDPC had larger tumor size (32.6 vs 24.0 mm), greater proportion of stage II tumor, and a shorter time from diagnosis to resection (27.3 vs 35.5 days) compared with the pre-MDPC. Microscopically negative resections were similar between MDPC and pre-MDPC (85.9% vs 88.0%) despite advanced tumor size and stage.

CONCLUSIONS

The MDPC demonstrates a high resection rate. Compared with a pre-MDPC, MDPC provides shorter time to surgery and selects for advanced tumors.

Five-Fraction Stereotactic Body Radiation Therapy (SBRT) and Chemotherapy for the Local Management of Metastatic Pancreatic Cancer

BACKGROUND

The majority of patients with pancreatic cancer are diagnosed with metastatic disease at presentation. Nevertheless, local progression is responsible for up to 30% of deaths and can lead to significant morbidity. As a consequence, further exploration of effective methods of local control and palliation is essential. Stereotactic body radiation therapy (SBRT) is a widely utilized technique for the treatment of localized pancreatic cancer. Here, we report our experience with SBRT and chemotherapy for the local treatment of the metastatic patient population.

METHODS

This single institution retrospective review analyzed 20 patients with pathologically diagnosed metastatic adenocarcinoma of the pancreas. All patients underwent fiducial placement under endoscopic ultrasound (EUS) guidance. SBRT was delivered in five fractions to a total dose of 25 to 30 Gy. Patients received concurrent (given within 1 week of the start of SBRT) or sequential chemotherapy. Local tumor control was evaluated using Response Evaluation Criteria in Solid Tumors. Toxicity was graded using Common Terminology Criteria for Adverse Events version 4.03. Local control and overall survival were reported using the Kaplan-Meier method.

RESULTS

Patient median age was 64 years, and the median pre-treatment Eastern Cooperative Oncology Group performance status was 1. All patients received chemotherapy and half of the patients (10 of 20) received concurrent chemotherapy with folinic acid, fluorouracil, and oxaliplatin or fluorouracil, leucovorin, irinotecan, and oxaliplatin. Nearly all patients (19 of 20) received post-SBRT chemotherapy. Median time from pathological diagnosis to SBRT was 3.9 months. The twelve-month local control and overall survival were 43 and 53%, respectively. However, in patients with planning target volume (PTV) targets smaller than the population median, the 12-month local control was 78%. Median time to local progression (17.8 vs. 3.0 months, p = 0.02) and overall survival (24.9 vs. 8.8, p = 0.001) were also significantly improved in this smaller PTV cohort. Though not statistically significant, there was a trend towards improvement in local control (17.8 vs. 4.3 months, p = 0.17) and overall survival (16.7 vs. 9.7 months, p = 0.087) for those who received concurrent versus sequential chemotherapy, respectively. Lastly, there were no reported grade 3-5 late toxicities.

CONCLUSIONS

As systemic therapies improve, the local management of pancreatic cancer will become increasingly important. Here, we report significantly improved local control with SBRT of smaller PTV tumors with concurrent chemotherapy. Five-fraction SBRT offers a quick and effective modality of local tumor control with minimal toxicity in the metastatic pancreatic cancer population.

Symptom Clusters in Patients With Pancreatic Cancer Undergoing Surgical Resection: Part I

OBJECTIVES

To describe patient-reported symptoms and symptom clusters in patients with pancreatic cancer (PC) undergoing surgical resection.

SAMPLE & SETTING

143 patients with stage II PC undergoing surgical resection alone or with subsequent adjuvant chemoradiation or chemotherapy were recruited to participate in a nested, longitudinal, exploratory study through convenience sampling techniques from Thomas Jefferson University Hospital, a National Cancer Institute-designated cancer center.

METHODS & VARIABLES

The Functional Assessment in Cancer Therapy-Hepatobiliary questionnaire was used to assess 17 PC symptoms preoperatively and at three, six, and nine months postoperatively. Exploratory and confirmatory factor analyses were used to identify symptom clusters.

RESULTS

Fatigue, trouble sleeping, poor appetite, trouble digesting food, and weight loss were consistently reported as the most prevalent and severe symptoms. Sixteen distinct symptom clusters were identified within nine months of surgery. Four core symptom clusters persisted over time.

IMPLICATIONS FOR NURSING

Findings may be used to provide anticipatory patient and family guidance and to inform clinical assessments of symptoms and symptom clusters in this population.

Quality of Life in Patients With Pancreatic Cancer and Their Caregivers: A Systematic Review

Little is known about quality of life (QOL) of patients with pancreatic cancer and their caregivers compared with adults with other cancers. This systematic review summarizes the available evidence base, identifies its limitations, and recommends directions for research and clinical application. A systematic review was conducted of research on QOL in adults with pancreatic cancer and their caregivers. Quality of life was examined in the following specific domains: psychological, physical, social, sexual, spiritual, and general. Of the 7130 articles reviewed, 36 studies met criteria for inclusion. Compared with healthy adults or population norms, adults with pancreatic cancer had worse QOL across all domains. Compared with patients with other cancer types, patients with pancreatic cancer evidenced worse psychological QOL. Physical and social QOL were either similar or more compromised than in patients with other cancers. Limited data preclude conclusions about sexual, spiritual, and caregiver QOL. Patients with pancreatic cancer evidence decrements in multiple QOL domains, with particular strain on psychological well-being. Methodological limitations of available studies restrict definitive conclusions. Future research with well-defined samples, appropriate statistical analyses, and longitudinal designs is needed. Findings from this review support the merits of distress screening, integration of mental health professionals into medical teams, and attention to caregiver burden.

Determinants and prognostic value of quality of life in patients with pancreatic ductal adenocarcinoma

BACKGROUND

Quality of life (QOL) is impaired in pancreatic cancer patients. Our aim was to investigate the determinants and prognostic value of QOL after diagnosis in a hospital-based cohort of racially/ethnically diverse patients with pancreatic ductal adenocarcinoma (PDAC).

PATIENTS AND METHODS

QOL was prospectively assessed using the Short Form-12 in 2478 PDAC patients. The Physical Component Summary (PCS) and Mental Component Summary (MCS) were categorised into tertiles based on their distribution. Ordered logistic regression was adopted to compare the risk of having lower PCS and MCS by patient sociodemographic and clinical characteristics. The association of PCS and MCS with mortality was assessed by Cox regression.

RESULTS

Compared with non-Hispanic whites, Hispanics were at significantly higher risk of having lower PCS (odds ratio [95% CI], 1.69 [1.26-2.26]; P < 0.001) and lower MCS (1.66 [1.24-2.23]; P < 0.001). Patients diagnosed with stage III (1.80 [1.10-2.94]; P = 0.02) and stage IV (2.32 [1.50-3.59]; P < 0.001) PDAC were more likely to have lower PCS than stage I patients. Other determinants of QOL included sex, age, drinking, smoking, education level, comorbidities and time since diagnosis. The low tertile of PCS (hazard ratio [95% CI], 1.94 [1.72-2.18]; P < 0.001) and MCS (1.42 [1.26-1.59]; P < 0.001) were each related to poor prognosis. Similar results were found for non-Hispanic whites as compared with African-Americans/Hispanics/others.

CONCLUSION

QOL after diagnosis is a significant prognostic indicator for patients with PDAC. Multiple factors determine QOL, suggesting possible means of intervention to improve QOL and outcomes of PDAC patients.

The outcomes of pancreaticoduodenectomy in patients aged 80 or older: a systematic review and meta-analysis

BACKGROUND

There is an increasing needed to consider pancreaticoduodenectomy (PD) for the treatment of pancreatic and periampullary malignancy in patients aged 80 and over, given the increasing aging population.

METHODS

A systematic literature search was undertaken to identify selected studies that compared the outcomes of patients aged 80 years or over to those younger undergoing PD.

RESULTS

In total 18 studies were included for evaluation. Octogenarian or older populations had significantly higher 30-day post-operative mortality rate (OR: 2.22, 95% CI = 1.48-3.31, p < 0.001) and length of hospital stay (OR: 2.23, 95% CI = 1.36-3.10, p < 0.001). The overall post-operative complication rate was higher in the older group compared to the younger population (OR: 1.51, 95% CI = 1.25-1.83, p < 0.001). Elderly patients were more likely to develop pneumonia (OR: 1.72, 95% CI = 1.39-2.13, p < 0.001) and experience delayed gastric emptying (DGE) (OR: 1.77, 95% CI = 1.35-2.31, p < 0.001). The incidence of post-operative pancreatic fistula and bile leak were not significantly different between the groups. Rehabilitation and home nursing care services was also more frequently required by the older patient group at the time of hospital discharge.

CONCLUSION

Patients aged 80 years and older have approximately double the risk of 30-day post-operative mortality and 50% increased rate of complications following PD. Careful patient selection is required when offering surgery in this age group.

Palliative Care for Pancreatic and Periampullary Cancer

Most patients with pancreatic cancer will present with metastatic or locally advanced disease. Unfortunately, most patients with localized disease will experience recurrence even after multimodality therapy. As such, pancreatic cancer patients arrive at a common endpoint where decisions pertaining to palliative care come to the forefront. This article summarizes surgical, endoscopic, and other palliative techniques for relief of obstructive jaundice, relief of duodenal or gastric outlet obstruction, and relief of pain due to invasion of the celiac plexus. It also introduces the utility of the palliative care triangle in clarifying a patient's and family's goals to guide decision making.

Anxiety, depression and quality of life in people with pancreatic cancer and their carers

BACKGROUND

People with pancreatic cancer have high levels of anxiety and depression and reduced quality of life (QoL), but few studies have assessed these outcomes for patient-carer dyads. We therefore investigated these issues in an Australian population-based study.

METHODS

Patients with pancreatic cancer (n = 136) and many of their carers (n = 84) completed the Hospital Anxiety and Depression Scale (HADS) and Functional Assessment of Cancer Therapy QoL questionnaire at a median of three months after diagnosis. Overall QoL and well-being subscales (physical, social, emotional, functional) were compared with general population norms. Intraclass correlation coefficients were used to compare anxiety, depression and QoL scores of patients and their respective carers.

RESULTS

Fifteen percent of patients and 39% of carers had HADS scores indicative of anxiety and 15% of patients and 14% of carers of depression, respectively. Overall, 70% of patients and 58% of carers had QoL scores below the Queensland population average. Patients' anxiety, depression, overall QoL, social, emotional and functional wellbeing scores were significantly related to those scores in their carers. Among patients and carers, accessing psychological help was associated with elevated anxiety. Not receiving chemotherapy was associated with elevated depression among patients and younger age was associated with poorer outcomes in carers.

CONCLUSIONS

More carers had symptoms of anxiety than patients with pancreatic cancer, but symptoms of depression were similarly common in patients and carers. Further research is needed to assess whether interventions to reduce patients' distress could also improve QoL among carers, or whether carer-focussed interventions are required.

Cancer survivorship: long-term side-effects of anticancer treatments of gastrointestinal cancer

PURPOSE OF REVIEW

Surveillance of patients with a history of cancer is a frequent practice in oncology. However, it is often aimed at the early diagnosis of relapse and tends to underestimate the evaluation and care of factors impairing quality of life (QoL). Among these, long-term toxicities of anticancer treatments are one of the major threats to a complete physical and psychosocial recovery. We aimed to review the relevant literature on long-term side-effects of treatment in gastrointestinal cancers.

RECENT FINDINGS

We focused on esophageal, gastric, pancreatic, liver and colorectal cancers. A significant fraction of patients treated for these cancers suffer with some form of late toxicity from surgery, radiotherapy or chemotherapy. Prompt evaluation and management is of the utmost importance in reducing the impact of these symptoms on QoL.

SUMMARY

The knowledge of the reviewed data should encourage a multidisciplinary approach to surveillance and convince clinicians of the comprehensive role of survivorship care.

Health-Related Quality of Life After Pancreatectomy: Results From a Randomized Controlled Trial

BACKGROUND

A recent prospective randomized trial demonstrated that prophylactic pasireotide reduces the incidence of pancreatic complications (PC) after resection. This secondary analysis aimed to describe quality of life (QoL) before and after resection, to characterize the impact of PC on QoL, and to assess whether pasireotide improves QoL.

METHODS

A randomized, double-blind, placebo-controlled trial of preoperative pasireotide in patients undergoing pancreatectomy was conducted. Participants completed the European Organization for Research and Treatment of Cancer (EORTC) C30 and PAN26 modules preoperatively and on postoperative days 14 and 60. Scores were compared using t tests. The percentage of patients with clinically important worsening (a decline ≥0.5 times the baseline standard deviation) was reported.

RESULTS

All questionnaires were completed by 87 % (260/300) of the patients. No major differences were observed between the pasireotide and placebo groups. Therefore, the data were pooled for further analyses. A significant worsening of function at 14 days was detected on all the PAN26 and C30 function scales except hepatic and emotional functioning (EF), and on all the C30 symptom scales. More than 75 % of the patients experienced clinically important worsening of fatigue, pain, and role functioning. Most effects persisted at 60 days, with the 60-day EF significantly better than at baseline (p = 0.03). PC were associated with worse outcomes on most function scales.

CONCLUSIONS

During the 14 days after resection, patients can be expected to have a significant decline in QoL. Many symptoms abate by 60 days, and EF improves. PC were associated with impaired QoL in several domains. Although pasireotide effectively reduced PC, its effect did not appear to translate to improved QoL in this sample of 300 patients.

Diagnostic laparoscopy should be performed before definitive resection for pancreatic cancer: a financial argument

OBJECTIVES

Laparoscopy is recommended to detect radiographically occult metastases in patients with pancreatic cancer before curative resection. This study was conducted to test the hypothesis that diagnostic laparoscopy (DL) is cost-effective in patients undergoing curative resection with or without neoadjuvant therapy (NAT).

METHODS

Decision tree modelling compared routine DL with exploratory laparotomy (ExLap) at the time of curative resection in resectable cancer treated with surgery first, (SF) and borderline resectable cancer treated with NAT. Costs (US$) from the payer's perspective, quality-adjusted life months (QALMs) and incremental cost-effectiveness ratios (ICERs) were calculated. Base case estimates and multi-way sensitivity analyses were performed. Willingness to pay (WtP) was US$4166/QALM (or US$50,000/quality-adjusted life year).

RESULTS

Base case costs were US$34,921 for ExLap and US$33,442 for DL in SF patients, and US$39,633 for ExLap and US$39,713 for DL in NAT patients. Routine DL is the dominant (preferred) strategy in both treatment types: it allows for cost reductions of US$10,695/QALM in SF and US$4158/QALM in NAT patients.

CONCLUSIONS

The present analysis supports the cost-effectiveness of routine DL before curative resection in pancreatic cancer patients treated with either SF or NAT.

Correlation of clinical stage and performance status with quality of life in patients seen in a pancreas multidisciplinary clinic

INTRODUCTION

The objectives of this study were to evaluate quality of life (QoL) in patients presenting to the Johns Hopkins Pancreas Multidisciplinary Clinic (PMDC), and to examine associations between disease status, performance status, and QoL in order to identify patient subgroups that are most at risk for reduced QoL.

PATIENTS AND METHODS

Data from 77 patients were evaluated. At initial presentation, disease and performance status were assessed, as well as QoL, which was obtained with the European Organisation for Research and Treatment of Cancer QLQ-PAN26 questionnaire. Statistical analyses examined associations between QoL, disease status, and performance status.

RESULTS

Digestive symptoms (P < .003) significantly differed by pancreatic disease status (resectable, resected, locally advanced, and metastatic). Patients with a worse performance status, defined as Eastern Cooperative Oncology Group ≥ 1, were more likely to report symptomatic pancreatic pain (P = .001), digestive symptoms (P = .017), cachexia (P = .004), and ascites (P < .001) compared with patients with a performance status of 0. The majority (92%) of patients reported a significant fear of future health problems, regardless of disease status or performance status.

CONCLUSION

Although several measures of QoL have been observed in all patients, certain measures appear to correlate specifically with worse disease status. Therefore, routine assessment of QoL is suggested in order to guide treatment decisions. Further investigation on optimizing the use of QoL measures and patient-reported outcomes to better tailor management is warranted.

Cost-effectiveness of the evaluation of a suspicious biliary stricture

BACKGROUND

Biliary stricture without mass presents diagnostic and therapeutic challenges because the poor sensitivity of the available tests and significant mortality and cost with operation.

METHODS

A decision model was developed to analyze costs and survival for 1) investigation first with endoscopic ultrasound (EUS) and fine needle aspiration, 2) investigation first with endoscopic retrograde cholangiopancreatography (ERCP) and brushing, or 3) surgery on every patient. The average age of someone with a biliary stricture was found to be 62-y-old and the rate of cancer was 55%. Incremental cost-effectiveness ratios (ICER) were calculated based on the change in quality adjusted life years (QALYs) and costs (US$) between the different options, with a threshold of $150,000 to determine the most cost-effective strategy. One-way, two-way, and probabilistic-sensitivity analysis were performed to validate the model.

RESULTS

ERCP results in 9.05 QALYs and a cost of $34,685.11 for a cost-effectiveness ratio of $3832.33. EUS results in an incremental increase in 0.13 QALYs and $2773.69 for an ICER of $20,840.28 per QALY gained. Surgery resulted in a decrease of 1.37 QALYs and increased cost of $14,323.94 (ICER-$10,490.53). These trends remained within most sensitivity analyses; however, ERCP and EUS were dependent on the test sensitivity.

CONCLUSIONS

In patients with a biliary stricture with no mass, the most cost-effective strategy is to investigate the patient before operation. The choice between EUS and ERCP should be institutionally dependent, with EUS being more cost-effective in our base case analysis.

A prospective, randomized, double-blind, placebo controlled trial on the efficacy of ethanol celiac plexus neurolysis in patients with operable pancreatic and periampullary adenocarcinoma

Background

Ethanol celiac plexus neurolysis (ECPN) has been shown to be effective in reducing cancer-related pain in patients with locally advanced pancreatic and periampullary adenocarcinoma (PPA). This study examined its efficacy in patients undergoing PPA resection.

Study Design

485 patients participated in this prospective, randomized, double blind placebo controlled trial. Patients were stratified by preoperative pain and disease resectability. They received either ECPN (50% ethanol) or 0.9% normal saline placebo control. The primary endpoint was short and long-term pain and secondary endpoints included postoperative morbidity, QOL and overall survival.

Results

Data from 467 patients were analyzed. The primary endpoint, the percentage of PPA patients experiencing a worsening of pain compared to preoperative baseline for resectable patients, was not different between the ethanol and saline groups in either the resectable/pain stratum (22% vs 18%, RR 1.23 (0.34, 4.46)), or the resectable/no pain stratum (37% vs 34%, RR 1.10 (0.67, 1.81)). On multivariable analysis of resected pancreatic ductal adenocarcinoma (PDA) patients, there was a significant reduction in pain in the resectable/pain group, suggesting that surgical resection of the malignancy alone (independent of ECPN) decrements pain to a significant degree.

Conclusions

In this study, we have demonstrated a significant reduction in pain following surgical resection of PPA. However the addition of ECPN did not synergize to result in a further reduction in pain, and in fact its effect may have been masked by surgical resection. Given this, we cannot recommend the use of ECPN to mitigate cancer related pain in resectable PPA patients.

Health-related quality of life in older adult survivors of selected cancers: data from the SEER-MHOS linkage

BACKGROUND

Research on health-related quality of life (HRQOL) among older adult cancer survivors is mostly confined to breast cancer, prostate cancer, colorectal cancer, and lung cancer, which account for 63% of all prevalent cancers. Much less is known about HRQOL in the context of less common cancer sites.

METHODS

HRQOL was examined with the 36-Item Short Form Health Survey, version 1, and the Veterans RAND 12-Item Health Survey in patients with selected cancers (kidney cancer, bladder cancer, pancreatic cancer, upper gastrointestinal cancer, cancer of the oral cavity and pharynx, uterine cancer, cervical cancer, thyroid cancer, melanoma, chronic leukemia, non-Hodgkin lymphoma, and multiple myeloma) and in individuals without cancer on the basis of data linked from the Surveillance, Epidemiology, and End Results cancer registry system and the Medicare Health Outcomes Survey. Scale scores, Physical Component Summary (PCS) and Mental Component Summary (MCS) scores, and a utility metric (Short Form 6D/Veterans RAND 6D), adjusted for sociodemographic characteristics and other chronic conditions, were calculated. A 3-point difference in the scale scores and a 2-point difference in the PCS and MCS scores were considered to be minimally important differences.

RESULTS

Data from 16,095 cancer survivors and 1,224,549 individuals without a history of cancer were included. The results indicated noteworthy deficits in physical health status. Mental health was comparable, although scores for the Role-Emotional and Social Functioning scales were worse for patients with most types of cancer versus those without cancer. Survivors of multiple myeloma and pancreatic malignancies reported the lowest scores, with their PCS/MCS scores less than those of individuals without cancer by 3 or more points.

CONCLUSIONS

HRQOL surveillance efforts revealed poor health outcomes among many older adults and specifically among survivors of multiple myeloma and pancreatic cancer.