1
|
Eaglehouse YL, Darmon S, Gage MM, Shriver CD, Zhu K. Characteristics Associated With Survival in Surgically Nonresected Pancreatic Adenocarcinoma in the Military Health System. Am J Clin Oncol 2024; 47:64-70. [PMID: 37851358 PMCID: PMC10805355 DOI: 10.1097/coc.0000000000001057] [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] [Indexed: 10/19/2023]
Abstract
OBJECTIVES Pancreatic cancer is often diagnosed at advanced stages with high-case fatality. Many tumors are not surgically resectable. We aimed to identify features associated with survival in patients with surgically nonresected pancreatic cancer in the Military Health System. METHODS We used the Military Cancer Epidemiology database to identify the Department of Defense beneficiaries aged 18 and older diagnosed with a primary pancreatic adenocarcinoma between January 1998 and December 2014 who did not receive oncologic surgery as treatment. We used Cox Proportional Hazard regression with stepwise procedures to select the sociodemographic and clinical characteristics related to 2-year overall survival, expressed as adjusted hazard ratios (aHR) and 95% CIs. RESULTS Among 1148 patients with surgically nonresected pancreatic cancer, sex, race-ethnicity, marital status, and socioeconomic indicators were not selected in association with survival. A higher comorbidity count (aHR 1.30, 95% CI: 1.06-1.59 for 5 vs. 0), jaundice at diagnosis (aHR 1.57, 95% CI: 1.33-1.85 vs. no), tumor grade G3 or G4 (aHR 1.32, 95% CI: 1.05-1.67 vs. G1/G2), tumor location in pancreas tail (aHR 1.49, 95% CI: 1.22-1.83 vs. head) or body (aHR 1.30, 95% CI: 1.04-1.62 vs. head), and metastases were associated with survival. Patients receiving chemotherapy (aHR 0.66, 95% CI: 0.57-0.76) had better survival compared with no treatment. CONCLUSIONS In a comprehensive health system, sociodemographic characteristics were not related to survival in surgically nonresected pancreatic cancer. This implicates access to care in reducing survival disparities in advanced pancreatic cancer and emphasizes the importance of treating patients based on clinical features.
Collapse
Affiliation(s)
- Yvonne L. Eaglehouse
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc
| | - Sarah Darmon
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc
| | - Michele M. Gage
- Departments of Surgery
- Division of Surgical Oncology, Walter Reed National Military Medical Center, Bethesda, MD
| | - Craig D. Shriver
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences
- Departments of Surgery
| | - Kangmin Zhu
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc
- Preventive Medicine & Biostatistics, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences
| |
Collapse
|
2
|
Mehtsun WT, McCleary NJ, Maduekwe UN, Wolpin BM, Schrag D, Wang J. Patterns of Adjuvant Chemotherapy Use and Association With Survival in Adults 80 Years and Older With Pancreatic Adenocarcinoma. JAMA Oncol 2022; 8:88-95. [PMID: 34854874 PMCID: PMC8640950 DOI: 10.1001/jamaoncol.2021.5407] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Patients 80 years and older with pancreatic ductal adenocarcinoma (PDAC) have not consistently received treatments that have established benefits in younger older adults (aged 60-79 years), yet patients 80 years and older are increasingly being offered surgery. Whether adjuvant chemotherapy (AC) provides additional benefit among patients 80 years and older with PDAC following surgery is not well understood. OBJECTIVE To describe patterns of AC use in patients 80 years and older following surgical resection of PDAC and to compare overall survival between patients who received AC and those who did not. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study among patients 80 years or older diagnosed with PDAC (stage I-III) between 2004 to 2016 who underwent a pancreaticoduodenectomy at hospitals across the US reporting to the National Cancer Database. EXPOSURES AC vs no AC 90 days following diagnosis of PDAC. MAIN OUTCOMES AND MEASURES The proportion of patients who received AC was assessed over the study period. Overall survival was compared between patients who received AC and those who did not using Kaplan-Meier estimates and multivariable Cox proportional hazards regression. A landmark analysis was performed to address immortal time bias. A propensity score analysis was performed to address indication bias. Subgroup analyses were conducted in node-negative, margin-negative, clinically complex, node-positive, and margin-positive cohorts. RESULTS Between 2004 and 2016, 2569 patients 80 years and older (median [IQR] age, 82 [81-84] years; 1427 were women [55.5%]) underwent surgery for PDAC. Of these patients, 1217 (47.4%) received AC. Findings showed an 18.6% (95% CI, 8.0%-29.0%; P = .001) absolute increase in the use of AC among older adults who underwent a pancreaticoduodenectomy comparing rates in 2004 vs 2016. Receipt of AC was associated with a longer median survival (17.2 months; 95% CI, 16.1-19.0) compared with those who did not receive AC (12.7 months; 95% CI, 11.8-13.6). This association was consistent in propensity and subgroup analyses. In multivariable analysis, receipt of AC (hazard ratio [HR], 0.72; 95% CI, 0.65-0.79; P < .001), female sex (HR, 0.88; 95% CI, 0.80-0.96; P < .001), and surgery in the more recent time period (≥2011) (HR, 0.90; 95% CI, 0.82-0.99; P = .02) were associated with a decreased hazard of death. An increased hazard of death was associated with higher pathologic stage (stage II: HR, 1.68; 95% CI, 1.43-1.97; P < .001; stage III: HR, 2.39; 95% CI, 1.88-3.04; P < .001), positive surgical margins (HR, 1.49; 95% CI, 1.34-1.65; P < .001), length of stay greater than median (10 days) (HR, 1.17; 95% CI, 1.07-1.28; P < .001), and receipt of oncologic care at a nonacademic facilities (Community Cancer Program: HR, 1.20; 95% CI, 1.07-1.35; P < .001; Integrated Network Cancer Program: HR, 1.25; 95% CI, 1.07-1.46; P < .001). CONCLUSIONS AND RELEVANCE In this cohort study, the use of AC among patients who underwent resection for PDAC increased over the study period, yet it still was administered to fewer than 50% of patients. Receipt of AC was associated with a longer median survival.
Collapse
Affiliation(s)
- Winta T. Mehtsun
- Division of Surgical Oncology, Department of Surgery, University of California San Diego
| | - Nadine J. McCleary
- Department of Medical Oncology, Gastrointestinal Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ugwuji N. Maduekwe
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill
| | - Brian M. Wolpin
- Department of Medical Oncology, Gastrointestinal Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Deborah Schrag
- Department of Medical Oncology, Gastrointestinal Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jiping Wang
- Division of Surgical Oncology, Department of Surgery, Dana-Farber Cancer Institute, Mass General Brigham, Boston, Massachusetts
| |
Collapse
|
3
|
Vela N, Davis LE, Cheng SY, Hammad A, Liu Y, Kagedan DJ, Paszat L, Bubis LD, Earle CC, Myrehaug S, Mahar AL, Mittmann N, Coburn NG. Economic Analysis of Adjuvant Chemoradiotherapy Compared with Chemotherapy in Resected Pancreas Cancer. Ann Surg Oncol 2019; 26:4193-4203. [PMID: 31535303 DOI: 10.1245/s10434-019-07808-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Population-based survival and costs of pancreas adenocarcinoma patients receiving adjuvant chemoradiation and chemotherapy following pancreaticoduodenectomy are poorly understood. METHODS This retrospective cohort study used linked administrative and pathological datasets to identify all patients diagnosed with pancreas adenocarcinoma and undergoing pancreaticoduodenectomy in Ontario between April 2004 and March 2014, who received postoperative chemoradiation or chemotherapy. Stage and margin status were defined by using pathology reports. Kaplan-Meier and Cox proportional hazards regression survival analyses were used to determine associations between adjuvant treatment approach and survival, while stratifying by margin status. Median overall health system costs were calculated at 1 and 3 years for chemoradiation and chemotherapy, and differences were tested using the Kruskal-Wallis test. RESULTS Among 709 patients undergoing pancreaticoduodenectomy for pancreas cancer during the study period, the median survival was 21 months. Median survival was 19 months for chemoradiation and 22 months for chemotherapy. Patients receiving chemoradiation were more likely to have positive margins: 47.7% compared with 19.2% in chemotherapy. After stratifying by margin status and controlling for confounders, adjusted hazard ratio of death were not statistically different between chemotherapy and chemoradiation [margin positive, hazard ratio (HR) = 0.99, 95% confidence interval (CI) = 0.88-1.27; margin negative, HR 0.95, 95% CI 0.91-1.18]. Overall 1-year health system costs were significantly higher for chemoradiation (USD $70,047) than chemotherapy (USD $54,005) (p ≤ 0.001). CONCLUSIONS Chemotherapy and chemoradiation yielded similar survival, but chemoradiation resulted in higher costs. To create more sustainable healthcare systems, both the efficacy and costs of therapies should be considered.
Collapse
Affiliation(s)
- Nivethan Vela
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Laura E Davis
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Ahmed Hammad
- Department of General Surgery, Mansoura University Hospitals, Mansoura, Egypt
| | - Ying Liu
- Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada
| | - Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Lawrence Paszat
- Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada.,Division of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Lev D Bubis
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Craig C Earle
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada.,Division of Medical Oncology and Hematology, Odette Cancer Centre, Sunnybrook Health Sciences, Toronto, ON, Canada
| | - Sten Myrehaug
- Division of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Alyson L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Nicole Mittmann
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada
| | - Natalie G Coburn
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. .,Institute for Clinical and Evaluative Sciences, Toronto, ON, Canada. .,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | | |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Davis LE, Bubis LD, Mahar AL, Li Q, Sussman J, Moody L, Barbera L, Holloway CMB, Coburn NG. Patient-reported symptoms after breast cancer diagnosis and treatment: A retrospective cohort study. Eur J Cancer 2018; 101:1-11. [DOI: 10.1016/j.ejca.2018.06.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 05/28/2018] [Accepted: 06/05/2018] [Indexed: 12/20/2022]
|
6
|
Bauman MD, Becerra DG, Kilbane EM, Zyromski NJ, Schmidt CM, Pitt HA, Nakeeb A, House MG, Ceppa EP. Laparoscopic distal pancreatectomy for pancreatic cancer is safe and effective. Surg Endosc 2017. [PMID: 28643065 DOI: 10.1007/s00464-017-5633-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE To compare the short-term and oncologic outcomes of patients with pancreatic ductal adenocarcinoma (PDAC) undergoing laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP). METHODS Consecutive cases of distal pancreatectomy (DP) (n = 422) were reviewed at a single high-volume institution over a 10-year period (2005-2014). Inclusion criteria consisted of any patient with PDAC by surgical pathology. Ninety-day outcomes were monitored through a prospectively maintained pancreatic resection database. The Social Security Death Index was used for 5-year survival. Two-way statistical analyses were used to compare categories; variance was reported with standard error of the mean; * indicates P value <0.05. RESULTS Seventy-nine patients underwent DP for PDAC. Thirty-three underwent LDP and 46 ODP. There were no statistical differences in demographics, BMI, and ASA classification. Intraoperative and surgical pathology variables were comparable for LDP versus ODP: operative time (3.9 ± 0.2 vs. 4.2 ± 0.2 h), duct size, gland texture, stump closure, tumor size (3.3 ± 0.3 vs. 4.0 ± 0.4 cm), lymph node harvest (14.5 ± 1.1 vs. 17.5 ± 1.2), tumor stage (see table), and negative surgical margins (77 vs. 87%). Patients who underwent LDP experienced lower blood loss (310 ± 68 vs. 597 ± 95 ml; P = 0.016*) and required fewer transfusions (0 vs. 13; P = 0.0008*). Patients who underwent LDP had fewer positive lymph nodes (0.8 ± 0.2 vs. 1.6 ± 0.3; P = 0.04*) and a lower incidence of type C pancreatic fistula (0 vs. 13%; P = 0.03*). Median follow-up for all patients was 11.4 months. Long-term oncologic outcomes revealed similar outcomes including distant or local recurrence (30 vs. 52%; P = 0.05) and median survival (18 vs. 15 months), as well as 1-year (73 vs. 59%), 3-year (22 vs. 21%), and 5-year (20 vs. 15%) survival for LDP and ODP, respectively. CONCLUSIONS The results of this series suggest that LDP is a safe surgical approach that is comparable from an oncologic standpoint to ODP for the management of pancreatic adenocarcinoma.
Collapse
Affiliation(s)
- Marita D Bauman
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA.
| | - David G Becerra
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA
| | - E Molly Kilbane
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA
| | - Henry A Pitt
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr, EH 541, Indianapolis, IN, 46202, USA
| |
Collapse
|