Underuse of surgical resection among elderly patients with early-stage pancreatic cancer. Surgery. 2015;158:1226-1234. [PMID: 26138347 DOI: 10.1016/j.surg.2015.04.031]

Treatment of pancreatic adenocarcinoma in relation to survival in the U.S. Military Health System

BACKGROUND

Pancreatic cancer has a high case fatality and relatively short survival after diagnosis. Treatment is paramount to improving survival, but studies on the effects of standard treatment by surgery or chemotherapy on survival in U.S. healthcare settings is limited. Further, variability in access to care may impact treatment and outcomes for patients. We aimed to assess the relationship between standard treatment(s) and survival of pancreatic adenocarcinoma in a population with access to comprehensive healthcare.

METHODS

We used the Military Cancer Epidemiology (MilCanEpi) database, which includes data from the Department of Defense cancer registry and medical encounter data from the Military Health System (MHS), to study a cohort of 1408 men and women who were diagnosed with pancreatic adenocarcinoma between 1998 and 2014. Treatment with surgery or chemotherapy in relation to overall survival was examined in multivariable time-dependent Cox regression models.

RESULTS

Overall, 75 % of 441 patients with early-stage and 51 % of 967 patients with late-stage pancreatic adenocarcinoma received treatment. In early-stage disease, surgery alone or surgery with chemotherapy were both associated with statistically significant 52 % reduced risks of death, but chemotherapy alone was not. In late-stage disease, surgery alone, chemotherapy alone, or both surgery and chemotherapy significantly reduced the risk of death by 42 %, 25 %, and 52 %, respectively.

CONCLUSIONS

Our findings from the MHS demonstrate improved survival after treatment with surgery or surgery with chemotherapy for early- or late-stage pancreatic cancer and after chemotherapy for late-stage pancreatic cancer. In the era of immunotherapy and personalized medicine, further research on treatment and survival of pancreatic cancer in observational settings is needed.

Role of neoadjuvant therapy for nonmetastatic pancreatic cancer: Current evidence and future perspectives

Pancreatic adenocarcinoma (PDAC) is one of the most common and lethal human cancers worldwide. Surgery followed by adjuvant chemotherapy offers the best chance of a long-term survival for patients with PDAC, although only approximately 20% of the patients have resectable tumors when diagnosed. Neoadjuvant chemotherapy (NACT) is recommended for borderline resectable pancreatic cancer. Several studies have investigated the role of NACT in treating resectable tumors based on the recent advances in PDAC biology, as NACT provides the potential benefit of selecting patients with favorable tumor biology and controls potential micro-metastases in high-risk patients with resectable PDAC. In such challenging cases, new potential tools, such as ct-DNA and molecular targeted therapy, are emerging as novel therapeutic options that may improve old paradigms. This review aims to summarize the current evidence regarding the role of NACT in treating non-metastatic pancreatic cancer while focusing on future perspectives in light of recent evidence.

Pancreatic surgery in elderly patients: results of 329 consecutive patients during 10 years

Introduction

There is a progressive shift from a younger population to an older population throughout the world. With the population age shift, surgeons will be more encountered with older patient profiles. We aim to determine age-related risk factors of pancreatic cancer surgery and the effect of patient age on outcomes after pancreatic surgery.

Materials and methods

A retrospective review was conducted with data obtained from consecutive 329 patients whose pancreatic surgery was performed by a single senior surgeon between January 2011 and December 2020. Patients were divided into three groups based on age: patients younger than 65 years old, between 65 and 74 years old, and older than 74 years old. Demographics and postoperative outcomes of the patients were evaluated and compared between these age groups.

Results

The distribution of a total of 329 patients into the groups was 168 patients (51.06%) in Group 1 (age <65 years old), 93 patients (28.26%) in Group 2 (age ≥65 and <75 years old), and 68 patients (20.66%) in Group 3 (age ≥75 years old). The overall postoperative complications were statistically significantly higher in Group 3 than in Group 1 and Group 2 (p = 0.013). The comprehensive complication index of the patients in each group was 23.1 ± 6.8, 20.4 ± 8.1, and 20.5 + 6.9, respectively (p = 0.33). Fisher's exact test indicated a significant difference in morbidity in patients with ASA 3-4 (p = 0.023). In-hospital or 90-day mortality was observed in two patients (0.62%), one from Group 2 and one from Group 3. The 3-year survival rates for each group were 65.4%, 58.8%, and 56.8%, respectively (p = 0.038).

Conclusion

Our data demonstrate that comorbidity, ASA score, and the possibility of achieving a curative resection do have significantly more impact than age alone.

Management of adenocarcinoma of the pancreatic tail in the elderly

INTRODUCTION

Elderly patients with adenocarcinoma of the pancreatic head can achieve reasonable survival with multimodal therapy. An analysis specific to cancers of the pancreatic tail has not been published.

METHODS

We identified patients ≥65 years with localized adenocarcinoma of the pancreatic tail in the National Cancer Database (2011-2017). Patients were grouped by age (65-79 and ≥80 years) and categorized by treatment regimen. Postoperative outcomes and survival were analyzed using propensity score matching and multivariable logistical regression.

RESULTS

2168 patients were included: 73.9% were 65-79 years and 26.1% were ≥80 years. 34.1% of octogenarians did not receive any treatment, relative to 15.9% of younger patients (p < 0.001). Thirty-day mortality rates were similar in operatively managed patients; however, the 90-day mortality rate among octogenarians was greater (3.0% vs. 7.8%, p < 0.001; odds ratio [OR] = 1.85, 95% confidence interval [CI] = 1.07-3.19). Age ≥ 80 was not associated with survival on multivariable hazards regression (hazard ratio [HR] = 1.08, 95% CI = 0.95-1.24). After propensity matching, the addition of chemotherapy was not associated with improved survival relative to distal pancreatectomy alone among octogenarians (HR = 1.09, 95% CI = 0.72-1.65).

CONCLUSIONS

Management of adenocarcinoma of the pancreatic tail varies based on patient age. Resection appears to play a key role in management, but there is substantial upfront risk. Shared decision making should be employed to balance the chance for long-term survival with the risk of early mortality.

Survival outcomes of surgical and non-surgical treatment in elderly patients with stage I pancreatic cancer: A population-based analysis

Background

Due to underrepresentation in randomized controlled trials among old people (≥65 years old), the effectiveness of clinical trial-based recommendations about the treatment for stage I pancreatic cancer remains controversial. In this research, we intended to investigate the different strategies of this population in surgery group and non-surgery group.

Materials and methods

Elderly patients aged 65 years or older with histologically diagnosed stage I pancreatic cancer from 2006 to 2017 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The included patients were divided into surgery group (receiving surgery with chemotherapy or chemoradiotherapy) and non-surgery group (receiving radiotherapy, chemotherapy, both, or neither). Overall survival (OS) and cancer-specific survival (CSS) were compared between groups by Kaplan–Meier analysis. Cox proportional hazards regression (Cox) proportional hazards regression was used to determine factors associated with survival.

Results

A total of 2,448 eligible patients were recruited. Among them, 18.4% were treated surgically and 81.6% were treated non-surgically. The median OS (mOS) was 26 months (95% CI: 24–30 months) in the surgery group and 7 months (95% CI: 7–8 months) in the non-surgery group. In multivariate analyses, surgery was an important factor in improving OS compared with non-surgical treatment (HR: 0.34, 95% CI: 0.29–0.39, p &lt; 0.001). In subgroup analysis, surgery plus chemotherapy was an independent factor for OS in the surgery group, while chemoradiotherapy, chemotherapy, and radiotherapy were independent prognostic factors for patients in the non-surgery group.

Conclusion

Surgical resection and post-operative chemotherapy are recommended for elderly patients with stage I pancreatic cancer who can tolerate treatment, but post-operative chemoradiotherapy does not bring survival benefits compared with post-operative chemotherapy. Moreover, radiotherapy, chemotherapy, or the combination of radiotherapy and chemotherapy are significantly related to the prognosis of elderly patients with untreated pancreatic cancer, but chemoradiotherapy has the most obvious benefit.

Preoperative measures predicting outcome after pancreatic resection in aged patients

BACKGROUND AND OBJECTIVE

High-risk surgery on aged patients raises challenging ethical and clinical issues. The aim of this study was to analyze the preoperative factors associated with severe complications and returning home after pancreatic resection among patients aged ⩾ 75 years.

PATIENTS AND METHODS

Patients aged ⩾ 75 years undergoing pancreatic resection in 2012-2019 were retrospectively searched from the hospital database. Preoperative indices (Clinical Frailty Scale, Skeletal Muscle Index, Geriatric Nutritional Risk Index, Charlson Comorbidity Index, and National Surgical Quality Improvement Program risk for severe complications) were determined. Postoperative outcome was evaluated by incidence of Clavien-Dindo 3b-5 complications, rate of returning home, and 1-year survival.

RESULTS

A total of 95 patients were included. American Society of Anesthesiologists Class 3-4 covered 50%, Clinical Frailty Scale > 3 22%, Charlson Comorbidity Index > 6 53%, and a sarcopenic Skeletal Muscle Index 51% of these patients. The National Surgical Quality Improvement Program risk for severe complications was higher than average among 21% of patients. Geriatric Nutritional Risk Index showed high risk among 3% of them. In total, 19 patients (20%) experienced a severe (Clavien-Dindo 3b-5) complication. However, 30- and 90-day mortality was 2.1%. Preoperative indices were not associated with severe complications. Most patients (79%) had returned home within 8 weeks of surgery. Not returning home was associated with severe complications (p = 0.010).

CONCLUSIONS

The short-term outcome after pancreatic resection of fit older patients is similar to that of younger, unselected patient groups. In these selected patients, the commonly used preoperative indexes were not associated with severe complications or returning home.

Elderly Patients with Nondistant Metastatic Pancreatic Head Adenocarcinoma Cannot Benefit from More Radical Surgery

BACKGROUND

The incidence of pancreatic cancer continues to rise globally, with pancreatic head cancer accounting for nearly 60-70%. Pancreatic head cancer occurs mainly in people over the age of 60, and its morbidity and mortality increase with age. We investigated whether these elderly patients with nondistant metastases would benefit more from expanded pancreaticoduodenectomy (EPD) compared with standard pancreaticoduodenectomy (SPD).

METHODS

3317 elderly patients with pancreatic head cancer from the SEER database were included in the study based on the inclusion and exclusion criteria. These patients were divided into a nonsurgical group and surgical group (including EPD and SPD). Univariate and multivariate Cox proportional hazards models were applied to identify the independent risk factors for cancer-specific survival (CSS). The survival differences between the nonsurgical group and surgical group were compared. Propensity score matching (PSM) methods were applied to balance covariates and reduce the interference of confounding variables. The two groups of patients were matched in a 1 : 1 ratio, and the covariates between the two groups were compared to verify the matching validity. The survival difference in different groups was compared after the matching analysis.

RESULTS

3317 enrolled patients were divided into the surgical group (n = 984) and nonsurgical group (n = 2333). Before PSM, there were significant differences in overall survival (OS) and CSS between the nonsurgical group and surgical group (median OS: 8 months vs. 20 months, P < 0.001; median CSS: 8 months vs. 22 months, P < 0.001). The multivariate CSS Cox regression analysis demonstrated surgery is an independent risk factor. However, no significant differences were founded between the SPD and EPD groups (median OS: 20 months vs. 22 months, P=0.636; median CSS: 22 months vs. 22 months, P=0.270). After PSM, there were also no significant differences in OS and CSS between the SPD and EPD groups (median OS: 23 months vs. 18 months, P=0.415; median CSS: 26 months vs. 18 months, P=0.329).

CONCLUSION

This study uses PSM to evaluate the effects of EPD and SPD for elderly patients with nondistant metastatic pancreatic head adenocarcinoma. It found that surgery is an independent prognostic factor, but expanded surgery has no survival advantage for these patients, whereas SPD provides a better survival advantage than EPD. SPD is a reasonable treatment option for these patients.

Pancreatic Resection in Older Patients: A Retrospective Single-Center Outcome Analysis

Due to increasing life expectancy and improved diagnostic sensitivity, a growing number of older patients are presenting with resectable pancreatic disease entities and are being evaluated for surgery. Intended as an internal quality control for patient selection, we aimed at evaluating septuagenarians and octogenarians compared with patients younger than 70 years of age regarding early postoperative outcome in general, and long-term oncologic outcome in the case of resection for pancreatic adenocarcinoma. A total number of 1231 patients who underwent pancreatic resection for any entity between 2007 and 2019 at our tertiary university medical center in Germany were retrospectively analyzed, accessing a prospectively maintained database. Participants were divided into three groups based on age (<70 years: N = 761; 70–79 years: N = 385; 80–89 years: N = 85) and were evaluated with regard to perioperative variables, postoperative morbidity, mortality and overall survival for the subgroup of patients with pancreatic adenocarcinoma. Pancreatic resection in older individuals was not infrequent. When surgery was performed for carcinoma, patients >70 years of age even constituted almost half of the cases. In spite of increased American Society of Anesthesiologists physical status classification (ASA)-scores and more frequent comorbidities in older patients, similar rates for postoperative morbidity and mortality were observed in all age groups. A significant disparity in the use of (neo-) adjuvant therapy between younger and older pancreatic adenocarcinoma patients was detected. However, median overall survival did not significantly differ between all age groups (<70 years: 28 (95%-CI: 22–34) months; 70–79 years: 21 (17–25) months; 80–89 years: 15 (9–21) months). In conclusion, elderly patients can experience similar perioperative outcomes to those of younger individuals after major pancreatic surgery. The survival benefit from resection of localized pancreatic adenocarcinoma is largely independent of patient age. The results are reassuring with respect to our preoperative practice and clinical judgment regarding careful patient selection. Future randomized trials should decidedly include elderly patients to generate more robust evidence to further optimize treatment recommendation and choice.

Pancreatic resections in elderly patients with high American Society of Anesthesiologists' risk score: a view from a tertiary care center

BACKGROUND

More than 60% of patients affected by pancreatic cancer are ≥ 65 years of age. Surgery represents the only potentially curative treatment for malignant pancreatic neoplasia and a useful treatment for benign diseases.

AIM

To evaluate outcomes in elderly patients with ASA risk score 4 who underwent pancreatic resection compared to younger patients and elderly patients with lower anesthesiological risk.

METHODS

A consecutive series of 345 patients underwent pancreatic resection between 2010 and 2017 was reviewed. We compared three groups based on age at the time of surgery: < 65 years (group A), 65-74 years (group B), and ≥ 75 years (group C). Patients in group C were split into two subgroups, ASA 1-3 versus ASA 4, and compared.

RESULTS

Group A consisted of 117 (34%) patients, group B 128 (37%) patients, and group C 100 (29%) patients. Group C had a significantly higher incidence of comorbidity and ASA 4 status (p < 0.05), and of overall post-operative complications (p < 0.01), because of the higher incidence of post-operative medical complications. No differences in terms of overall surgical complications and post-operative mortality were reported. The mean overall survival was significantly lower for group C (p < 0.01), with no difference in mortality for cancer. Within group C, no differences were reported regarding surgical complications (p = 0.59), mortality (p = 0.34), and mean overall survival (p = 0.53) between ASA 1-3 and ASA 4 patients.

CONCLUSIONS

Advanced age should not preclude elderly patients with pancreatic diseases from being treated surgically, and ASA 4 in subjects aged ≥ 75 years should not be an absolute contraindication.

Surgery for elderly patients with resectable pancreatic cancer, a comparison with non-surgical treatments: a retrospective study outcomes of resectable pancreatic cancer

Background

We designed a retrospective study to compare prognostic outcomes based on whether or not surgical resection was performed in elderly patients aged(≥75 years) with resectable pancreatic cancer.

Methods

We retrospectively analyzed 49 patients with resectable pancreatic cancer (surgery group, resection was performed for 38 cases; no surgery group, resection was not performed for 11 cases) diagnosed from January 2003 to December 2014 at the National Cancer Center, Korea.

Results

There was no significant difference in demographics between the two groups. The surgery group showed significantly better overall survival after diagnosis than the no surgery group (2-year survival rate, 40.7% vs. 0%; log-rank test, p = 0.015). Multivariate analysis revealed that not having undergone surgical resection [hazard ratio (HR) 2.412, P = 0.022] and a high Charlson comorbidity index (HR 5.252, P = 0.014) were independent prognostic factors for poor overall survival in elderly patients with early stage pancreatic cancer.

Conclusions

In the present study, surgical resection resulted in better prognosis than non-surgical resection for elderly patients with resectable pancreatic cancer. Except for patients with a high Charlson comorbidity index, an aggressive surgical approach seems to be beneficial for elderly patients with resectable pancreatic cancer.

Resection of pancreatic cancer in Europe and USA: an international large-scale study highlighting large variations

OBJECTIVE

Resection can potentially cure resectable pancreatic cancer (PaC) and significantly prolong survival in some patients. This large-scale international study aimed to investigate variations in resection for PaC in Europe and USA and determinants for its utilisation.

DESIGN

Data from six European population-based cancer registries and the US Surveillance, Epidemiology, and End Results Program database during 2003-2016 were analysed. Age-standardised resection rates for overall and stage I-II PaCs were computed. Associations between resection and demographic and clinical parameters were assessed using multivariable logistic regression models.

RESULTS

A total of 153 698 records were analysed. In population-based registries in 2012-2014, resection rates ranged from 13.2% (Estonia) to 21.2% (Slovenia) overall and from 34.8% (Norway) to 68.7% (Denmark) for stage I-II tumours, with great international variations. During 2003-2014, resection rates only increased in USA, the Netherlands and Denmark. Resection was significantly less frequently performed with more advanced tumour stage (ORs for stage III and IV versus stage I-II tumours: 0.05-0.18 and 0.01-0.06 across countries) and increasing age (ORs for patients 70-79 and ≥80 versus those <60 years: 0.37-0.63 and 0.03-0.16 across countries). Patients with advanced-stage tumours (stage III-IV: 63.8%-81.2%) and at older ages (≥70 years: 52.6%-59.5%) receiving less frequently resection comprised the majority of diagnosed cases. Patient performance status, tumour location and size were also associated with resection application.

CONCLUSION

Rates of PaC resection remain low in Europe and USA with great international variations. Further studies are warranted to explore reasons for these variations.

Trends in treatment and survival of patients with nonresected, nonmetastatic pancreatic cancer: A population-based study

Background

Nonresected, nonmetastatic (NR‐M0) pancreatic cancer involves both locally advanced pancreatic cancer and patients who did not undergo resection due to poor health status or patient preference. This study investigates nationwide trends of characteristics, treatment, and survival of patients with NR‐M0 pancreatic cancer.

Methods

From the Netherlands Cancer Registry, all patients diagnosed with pancreatic cancer between 2006 and 2014 were selected. Chemotherapy and overall survival (OS) of NR‐M0 patients were evaluated for 3‐year time periods and 2 age groups using chi‐square tests for trend and Cox proportional hazard regression analysis.

Results

Of 18 234 patients, 33% had NR‐M0 pancreatic cancer, which decreased over time (in consecutive 3‐year periods: 38%‐33%‐28%, P < 0.001). Of 5964 NR‐M0 patients, 52% was over 75 years of age, 16% received chemotherapy, and median OS was 5.1 months. Chemotherapy use increased over time in younger patients (<75 years: from 23 to 36%, P‐trend < 0.001, ≥75 years: 3% to 4%, P‐trend = 0.053). In multivariable survival analysis, elderly age, low SES, nonconfirmed cancer, stage II‐III disease, and earlier years of diagnosis were independently associated with a worse OS. Age of patients who received chemotherapy increased over time (median 62‐66 years) and median OS was 10.4 months without significant differences between time periods (P = 0.177) or age groups (P = 0.207).

Conclusions

Overall survival of NR‐M0 pancreatic cancer remains poor which is partly related to advanced age of many patients. Despite an increase, chemotherapy is infrequently used. Future research should investigate to what extent the more widespread use of chemotherapy could improve survival in relation to age‐related morbidity.

Age as a prognostic indicator for adjuvant therapy in patients who underwent pancreatic resections for cancer

PURPOSE

In pancreatic cancer, the greatest increase in survival is attained by surgical resection followed by adjuvant chemotherapy. Although surgical complications and functional status are recognized as independent factors for halting adjuvant therapy in patients that undergo pancreatic resections, other elements may play a role in deciding which patients get treated postoperatively. Here we determined demographic and clinical characteristics of patients receiving adjuvant chemotherapy, with the primary intent to investigate if age alone affects rates of adjuvant therapy.

METHODS/MATERIALS

National Cancer Database (NCDB) was queried for patients that underwent surgery for pancreatic cancer. Groups were divided into: adjuvant chemotherapy (n=17,924) and no adjuvant chemotherapy (n=12,947). Basic demographics and treatment characteristics were analyzed. Age was compared with an independent means test; other comparisons used Chi-square test of independence.

RESULTS

There was a statistical difference in age (adjuvant therapy 64.86±9.89 vs. no therapy 67.78±11.22, p<0.001), insurance type, facility type, and cancer stage for patients that received adjuvant therapy and those that did not. Average age of patients not receiving chemotherapy was significantly older at each pathologic stage. Subset analysis of patients treated with chemotherapy showed that the majority of patients received single agent regimens (62%), at an average of 59days following surgery, and at academic cancer programs (52%).

CONCLUSIONS

Regardless of postoperative complications and functional status, age alone appears to affect rates of adjuvant therapy in patients with resected pancreatic cancer. Older patients should be offered tailored regimens that would allow them to complete the intended extent of treatment.

One- vs. Three-Fraction Pancreatic Stereotactic Body Radiation Therapy for Pancreatic Carcinoma: Single Institution Retrospective Review

Background/introduction

Early reports of stereotactic body radiation therapy (SBRT) for pancreatic ductal adenocarcinoma (PDAC) used single fraction, but eventually shifted to multifraction regimens. We conducted a single institution review of our patients treated with single- or multifraction SBRT to determine whether any outcome differences existed.

Methods and materials

Patients treated with SBRT in any setting for PDAC at our facility were included, from 2004 to 2014. Overall survival (OS), local control (LC), regional control (RC), distant metastasis (DM), and late grade 3 or greater radiation toxicities from the time of SBRT were calculated using Kaplan–Meier estimation to either the date of last follow-up/death or local/regional/distant failure.

Results

We identified 289 patients (291 lesions) with pathologically confirmed PDAC. Median age was 69 (range, 33–90) years. Median gross tumor volume was 12.3 (8.6–21.3) cm³ and planning target volume 17.9 (12–27) cm³. Single fraction was used in 90 (30.9%) and multifraction in 201 (69.1%) lesions. At a median follow-up of 17.3 months (IQR 10.1–29.3 months), the median survival for the entire cohort 17.8 months with a 2-year OS of 35.3%. Univariate analysis showed multifraction schemes to have a higher 2-year OS 30.5% vs. 37.5% (p = 0.019), it did not hold significance on MVA. Multifractionation schemes were found to have a higher LC on MVA (HR = 0.53, 95% CI, 0.33–0.85, p = 0.009). At 2 years, late grade 3+ toxicity was 2.5%. Post-SBRT CA19-9 was found on MVA to be a prognostic factor for OS (HR = 1.01, 95% CI, 1.01–1.01, p = 0.009), RC (HR = 1.01, 95% CI 1.01–1.01, p = 0.02), and DM (HR = 1.01, 95% CI, 1.01–1.01, p = 0.001).

Conclusion

Our single institution retrospective review is the largest to date comparing single and multifraction SBRT and the first to show multifraction regimen SBRT to have a higher LC than single fractionation. Additionally, we show low rates of severe late toxicity with SBRT.

Update on the Management of Pancreatic Cancer in Older Adults

Pancreatic cancer is more common in older adults, who are underrepresented in clinical trials and frequently under treated. Chronological age alone should not deter clinicians from offering treatment to geriatric patients, as they are a heterogeneous population. Geriatric assessment, frailty assessment tools, and toxicity risk scores help clinicians select appropriate patients for therapy. For resectable disease, surgery can be safe but should be done at a high-volume center. Adjuvant therapy is important; though there remains controversy on the role of radiation, chemotherapy is well studied and efficacious. In locally advanced unresectable disease, chemoradiation or chemotherapy alone is an option. Neoadjuvant therapy improves the chances of resectability in borderline resectable disease. Chemotherapy extends survival in metastatic disease, but treatment goals and risk-benefit ratios have to be clarified. Adequate symptom management and supportive care are important. There are now many new treatment strategies and novel therapies for this disease.

Pancreatic resection in very elderly patients: A critical analysis of existing evidence

The aging of the population results in a rise of number of elderly patients (aged 80 years and older) with pancreatic or periampullary cancer, and more pancreatectomies could eventually be performed in such complex patients. However, early and long-term results after pancreatic resection in octogenarians are still controversial, and may trouble the surgeon when approaching this type of population. Evaluation of reported experiences shows that for almost all Authors, pancreatectomy can be performed safely in elderly population, although overall morbidity and mortality rates were 34.9% and 13.2% respectively, with a mean length of hospital stay of 18 d. These features appear higher in older patients compared to the younger counterpart. Less than 50% of patients underwent adjuvant therapy after operation. Long-term survival is reported not significantly different in aged 80 years and older patients, with a median overall survival time of 17.6 mo. The quality of life after pancreatic resection is only sporadically evaluated but, when considered, it highlights the need of health facility service after operation for these “frail” patients. Prospective studies on the quality of life of pancreatectomized octogenarians are welcome. Proper selection of patients, geriatric assessment with multidisciplinary approach, centralization of pancreatic surgery in high-volume centres and rehabilitation programs after surgery appear to be crucial points in order to improve surgical treatments of pancreatic tumors in very elderly patients.

Factors associated with quality of care for patients with pancreatic cancer in Australia

OBJECTIVES

To develop a composite score for the quality of care for patients with pancreatic cancer in Australia; to determine whether it was affected by patient and health service-related factors; to assess whether the score and survival were correlated.

DESIGN, PARTICIPANTS AND SETTING

We reviewed medical records of patients diagnosed with pancreatic cancer during July 2009 - June 2011 and notified to the Queensland and New South Wales cancer registries.

DESIGN AND MAIN OUTCOME MEASURES

Participants were allocated proportional quality of care scores based on indicators derived from a Delphi process, ranging from 0 (lowest) to 1 (highest quality care). Associations between patient and health service-related factors and the score were tested by linear regression, and associations between the score and survival with Kaplan-Meier and Cox proportional hazards methods.

RESULTS

Proportional quality of care scores were assigned to 1571 patients. Scores for patients living in rural areas were significantly lower than for those in major cities (adjusted difference, 11%; 95% CI, 8-13%); they were higher for patients in the least socio-economically disadvantaged areas (v most disadvantaged areas: 8% higher; 95% CI, 6-11%), who were younger, had better Eastern Cooperative Oncology Group performance status, or who first presented to a hospital with a high pancreatic case volume. Higher scores were associated with improved survival; after adjusting for patient-related factors, each 10 percentage point increase in the score reduced the risk of dying by 6% (hazard ratio, 0.94; 95% CI, 0.91-0.97).

CONCLUSION

Geographic category of residence may influence the quality of care received by patients with pancreatic cancer, and survival could be improved if they received optimal care.

Deviations from Expected Treatment of Pancreatic Cancer in Octogenarians: Analysis of Patient and Surgeon Factors

BACKGROUND

Morbidity and mortality of pancreatectomy has improved and chemotherapeutic options for pancreatic cancer (PC) are growing, yet there is reluctance to treat octogenarians. This study examined the reasons for failure to treat and analyzes outcomes in octogenarians with PC.

METHODS

Retrospective chart review 2005-2013. Demographics, tumor characteristics, treatment, reason for lack of treatment, Charlson comorbidity index (CCI), and survival were analyzed. Expected treatment for early-stage patients (I/II) included surgery ± chemotherapy ± radiation. Expected treatment for advanced stage patients (III/IV) was chemotherapy.

RESULTS

A total of 431 octogenarians were analyzed. Mean age was 84.0 ± 3.4, 59.6 % female, and 44.1 % received no treatment. Patients with operable tumors (I = 31 [7.2 %]/II = 214 [49.7 %]) had surgery 39.2 % of the time. Age was a predictor of not receiving surgery (odds ratio [OR] 0.78; 95 % confidence interval [CI] 0.70-0.86; p = 0.0001), whereas CCI was not. The most common reason for no surgery was contraindication despite similar CCI. Median overall survival for early-stage patients was better in the surgical group (15.8 vs. 5.5 months) than nonsurgical group (p < 0.0001). Advanced patients (III = 54 [12.5 %]/IV = 132 [30.6 %]) had similarly low treatment rates (n = 65 [34.9 %]). Survival for advanced disease was best for treated patients (6.9 vs. 1.8 months; p < 0.0001). CCI did not differ between those receiving chemotherapy and not, although age was significantly different (p < 0.0001).

CONCLUSIONS

There is significant deviation from expected treatment for octogenarians with PC. While no correlation existed between CCI and treatment, age correlated with therapy for nearly all stages. Chronological age, not comorbidity, may drive recommendation for treatment in elderly patients.

Determinants of survival and attempted resection in patients with non-metastatic pancreatic cancer: An Australian population-based study

BACKGROUND

There are indications that pancreatic cancer survival may differ according to sociodemographic factors, such as residential location. This may be due to differential access to curative resection. Understanding factors associated with the decision to offer a resection might enable strategies to increase the proportion of patients undergoing potentially curative surgery.

METHODS

Data were extracted from medical records and cancer registries for patients diagnosed with pancreatic cancer between July 2009 and June 2011, living in one of two Australian states. Among patients clinically staged with non-metastatic disease we examined factors associated with survival using Cox proportional hazards models. To investigate survival differences we examined determinants of: 1) attempted surgical resection overall; 2) whether patients with locally advanced disease were classified as having resectable disease; and 3) attempted resection among those considered resectable.

RESULTS

Data were collected for 786 eligible patients. Disease was considered locally advanced for 561 (71%) patients, 510 (65%) were classified as having potentially resectable disease and 365 (72%) of these had an attempted resection. Along with age, comorbidities and tumour stage, increasing remoteness of residence was associated with poorer survival. Remoteness of residence and review by a hepatobiliary surgeon were factors influencing the decision to offer surgery.

CONCLUSIONS

This study indicated disparity in survival dependent on patients' residential location and access to a specialist hepatobiliary surgeon. Accurate clinical staging is a critical element in assessing surgical resectability and it is therefore crucial that all patients have access to specialised clinical services.