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Reni M, Giordano G, Audisio M, Orsi G, Macchini M, Gobba SM, Rapposelli I, Lucenti A, Luchena G, Faloppi L, Zustovich F, Ricci V, Cergnul M, Formica V, Procaccio L, Baccolini V, Briccolani A, Cascinu S, Peretti U. Exploring external validity of chemotherapy for pancreatic ductal adenocarcinoma in real life. Dig Liver Dis 2024:S1590-8658(24)00835-1. [PMID: 39003164 DOI: 10.1016/j.dld.2024.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 06/23/2024] [Accepted: 06/25/2024] [Indexed: 07/15/2024]
Abstract
INTRODUCTION Cisplatin, nab-paclitaxel, capecitabine, and gemcitabine (PAXG) regimen activity was assessed in a single institution phase II trial (PACT-19) on pancreatic ductal adenocarcinoma (PDAC). The PACT-31 study explored the external validity of PACT-19 results. MATERIALS AND METHODS Patients aged ≥18 and ≤75 years with KPS ≥70, and PDAC diagnosis receiving PAXG in the participating institutions were eligible and categorized as follows: A) PACT-19; B) PACT-31-HSR; C) PACT-31-non-HSR. With a sample of 175 patients, assuming a target 1-year overall survival of 60 % for metastatic and of 80 % for non-metastatic patients, the trial will be considered successful with the 1-year OS falling into the 95 % CI. RESULTS Data from 68 PACT-19 and 168 PACT-31 patients were retrieved. After 124 events, 1yOS was 52.5 % (95 %CI: 44.6-60.4 %) for metastatic and 80.5 % (95 %CI: 71.9-89.1 %) for non-metastatic patients. Survival overlapped between PACT-19 and PACT-31-HSR (median 17.6 and 17.4 months, p = 0.21) and was significantly shorter in PACT-31-non-HSR (median 11.3 months; p = 0.03). Differences of dose-intensity, use of maintenance therapy, and treatment after progression between PACT-31-HSR and non-HSR were evidenced. DISCUSSION PACT-19 results have external validity. The outcome difference between HSR and non-HSR centers endorses the need of creating a hub-and-spoke network aimed at sharing the expertise on rare-diseases.
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Affiliation(s)
- Michele Reni
- Department of Medical Oncology IRCCS Ospedale San Raffaele, Vita e Salute University, Via Olgettina 60, 20132 Milan, Italy.
| | - Guido Giordano
- Unit of Medical Oncology and Biomolecular Therapy, Policlinico Ospedali Riuniti di Foggia, Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto, 251, 71122 Foggia, Italy
| | - Marco Audisio
- Department of Oncology, University of Turin, AO Ordine Mauriziano, Medical Oncology Unit, ASL Torino 4, Ivrea, Turin, Italy
| | - Giulia Orsi
- Department of Medical Oncology IRCCS Ospedale San Raffaele, Vita e Salute University, Via Olgettina 60, 20132 Milan, Italy
| | - Marina Macchini
- Department of Medical Oncology IRCCS Ospedale San Raffaele, Vita e Salute University, Via Olgettina 60, 20132 Milan, Italy
| | - Stefania Maria Gobba
- Department of Medical Oncology, ASST-Settelaghi, Ospedale di Circolo, Viale Luigi Borri, 57, 21100 Varese, Italy
| | - Ilario Rapposelli
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Via Piero Maroncelli, 40, 47014 Meldola, (FC), Italy
| | - Antonio Lucenti
- U.O.C. Oncologia Medica Ospedale Maria Paternò Arezzo, 97100, Maria Paternò E Arezzo, Ragusa, Italy
| | - Giovanna Luchena
- U.O.C. Oncologia, Ospedale S. Anna ASST-LARIANA, Via Ravona, 1, 22020 San Fermo della Battaglia, Como, Italy
| | - Luca Faloppi
- Medical Oncology Unit, Azienda Sanitaria Territoriale di Macerata, Via Santa Lucia, 2, Macerata, Italy
| | - Fable Zustovich
- Department of Medical Oncology, AULSS 1 Dolomiti, Ospedale S.Martino, V.le Europa, 22, 32100 Belluno, Italy
| | - Vincenzo Ricci
- Medical Oncology Unit, Azienda Ospedaliera di Rilievo Nazionale 'San Pio', Via Dell'Angelo 1, Benevento, Italy
| | - Massimiliano Cergnul
- Ospedale Civile di Legnano, ASST OVEST MILANESE, Via Candiani, 2, 20025 Legnano, Italy
| | - Vincenzo Formica
- Medical Oncology Unit, Department of Systems Medicine, University of Rome Tor Vergata, Viale Oxford, 81, 00133 Roma, Italy
| | - Letizia Procaccio
- Dept of Oncology Veneto Institute of Oncology IOV, IRCCS, Via Gattamelata, 64, 35128 Padova, Italy
| | - Valeria Baccolini
- Department of Medical Oncology IRCCS Ospedale San Raffaele, Vita e Salute University, Via Olgettina 60, 20132 Milan, Italy
| | - Assunta Briccolani
- Department of Medical Oncology IRCCS Ospedale San Raffaele, Vita e Salute University, Via Olgettina 60, 20132 Milan, Italy
| | - Stefano Cascinu
- Department of Medical Oncology IRCCS Ospedale San Raffaele, Vita e Salute University, Via Olgettina 60, 20132 Milan, Italy
| | - Umberto Peretti
- Department of Medical Oncology IRCCS Ospedale San Raffaele, Vita e Salute University, Via Olgettina 60, 20132 Milan, Italy
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Kirkegård J, Gaber C, Heide-Jørgensen U, Fristrup CW, Lund JL, Cronin-Fenton D, Mortensen FV. Effect of surgery versus chemotherapy in pancreatic cancer patients: a target trial emulation. J Natl Cancer Inst 2024; 116:1072-1079. [PMID: 38310365 DOI: 10.1093/jnci/djae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/08/2023] [Accepted: 01/28/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND To estimate the causal effect of surgery vs chemotherapy on survival in patients with T1-3NxM0 pancreatic cancer in a rigorous framework addressing selection bias and immortal time bias. METHODS We used population-based Danish health-care registries to conduct a cohort study emulating a hypothetical randomized trial to estimate the absolute difference in survival, comparing surgery with chemotherapy. We included pancreatic cancer patients diagnosed during 2008-2021. Exposure was surgery or chemotherapy initiated within a 16-week grace period after diagnosis. At the time of diagnosis, data of each patient were duplicated; one copy was assigned to the surgery protocol, and one copy to the chemotherapy protocol of the hypothetical trial. Copies were censored when the assigned treatment deviated from the observed treatment. To account for informative censoring, uncensored patients were weighted according to confounders. For comparison, we also applied a more conventional analysis using propensity score-based inverse probability weighting. RESULTS We included 1744 patients with a median age of 68 years: 73.6% underwent surgery, and 18.6% had chemotherapy without surgery; 7.8% received no treatment. The 3-year survival was 39.7% (95% confidence interval [CI] = 36.7% to 42.6%) after surgery and 22.7% (95% CI = 17.7% to 28.4%) after chemotherapy, corresponding to an absolute difference of 17.0% (95% CI = 10.8% to 23.1%). In the conventional survival analysis, this difference was 23.0% (95% CI = 17.0% to 29.0%). CONCLUSION Surgery was superior to chemotherapy in achieving long-term survival for pancreatic cancer. The difference comparing surgery and chemotherapy was substantially smaller when using the clone-censor-weight approach than conventional survival analysis.
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Affiliation(s)
- Jakob Kirkegård
- Department of Surgery, HPB Section, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Charles Gaber
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois, Chicago, IL, USA
| | - Uffe Heide-Jørgensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jennifer L Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Deirdre Cronin-Fenton
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Frank Viborg Mortensen
- Department of Surgery, HPB Section, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Rasmussen LS, Winther SB, Chen IM, Weber B, Ventzel L, Liposits G, Johansen JS, Detlefsen S, Egendal I, Shim S, Christensen S, Pfeiffer P, Ladekarl M. A randomized phase II study of full dose gemcitabine versus reduced dose gemcitabine and nab-paclitaxel in vulnerable patients with non-resectable pancreatic cancer (DPCG-01). BMC Cancer 2023; 23:552. [PMID: 37328835 DOI: 10.1186/s12885-023-11035-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 05/31/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND According to current evidence, the best treatment for fit patients with non-resectable pancreatic cancer (PC) is combination chemotherapy, whereas frail patients are recommended gemcitabine (Gem) monotherapy. Randomized controlled trials in colorectal cancer and a post-hoc analysis of gemcitabine and nab-paclitaxel (GemNab) in PC suggest, however, that reduced dose of combination chemotherapy may be feasible and more efficient compared to monotherapy in frail patients. The aim of this study is to investigate whether reduced dose GemNab is superior to full dose Gem in patients with resectable PC, who are not candidates for full dose combination chemotherapy in first line. METHODS The Danish Pancreas Cancer Group (DPCG)-01 trial is a national multicenter prospective randomized phase II trial. A total of 100 patients in ECOG performance status 0-2 with non-resectable PC, not candidate for full dose combination chemotherapy in first line, but eligible for full dose Gem, will be included. Patients are randomized 1:1 to either full dose Gem or GemNab in 80% of recommended dose. The primary endpoint is progression-free survival. Secondary endpoints are overall survival, overall response rate, quality of life, toxicity and rate of hospitalizations during treatment. The correlation between blood inflammatory markers, including YKL-40 and IL-6, circulating tumor DNA, and tissue biomarkers of resistance to chemotherapy and outcome will be explored. Finally, the study will include measures of frailty (G8, modified G8, and chair-stand-test) to assess whether scoring would enable a personalized allocation to different treatments or indicates a possibility for interventions. DISCUSSION Single-drug treatment with Gem has for frail patients with non-resectable PC been the main treatment option for more than thirty years, but the impact on outcome is modest. If improved results and sustained tolerability with reduced dose combination chemotherapy can be shown, this could change the future practice for this increasing group of patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05841420. Secondary Identifying No: N-20210068. EudraCT No: 2021-005067-52. PROTOCOL VERSION 1.5, 16-MAY-2023.
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Affiliation(s)
- Louise Skau Rasmussen
- Department of Oncology and Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Stine B Winther
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Inna M Chen
- Department of Oncology, Herlev-Gentofte University Hospital, Copenhagen, Denmark
| | - Britta Weber
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Lise Ventzel
- Department of Oncology, University Hospital of Southern Denmark, Vejle, Denmark
| | - Gabor Liposits
- Department of Oncology, Gødstrup Hospital, Herning, Denmark
| | - Julia Sidenius Johansen
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Sönke Detlefsen
- Department of Pathology, Odense University Hospital, and Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Ida Egendal
- Center for Clinical Data Science (CLINDA), and Clinical Cancer Research Center, Aalborg University and, Aalborg University Hospital, Aalborg, Denmark
| | - Susy Shim
- Department of Oncology and Clinical Cancer Research Center, Aalborg University Hospital, and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Signe Christensen
- Department of Oncology and Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, and Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Morten Ladekarl
- Department of Oncology and Clinical Cancer Research Center, Aalborg University Hospital, and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Kirkegård J, Bojesen AB, Nielsen MF, Mortensen FV. Trends in pancreatic cancer incidence, characteristics, and outcomes in Denmark 1980-2019: A nationwide cohort study. Cancer Epidemiol 2022; 80:102230. [PMID: 35901622 DOI: 10.1016/j.canep.2022.102230] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe time-trends in incidence, characteristics, treatments, and survival in pancreatic cancer patients in Denmark during 1980-2019. DESIGN A nationwide population-based cohort study of all Danish patients diagnosed with exocrine pancreatic cancer during the study period. Data was obtained from individual-level cross linkage between Danish healthcare registries. We present descriptive characteristics and survival estimates, which was obtained using the Kaplan-Meier estimator and Cox proportional hazards regression models. RESULTS During the study period, 32,107 patients were diagnosed with pancreatic cancer. In the most recent period, the age-standardized incidence rate was 17.7 per 100,000 person-years. Throughout the study period, between 18.4% and 27.5% of patients had no tumor staging performed, and approximately half of the patient were only offered best supportive care. The proportion of patients treated with surgery doubled during the study period, and the use of adjuvant and neoadjuvant oncological therapy increased substantially. Median survival after surgical resection also increased to 25.8 months in the most recent time period. CONCLUSION Pancreatic cancer incidence is increasing in Denmark, and this increase is projected to continue. The proportion of patients offered curative-intent treatment increased, which translates into an increase in overall survival. All numbers are comparable to best international standards.
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Affiliation(s)
- Jakob Kirkegård
- Department of Surgery, Section for Hepato-Pancreato-Biliary Surgery, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark; Department of Surgery, Gødstrup Regional Hospital, Denmark.
| | - Anders Bo Bojesen
- Department of Surgery, Section for Hepato-Pancreato-Biliary Surgery, Aarhus University Hospital, Denmark
| | - Mette Fugleberg Nielsen
- Department of Surgery, Section for Hepato-Pancreato-Biliary Surgery, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark; Department of Surgery, Gødstrup Regional Hospital, Denmark
| | - Frank Viborg Mortensen
- Department of Surgery, Section for Hepato-Pancreato-Biliary Surgery, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
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Nilbert M. Changing before we have to; how to mitigate disparities in pancreatic cancer care? Acta Oncol 2022; 61:275-276. [PMID: 35172684 DOI: 10.1080/0284186x.2022.2041720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Mef Nilbert
- Department of Hematology, Oncology, and Radiophysics, Skåne University Hospital, Lund, Sweden
- Hvidovre University Hospital, University of Copenhagen, Copenhagen, Denmark
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