Closing the Disparity in Pancreatic Cancer Outcomes: A Closer Look at Nonmodifiable Factors and Their Potential Use in Treatment

Trends in the Care of Locally Advanced Pancreatic Cancer in the Modern Era of Chemotherapy

INTRODUCTION

Current guidelines for treatment for locally advanced pancreatic cancer recommend chemotherapy ± radiation, or radiation alone when multimodal therapy is contraindicated. In a subset of patients, guideline-recommended treatment (GRT) achieves sufficient response to qualify for potentially curative resection. This study evaluated trends in treatment utilization and aimed to identify barriers to GRT.

METHODS

Patients with clinical T4M0 disease in the National Cancer Database from 2010 to 2017 were included. Potential predictors were assessed by relative risk regression with Poisson distribution and compared by log-link function.

RESULTS

In total, 28 056 patients met the criteria. Among 17 059 (67.67%) patients treated primarily with chemotherapy, 41.19% also had radiation and 8.89% went onto resection. Many received no cancer-directed treatment or failed to receive GRT. Another 710 patients had radiation (±surgery) without chemotherapy despite few contraindications to chemotherapy. Over time, patients were more likely to undergo resection after chemotherapy (aRR = 1.58; p < 0.0001) and less likely to have chemoradiation (aRR = 0.78; p < 0.0001) or go untreated (aRR = 0.90; p < 0.0001). Socioeconomic factors (race, education, income, and insurance status) affected the likelihood of receiving chemotherapy and surgery. Median overall survival (OS) was significantly improved for patients treated with chemotherapy and particularly in those patients who went on to receive RT or undergo surgical resection. OS was also longer for patients treated at high-volume academic centers. Patients insured by Medicaid, Medicare, or those without insurance had worse OS.

CONCLUSIONS

Despite improvement over time, many patients go untreated. Clinical factors were influential, but the impact of vulnerable social standing suggests persistent inequity in access to care.

Accessibility to ERCP-performing hospitals among patients with pancreatic cancer living in SEER regions

BACKGROUND AND AIMS

The two most common interventions used to treat painless jaundice from pancreatic cancer are endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic biliary drainage (PTBD). Our study aimed to characterize the geographic distribution of ERCP-performing hospitals among patients with pancreatic cancer in the United States and the association between geographic accessibility to ERCP-performing hospitals and biliary interventions patients receive.

METHODS

This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database for pancreatic cancer from 2005 to 2013. Multilevel models were used to examine the association between accessibility to ERCP hospitals within a 30- and 45-min drive from the patient's residential ZIP Code and the receipt of ERCP treatment. A two-step floating catchment area model was used to calculate the measure of accessibility based on the distribution across SEER regions.

RESULTS

7464 and 782 patients underwent ERCP and PTBD, respectively, over the study period. There were 808 hospitals in which 8246 patients diagnosed with pancreatic cancer in SEER regions from 2005 to 2013 received a procedure. Patients with high accessibility within both 30- and 45-min drive to an ERCP-performing hospital were more likely to receive an ERCP (30-min adjusted odds ratio [aOR]: 1.53, 95% confidence interval [CI]: 1.17-2.01; 45-min aOR: 1.31, 95% CI: 1.01-1.70). Furthermore, in the adjusted model, Black patients (vs. White) and patients with stage IV disease were less likely to receive ERCP than PTBD.

CONCLUSIONS

Patients with pancreatic cancer and high accessibility to an ERCP-performing hospital were more likely to receive ERCP. Disparities in the receipt of ERCP persisted for Black patients regardless of their access to ERCP-performing hospitals.

Impact of Biopsy Attempts, Race, and Access on Time to Initiation of Treatment for Pancreatic Cancer

BACKGROUND

Biopsy of suspected pancreatic cancer (PDAC) in surgical candidates is informative however not always necessary. Biopsies impact treatment options as histological diagnosis are presently required for neo-adjuvant therapy, but not surgical resection. We explored the impact of pursuing tissue diagnosis by endoscopic ultrasound (EUS) biopsy on time to treatment in patients with resectable and borderline resectable PDAC.

METHODS

A retrospective review of surgical patients with ultimately proven PDAC was performed (2011-2021). Milestone dates (cancer suspected, biopsy(ies), surgical or neo-adjuvant treatment) were collected. Mann-Whitney-Wilcoxon tests, Pearson's chi-squared tests, Fisher's exact tests, linear regressions, and Cox proportional hazard models were used for data analysis.

RESULTS

Among 131 resectable and 58 borderline resectable patients, the borderline resectable group underwent more biopsies (1.2 vs 0.7, p < 0.0001), were more likely to undergo biopsy at tertiary care centers (67.2% vs 30.5%, p < 0.0001), and trended toward longer time to treatment (49 vs 44 days, p = 0.070). Significant increases in days to treatment were seen in patients with Black race (29 days, p = 0.0002) and Medicare insurance (22 days, p = 0.038) and no biopsies at a tertiary care center (10 days, p = 0.039). After adjusting for covariates, additional biopsies significantly delayed treatment (1 biopsy: 21 days, p = 0.0001; 2 biopsies: 44 days, p < 0.0001; 3 biopsies: 68 days, p < 0.0001).

CONCLUSIONS

EUS biopsy significantly impacts time between suspicion and treatment of PDAC. This may be exacerbated by clinical practices increasingly favoring neo-adjuvant therapy that necessitates biopsy-proven disease. Time to treatment may also be impacted by access to tertiary centers and racial disparities.

Association between the Environmental Quality Index and Textbook Outcomes Among Medicare Beneficiaries Undergoing Surgery for Early-Stage Pancreatic Adenocarcinoma

BACKGROUND

Access to high-quality cancer care is affected by environmental exposures and structural inequities. This study sought to investigate the association between the environmental quality index (EQI) and achievement of textbook outcomes (TO) among Medicare beneficiaries over the age of 65 who underwent surgical resection for early-stage pancreatic adenocarcinoma (PDAC).

METHODS

Patients diagnosed with early-stage PDAC from 2004 to 2015 were identified using the SEER-Medicare database and combined with the US Environmental Protection Agency's EQI data. High EQI category indicated poor environmental quality, whereas low EQI indicated better environmental conditions.

RESULTS

A total of 5,310 patients were included, of which 45.0% (n = 2,387) patients achieved TO. Median age was 73 years and more than half were female (n = 2,807, 52.9%), married (n = 3,280, 61.8%), and resided in the Western region of the US (n = 2,712, 51.1%). On multivariable analysis, patients residing in moderate and high EQI counties were less likely to achieve a TO (referent: low EQI; moderate EQI: OR 0.66, 95% CI 0.46-0.95; high EQI: OR 0.65, 95% CI 0.45-0.94; p < 0.05). Increasing age (OR 0.98, 95%CI 0.97-0.99), racial minorities (OR 0.73, 95% CI 0.63-0.85), having a Charlson co-morbidity index > 2 (OR 0.54, 95%CI 0.47-0.61) and stage II disease (OR 0.82, 95%CI 0.71-0.96) were also associated with not achieving a TO (all p < 0.001).

CONCLUSION

Older Medicare patients residing in moderate or high EQI counties were less likely to achieve an "optimal" TO after surgery. These results demonstrate that environmental factors may drive post-operative outcomes among patients with PDAC.

Racial and Gender Disparities Among Obese Patients With Pancreatic Cancer: A Trend Analysis in the United States

BACKGROUND

Pancreatic cancer (PC) is the third leading cause of cancer death. Obesity can increase the risk of PC by up to 50%. Studies have shown racial and gender disparities in PC, however, there is a paucity of such information in obese PC patients.

AIM

The aim of this study was to: (1) evaluate the incidence and prevalence of obesity among PC patients in the United States over the last 15 years, and (2) determine if variation exists in the demographic of obese PC patients over the last 15 years. It is hoped that this information could be used to assist in primary prevention and early detection of PC.

METHODS

A population-based retrospective analysis in IBM Explorys, a pooled, national, deidentified database of 63 million patients from 300 hospitals in the United States. Patient populations were identified using SNOMED and ICD codes. Cochrane-Armitage testing was performed to analyze trends in obesity among PC. Subgroup analysis for gender, age, race, and mortality rate were assessed.

RESULTS

The percentage of obese patients with PC increased over the 15-year period (2.5% to 8.5%, P <0.0001). Rates of obesity among PC patients increased among females ( P =0.0004), individuals under age 65 years ( P =0.0002), and all races, but especially for African Americans ( P =0.0007) and those in minority groups.

CONCLUSION

Awareness of disparities in PC and applying targeted care to those at increased risk are essential to improve future outcomes, including increased health care access and recruitment in research studies for minority groups.

Are Lymph Node Metastases Associated With Survival in Black Patients With Pancreatic Cancer?

INTRODUCTION

Despite aggressive surgical care and systemic therapy, patients with pancreatic ductal adenocarcinoma (PDAC) have a poor prognosis. Recent studies show that racial disparities in outcome also exist. We sought to investigate the association lymph node (LN) metastases had with survival between Black and White patients with PDAC after resection.

METHODS

Retrospective analysis of 226 PDAC patients who underwent resection at a single institution from 2010 to 2018 was performed with attention to LN metastasis and patient race. The number of patients who received chemotherapy was also evaluated.

RESULTS

One Hundred Seventy Five (77.4%) PDAC patients were White and 51 (22.6%) were Black. 130 (59.3%) patients had LN metastasis (LN+). LN+ and LN- groups were similar in race (P = 0.93), sex (P = 0.10) and age at the time of diagnosis (P = 0.45). Patients with LN + disease were more likely to present with larger tumors (3.4 versus 2.8 cm, P = 0.02) and higher T status (P = 0.001). White and Black patients had similar rates of LN metastasis (59% versus 58.8%, P = 1.0). The median survival for LN- Black and White patients were similar (43.2 versus 30.2 mo, P = 0.82). LN + Black patients trended towards receiving more systemic therapy than White LN + patients (55% versus 42%, P = 0.10). The median survival for LN + Black patients was significantly less than LN + White patients (17.5 versus 24.6 mo, P = 0.04).

CONCLUSIONS

Black LN + PDAC patients have an inferior survival rate after resection when compared to their White counterparts. Our disparity in outcome cannot be solely explained by a difference in systemic treatment. Further investigation is warranted to determine racial differences in tumor biology or response to chemotherapy.

The impact of race/ethnicity and county-level upward economic mobility on textbook outcomes in hepatopancreatic surgery

BACKGROUND

The impact of upward economic mobility and race/ethnicity on achieving quality metrics such as textbook outcomes remains ill-defined. As such, we sought to define the impact of race and county-level upward economic mobility on the ability to achieve a textbook outcome among patients undergoing hepatic and pancreatic surgery.

METHODS

Patients who underwent hepatic or pancreatic procedures between 2013 and 2017 were identified from the Medicare Standard Analytic Files. The primary outcomes of interest were textbook outcome and its components.

RESULTS

Among 35,403 patients, 17,923 (50.6%) patients were classified as living in a low upward economic mobility county, whereas 17,480 (49.4%) lived in a high upward economic mobility county. Furthermore, 32,981 (93.1%) patients were White, and 2,422 (6.8%) were Black. Overall, a textbook outcome was achieved in 45.6% of patients (n = 16,139), with textbook outcome most likely in patients from a high upward economic mobility county compared with a low upward economic mobility county (low: 44.6% vs high: 46.6%, P < .001). On multivariable analysis, patients in a low upward economic mobility county had 6% lower odds of achieving a textbook outcome compared with a high upward economic mobility county (odds ratio 0.94, 95% confidence interval 0.90-0.98). Furthermore, Black patients were less likely to achieve a textbook outcome (odds ratio 0.91, 95% confidence interval 0.84-0.99) and had 17% and 15% higher odds of developing a complication (odds ratio 1.17, 95% confidence interval 1.07-1.28) and extended length of stay (odds ratio 1.15, 95% confidence interval 1.05-1.27), respectively. Within races, White patients in a high upward economic mobility county had 7% higher odds of achieving a textbook outcome compared with White patients in a low upward economic mobility county (odds ratio 1.07, 95% confidence interval 1.02-1.12), although no such effect was observed in Black patients (odds ratio 0.94, 95% confidence interval 0.77-1.15). Furthermore, Black patients in a high upward economic mobility county had similar odds of achieving a textbook outcome compared with White patients in a low upward economic mobility county (odds ratio 0.92, 95% confidence interval 0.77-1.09).

CONCLUSION

These results highlight the differential impact of upward economic mobility and race on postoperative outcomes. Due to the health care implications of socioeconomic status, future policy initiatives should target economic mobility as a means to ensure greater health care equity.

Socioeconomic Predictors of Access to Care for Patients with Operatively Managed Pancreatic Cancer in New York State

PURPOSE

We evaluated how race and socioeconomic factors impact access to high-volume surgical centers, treatment initiation, and postoperative care for pancreatic cancer in a state with robust safety net insurance coverage and healthcare infrastructure.

METHODS

The New York Statewide Planning and Research Cooperative System was analyzed. Patients with pancreatic cancer resected from 2007 to 2017 were identified by ICD and CPT codes. Primary outcomes included surgery at low-volume facilities (< 20 pancreatectomies/year), time to therapy initiation, and time to postoperative surveillance imaging (within 60-180 days after surgery).

RESULTS

In total, 3312 patients underwent pancreatectomy across 124 facilities. Median age was 67 years (IQR 59, 75) and 55% of patients were male. Most (72.7%) had surgery at high-volume centers. On multivariable analysis, odds ratios for surgery at low-volume centers were increased for Black race (2.21 (95% CI 1.69-2.88)), Asian race (1.64 (95% CI 1.09-2.43)), Hispanic ethnicity (1.68 (95% CI 1.24-2.28)), Medicaid insurance (2.52 (95% CI 1.79-3.56)), no insurance (2.24 (95% CI 1.38-3.61)), lowest income quartile (3.31 (95% CI 2.14-5.32)), and rural zip code (2.49 (95% CI 1.69-3.65)). Patients treated at low-volume centers waited longer to initiate treatment (hazard ratio (HR) 0.91 (95% CI 0.81-1.01)). Black patients underwent the least surveillance imaging (50.4%; p < 0.0001), while Asian (HR 2.04, 95% CI 1.40-2.98)) and Hispanic patients (HR 1.36 (95% CI 1.00-1.84)) were more likely to have surveillance imaging.

CONCLUSIONS

Race independently affected access to high-volume facilities and surveillance imaging. When considered in light of other accumulating evidence, future efforts might investigate the perceptions and logistical considerations noted by providers and patients alike to identify the etiology of these disparities and then institute corrective measures.

Social determinants of health associated with poor outcome for rural patients following resected pancreatic cancer

BACKGROUND

The impact of rurality on outcome for patients who had resected pancreatic ductal adenocarcinoma (PDAC) is unclear. We hypothesize that poor outcomes for rural patients are associated with adverse social determinants of health (SDoH). The objective of this study is to assess the difference in overall survival (OS) of PDAC patients between rural, urban, and contributing factors.

METHODS

A cohort of 25,536 patients diagnosed with stage I-III pancreatic adenocarcinoma from 2003 to 2011 and underwent resection were evaluated from the National Cancer Database. Socioeconomic/demographic, clinicopathological, and treatment variables were compared between rural and urban residences. The 5-year OS was calculated using the Kaplan-Meier method. The Cox regression model was used to assess factors associated with OS. P value <0.05 was considered significant.

RESULTS

In univariate analysis, the rural residence was a predictor of poor OS. The 5-year OS for rural (N=4,389) and urban (N=21,147) was 18.8% (95% CI: 17.4-20.2%) and 22.3% (95% CI: 21.6-22.9%; P<0.0001), respectively. The risk of all causes of death was 10.3% higher (P<0.0001) in rural than urban patients. In multivariable analysis, rurality was not an independent predictor of OS (P=0.407). Independent predictors of worse OS included adverse social determinants of health associated with the rural population and these included a low income (P<0.0001), low education level (P<0.01), low insurance status (P<0.01), and treatment at a low-volume facility (P<0.0001).

CONCLUSIONS

Rural/urban outcome disparities for resected stage I-III pancreatic cancer outcome can be explained by adverse social determinants of health associated with rural population.

Undertreatment of Pancreatic Cancer: The Intersection of Bias, Biology, and Geography

Pancreatic cancer is the third leading cause of cancer deaths in the United States. Black patients with pancreatic cancer experience higher incidence and increased mortality. Although racial biologic differences exist, socioeconomic status, insurance type, physician bias, and patient beliefs contribute to the disparities in outcomes observed among patients who are Black, indigenous, and people of color.

Health Care Disparities and the Future of Pancreatic Cancer Care

There have been tremendous advances in the diagnosis and treatment of pancreatic cancer in the past decade, yet we are failing to achieve equitable outcomes for all patient populations. Disparities exist in the incidence, diagnosis, treatment, and outcomes of patients with pancreatic cancer. Inequities are based on racial and ethnic group, sex, socioeconomic status, and geography. To address disparities, future steps must focus on research methods, including collection and methodology, and policy measures, including access, patient tools, hospital incentives, and workforce diversity. Through these comprehensive efforts, we can begin to rectify inequitable care for treatment of patients with pancreatic cancer.

The role of education on Cancer amenable mortality among non-Hispanic blacks & non-Hispanic whites in the United States (1989-2018)

Background

Cancer mortality in the U.S. has fallen in recent decades; however, individuals with lower levels of education experienced a smaller decline than more highly educated individuals. This analysis aimed to measure the influence of education lower than a high school diploma, on cancer amenable mortality among Non-Hispanic Whites (NHW) and Non-Hispanic Blacks (NHB) in the U.S. from 1989 to 2018.

Methods

We analyzed data from 8.2 million death certificates of men and women who died from cancer between 1989 and 2018. We examined 5-year and calendar period intervals, as well as annual percent changes (APC). APC was adjusted for each combination of sex, educational level, and race categories (8 models) to separate the general trend from the effects of age.

Results

Our study demonstrated an increasing mortality gap between the least and the most educated NHW and NHB males and females who died from all cancers combined and for most other cancer types included in this study. The gap between the least and the most educated was broader among NHW males and females than among NHB males and females, respectively, for most malignancies.

Conclusions

In summary, we reported an increasing gap in the age-adjusted cancer mortality among the most and the least educated NHW and NHB between 25 and 74 years of age. We demonstrated that although NHB exhibited the greatest age-adjusted mortality rates for most cancer locations, the gap between the most and the least educated was shown for NHW.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08633-7.

Racial Disparity and Social Determinants in Receiving Timely Surgery Among Stage I-IIIA Non-small Cell Lung Cancer Patients in a U.S. Southern State

Delayed surgery is associated with worse lung cancer outcomes. Social determinants can influence health disparities. This study aimed to examine the potential racial disparity and the effects from social determinants on receipt of timely surgery among lung cancer patients in Louisiana, a southern state in the U.S. White and black stage I-IIIA non-small cell lung cancer patients diagnosed in Louisiana between 2004 and 2016, receiving surgical lobectomy or a more extensive surgery, were selected. Diagnosis-to-surgery interval >6 weeks were considered as delayed surgery. Social determinants included marital status, insurance, census tract level poverty, and census tract level urbanicity. Multivariable logistic regression and generalized multiple mediation analysis were conducted. A total of 3,616 white (78.9%) and black (21.1%) patients were identified. The median time interval from diagnosis to surgery was 27 days in whites and 42 days in blacks (P < 0.0001). About 28.7% of white and 48.4% of black patients received delayed surgery (P < 0.0001). Black patients had almost two-fold odds of receiving delayed surgery than white patients (adjusted odds ratio: 1.91; 95% confidence interval: 1.59-2.30). Social determinants explained about 26% of the racial disparity in receiving delayed surgery. Having social support, private insurance, and living in census tracts with lower poverty level were associated with improved access to timely surgery. The census tract level poverty level a stronger effect on delayed surgery in black patients than in white patients. Tailored interventions to improve the timely treatment in NSCLC patients, especially black patients, are needed in the future.

Race and ethnicity representation in clinical trials: findings from a literature review of Phase I oncology trials

Aim: To provide an assessment of published literature on the demographic representation in Phase I trials of biopharmaceutical oncology agents. Materials & methods: We conducted a rapid evidence assessment to identify demographic representation reported in Phase I clinical trials for biopharmaceutical oncology agents published in 2019. Results: Globally, the population was predominantly White/Caucasian (62.2%). In the USA, the distribution was heavily skewed toward White/Caucasian (84.2%), with minimal representation of Blacks/African-Americans (7.3%), Asians (3.4%), Hispanics/Latinos (2.8%) or other race/ethnicity groups. Conclusion: Our data highlight that Phase I oncology trials do not reflect the population at large, which may perpetuate health disparities. Further research is needed to understand and address barriers to participation, particularly among under-represented groups.

Impact of Race/Ethnicity and County-Level Vulnerability on Receipt of Surgery Among Older Medicare Beneficiaries With the Diagnosis of Early Pancreatic Cancer

BACKGROUND

Patients can experience barriers and disparities to access high-quality cancer care. This study sought to characterize receipt of surgery and chemotherapy among Medicare beneficiaries with a diagnosis of early-stage pancreatic adenocarcinoma cancer (PDAC) relative to race/ethnicity and social vulnerability.

METHODS

The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify patients with a diagnosis of early-stage (stage 1 or 2) PDAC between 2004 and 2016. Data were merged with the CDC's Social Vulnerability Index (SVI) at the beneficiary's county of residence. Multivariable, mixed-effects logistic regression was used to assess the association of SVI with resection.

RESULTS

Among 15,931 older Medicare beneficiaries with early-stage PDAC (median age, 77 years; interquartile range [IQR], 71-82 years), the majority was White (n = 12,737, 80.0 %), whereas a smaller subset was Black or Latino (n = 3194, 20.0 %) A minority of patients was more likely to live in highly vulnerable communities (low SVI: white [90.5 %] vs minority [9.5 %] vs high SVI: white [71.9 %] vs minority [28.1 %]; p < 0.001). Use of resection for early-stage PDAC was lowest among the patients who resided in high-SVI areas (low [38.0 %] vs average [34.3 %] vs high [31.9 %]; p < 0.001). The minority patients were less likely to undergo resection than the White patients (no resection: white [64.1 %] vs minority [70.7 %]; p < 0.001). The median SVI was higher among the patients who underwent resection (57.6; IQR, 36.0-81.0) than among those who did not (60.4; IQR, 41.9-84.3), and increased SVI resulted in a decline in the likelihood of resection (SVI trend: OR, 0.98; 95 % confidence interval [CI], 0.97-1.00), especially among the minority patients. Minority patients from high-SVI counties had markedly lower odds of preoperative chemotherapy than minority patients from a low-SVI neighborhood (OR, 0.62; 95 % CI, 0.52-0.73).

CONCLUSIONS

Older Medicare beneficiaries with early-stage PDAC residing in counties with higher social vulnerability had lower odds of undergoing pancreatic resection, which was more pronounced among minority versus older White Medicare beneficiaries.

Municipality and Adjusted Gross Income Influence Outcome of Patients Diagnosed with Pancreatic Cancer in a Newly Developed Cancer Center in Mercer County New Jersey, USA, a Single Center Study

Socioeconomic status (SES) correlates directly to ZIP code. Mercer County is not atypical as a collection of a dozen municipalities with a suburban/metropolitan population of 370,430 in the immediate vicinity of a major medical center. The purpose of this study for Mercer County, New Jersey, USA is to determine whether a patient's ZIP code is related to the outlook of pancreatic cancer defined as staging at diagnosis, prevalence, overall survival, type of insurance, and recurrence. Our hypothesis was that specific variables such as socio-economic status or race could be linked to the outcome of patients with pancreatic cancer. We interrogated a convenience sample from our cancer center registry and obtained 479 subjects diagnosed with pancreatic cancer in 1998-2018. We selected 339 subjects by ZIP code, representing the plurality of the cases in our catchment area. The outcome variable was overall survival; predictor variables were socio-economic status (SES), recurrence, insurance, type of treatment, gender, cancer stage, age, and race. We converted ZIP code to municipality and culled data using adjusted gross income (AGI, FY 2017). Comparative statistical analysis was performed using chi-square tests for nominal and ordinal variables, and a two-way ANOVA test was used for continuous variables; the p-value was set at 0.05. Our analysis confirmed that overall survival was significantly higher for Whites and for individuals who live in a municipality with a high SES. Tumor stage at the time of diagnosis was not different among race and SES; however, statistically significant differences for race or SES existed in the type of treatment received, with disparities found in those who received radiation therapy and surgery but not chemotherapy. The data may point to a lack of access to specific care modalities that subsequently may lead to lower survival in an underserved population. Access to care, optimal nutritional status, overall fitness, and co-morbidities could play a major role and confound the results. Our study suggests that low SES has a negative impact on overall pancreatic cancer survival. Surgery for pancreatic cancer should be appropriately decentralized to those community cancer centers that possess the expertise and the infrastructure to carry out specialized treatments regardless of race, ethnicity, SES, and insurance.

Microbiome and pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) incidence and related-deaths are increasing worldwide. PDAC is characterized by poor prognosis due to late diagnosis, high metastatic capacity and resistance to therapy. This is partially due to its specific microenvironment, where the stroma is prominent over tumor cells. Besides the oral and gut microbiota, the intratumor microbiome, i.e. the bacterial and fungal microorganisms present within the tumor, was recently introduced as a new partner of the tumor microenvironment of PDAC modulating pancreatic carcinogenesis, intratumor immune infiltrates, and response to chemotherapy. In this review, we propose an overview of current knowledge about the roles of bacteria and fungi in PDAC development and biology, and discuss potential therapeutic implications.

Thirty-day complication rates do not differ by race among patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma

BACKGROUND AND OBJECTIVES

Black patients with pancreatic ductal adenocarcinoma (PDAC) are less likely to receive multimodality treatment and have worse survival compared to White patients. However, little is known regarding racial differences in postoperative outcomes. The primary aim of this study was to determine if 30-day complication rates following pancreaticoduodenectomy (PD) differ by race.

METHODS

A retrospective cohort study of patients who underwent PD for PDAC from 2014 to 2016 within the ACS-NSQIP pancreatectomy-specific data set was performed. Primary outcomes were 30-day pancreas-specific and overall major complications.

RESULTS

A total of 6936 patients were identified, including 91.4% (N = 6337) White and 8.6% (N = 599) Black. Pathologic stage and rates of neoadjuvant therapy were similar among Whites and Blacks. Rates of pancreas-specific (23.9% vs. 23.1%, p = .88) and major postoperative complications (39.2% vs. 39.9%, p = .55) were similar between Whites and Blacks. By multivariable regression analysis, there was no association between race and odds of pancreas-specific complications (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.89-1.37) or overall major complications (OR 1.13, 95% CI 0.95-1.36).

CONCLUSIONS

Among patients undergoing PD for PDAC, Black race is not associated with increased pancreas-specific or overall 30-day postoperative complications. Short-term postoperative outcomes do not appear to explain the increase in pancreatic cancer mortality among Black patients.

Cancer health disparities in racial/ethnic minorities in the United States

There are well-established disparities in cancer incidence and outcomes by race/ethnicity that result from the interplay between structural, socioeconomic, socio-environmental, behavioural and biological factors. However, large research studies designed to investigate factors contributing to cancer aetiology and progression have mainly focused on populations of European origin. The limitations in clinicopathological and genetic data, as well as the reduced availability of biospecimens from diverse populations, contribute to the knowledge gap and have the potential to widen cancer health disparities. In this review, we summarise reported disparities and associated factors in the United States of America (USA) for the most common cancers (breast, prostate, lung and colon), and for a subset of other cancers that highlight the complexity of disparities (gastric, liver, pancreas and leukaemia). We focus on populations commonly identified and referred to as racial/ethnic minorities in the USA-African Americans/Blacks, American Indians and Alaska Natives, Asians, Native Hawaiians/other Pacific Islanders and Hispanics/Latinos. We conclude that even though substantial progress has been made in understanding the factors underlying cancer health disparities, marked inequities persist. Additional efforts are needed to include participants from diverse populations in the research of cancer aetiology, biology and treatment. Furthermore, to eliminate cancer health disparities, it will be necessary to facilitate access to, and utilisation of, health services to all individuals, and to address structural inequities, including racism, that disproportionally affect racial/ethnic minorities in the USA.

Sex-based differences in time to surgical care among pancreatic cancer patients: A national study of Medicare beneficiaries

INTRODUCTION

The objective of this study was to characterize time from cancer symptoms to diagnosis and time from diagnosis to surgical treatment among patients undergoing pancreatectomy for cancer.

METHODS

Medicare beneficiaries who underwent pancreatectomy for cancer between 2013 and 2017 were identified using the 100% Medicare Inpatient Standard Analytic Files. Mixed effects negative binomial regression models were utilized to determine which factors were associated with the number of weeks to diagnosis and pancreatic resection.

RESULTS

Among 7647 Medicare beneficiaries, two-thirds (n = 5127, 67%) had symptoms associated with a pancreatic cancer diagnosis before surgery. Median time from the first symptom to diagnosis was 6 weeks (IQR: 1-25) and the median time from diagnosis to surgery was 4 weeks (IQR: 2-15). In risk-adjusted models, female patients had 13% longer waiting times from identification of a related symptom to pancreatic cancer diagnosis (OR = 1.13, 95% CI: 1.05-1.21) and 12% longer waiting times from diagnosis to surgery (OR = 1.12, 95% CI: 1.07-1.18). Older age was associated with 10% longer waiting times from symptom identification to diagnosis (p < .0001).

CONCLUSIONS

Female and older patients had longer wait times between symptom presentation and pancreatic cancer diagnosis. Sex-based disparities in cancer care need to be recognized and addressed by policymakers and health care institutions.

Cholangiocyte derived carcinomas and local microbiota

Trillions of bacteria are present in the gastrointestinal tract as part of the local microbiota. Bacteria have been associated with a wide range of gastrointestinal diseases including malignant neoplasms. The association of bacteria in gastrointestinal and biliary tract carcinogenesis is supported in the paradigm of Helicobacter pylori and intestinal-type gastric cancer. However, the association of bacterial species to a specific carcinoma, different from intestinal-type gastric cancer is unresolved. The relationship of bacteria to a specific malignant neoplasm can drive clinical interventions. We review the classic bacteria risk factors identified using cultures and PCR (polymerase chain reaction) with new research regarding a microbiota approach through 16S rRNA (16S ribosomal ribonucleic acid gene) or metagenomic analysis for selected carcinomas in the biliary tract.

Biliary Tract Carcinogenesis Model Based on Bile Metaproteomics

Purpose: To analyze human and bacteria proteomic profiles in bile, exposed to a tumor vs. non-tumor microenvironment, in order to identify differences between these conditions, which may contribute to a better understanding of pancreatic carcinogenesis.

Patients and Methods: Using liquid chromatography and mass spectrometry, human and bacterial proteomic profiles of a total of 20 bile samples (7 from gallstone (GS) patients, and 13 from pancreatic head ductal adenocarcinoma (PDAC) patients) that were collected during surgery and taken directly from the gallbladder, were compared. g:Profiler and KEGG (Kyoto Encyclopedia of Genes and Genomes) Mapper Reconstruct Pathway were used as the main comparative platform focusing on over-represented biological pathways among human proteins and interaction pathways among bacterial proteins.

Results: Three bacterial infection pathways were over-represented in the human PDAC group of proteins. IL-8 is the only human protein that coincides in the three pathways and this protein is only present in the PDAC group. Quantitative and qualitative differences in bacterial proteins suggest a dysbiotic microenvironment in the PDAC group, supported by significant participation of antibiotic biosynthesis enzymes. Prokaryotes interaction signaling pathways highlight the presence of zeatin in the GS group and surfactin in the PDAC group, the former in the metabolism of terpenoids and polyketides, and the latter in both metabolisms of terpenoids, polyketides and quorum sensing. Based on our findings, we propose a bacterial-induced carcinogenesis model for the biliary tract.

Conclusion: To the best of our knowledge this is the first study with the aim of comparing human and bacterial bile proteins in a tumor vs. non-tumor microenvironment. We proposed a new carcinogenesis model for the biliary tract based on bile metaproteomic findings. Our results suggest that bacteria may be key players in biliary tract carcinogenesis, in a long-lasting dysbiotic and epithelially harmful microenvironment, in which specific bacterial species' biofilm formation is of utmost importance. Our finding should be further explored in future using in vitro and in vivo investigations.

Young Adults With Pancreatic Cancer: National Trends in Treatment and Outcomes

OBJECTIVES

The treatment and outcomes of patients younger than 50 years (young adults [YAs]) with pancreatic cancer are largely unknown. We evaluated the presentation, treatment, and outcomes of these patients.

METHODS

The National Cancer Database was analyzed. Univariate and multivariate Cox proportional hazards models were performed to identify variables associated with overall survival.

RESULTS

A total of 124,442 patients with pancreatic cancer were identified, with 9657 between 18 and 50 years of age. Mean age was 45.4 years (standard deviation, 4.6 years). About 30.9% of YA patients and 25% of patients older than 50 years underwent resection of the primary tumor. Survival advantage was seen for patients 18 to 39 years (hazard ratio, 1.14; 95% confidence interval, 1.07-1.23; P < 0.001). This age advantage was similar across all the racial groups. Overall, YAs treated between 2009 and 2013 had higher survival rates compared with 2004 to 2008 (hazard ratio, 0.85; 95% confidence interval, 0.81-0.89; P < 0.001). This survival improvement was highest in American Indians and Asian/Pacific Islanders (16.6% vs 6.5%), African Americans (10.6% vs 8.5%), and Hispanics (14.5% vs 12.6%).

CONCLUSIONS

Survival of YAs with pancreatic cancer patients is superior to older patients and has improved over time, especially in minority populations.

SWATH-MS based proteomic profiling of pancreatic ductal adenocarcinoma tumours reveals the interplay between the extracellular matrix and related intracellular pathways

Pancreatic cancer accounts for 2.8% of new cancer cases worldwide and is projected to become the second leading cause of cancer-related deaths by 2030. Patients of African ancestry appear to be at an increased risk for pancreatic ductal adenocarcinoma (PDAC), with more severe disease and outcomes. The purpose of this study was to map the proteomic and genomic landscape of a cohort of PDAC patients of African ancestry. Thirty tissues (15 tumours and 15 normal adjacent tissues) were obtained from consenting South African PDAC patients. Optimisation of the sample preparation method allowed for the simultaneous extraction of high-purity protein and DNA for SWATH-MS and OncoArray SNV analyses. We quantified 3402 proteins with 49 upregulated and 35 downregulated proteins at a minimum 2.1 fold change and FDR adjusted p-value (q-value) ≤ 0.01 when comparing tumour to normal adjacent tissue. Many of the upregulated proteins in the tumour samples are involved in extracellular matrix formation (ECM) and related intracellular pathways. In addition, proteins such as EMIL1, KBTB2, and ZCCHV involved in the regulation of ECM proteins were observed to be dysregulated in pancreatic tumours. Downregulation of pathways involved in oxygen and carbon dioxide transport were observed. Genotype data showed missense mutations in some upregulated proteins, such as MYPN, ESTY2 and SERPINB8. Approximately 11% of the dysregulated proteins, including ISLR, BP1, PTK7 and OLFL3, were predicted to be secretory proteins. These findings help in further elucidating the biology of PDAC and may aid in identifying future plausible markers for the disease.

Community-based exercise programs for cancer survivors: a scoping review of practice-based evidence

PURPOSE

Based on randomized controlled trials, exercise is an efficacious strategy to improve quality of life (QOL) among cancer survivors. However, the effectiveness of exercise programs to improve QOL in real-world settings is unknown, as are factors related to external validity. This hinders dissemination and scalability. This scoping review synthesized published research on community-based exercise programs for cancer survivors and reported on the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM).

METHODS

A systematic literature search identified community-based exercise programs for adult cancer survivors (1980-March 2018), that met the following inclusion criteria: at least one face-to-face exercise session, the primary aim of program evaluation (i.e., feasibility/effectiveness), and pre/post measure of QOL. Data were coded using the RE-AIM framework. The effect size was calculated for overall QOL.

RESULTS

Electronic database search yielded 553 articles; 31 studies describing unique programs were included for review. All studies described at least one element of implementation and most (80.6%) reported a significant (p < .05) improvement in at least one subscale, or total QOL. Few studies reported on indicators of reach (16.1%), adoption (6.5%), individual (16.1%), or system-level maintenance (32.3%).

CONCLUSIONS

Community-based exercise programs are effective for improving QOL in adult cancer survivors. Recommendations are provided to improve reporting across RE-AIM dimensions, which is an important step to enhance the scalability of programs and thus, the potential for exercise to be fully integrated into system-level standard care for cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Community-based exercise programs are a resource to improve QOL for adult cancer survivors.

Disparities in Pancreatic Cancer Treatment and Outcomes

Purpose: Pancreatic cancer remains a major health concern; in the next 2 years, it will become the second leading cause of cancer deaths in the United States. Health disparities in the treatment of pancreatic cancer exist across many disciplines, including race and ethnicity, socioeconomic status (SES), and insurance. This narrative review discusses what is known about these disparities, with the goal of highlighting targets for equity promoting interventions.

Methods: We performed a narrative review of health disparities in pancreatic cancer spanning greater than ten areas, including epidemiology, treatment, and outcome, using the PubMed NIH database from 2000 to 2019 in the Unites States.

Results: African Americans (AAs) tend to present at diagnosis with later stage disease. AAs and Hispanics have lower rates of surgical resection, are more likely to be treated at low volume hospitals, and often experience higher rates of morbidity and mortality compared to white patients, although control for confounders is often limited. Insurance and SES also factor into the delivery of treatment for pancreatic cancer.

Conclusion: Disparities by race and SES exist in the diagnosis and treatment of pancreatic cancer that are largely driven by race and SES. Improved understanding of underlying causes could inform interventions.

Racial and ethnic disparities in a state-wide registry of patients with pancreatic cancer and an exploratory investigation of cancer cachexia as a contributor to observed inequities

Pancreatic cancer (PC) is characterized by racial/ethnic disparities and the debilitating muscle-wasting condition, cancer cachexia. Florida ranks second in the number of PC deaths and has a large and understudied minority population. We examined the primary hypothesis that PC incidence and mortality rates may be highest among Black Floridians and the secondary hypothesis that biological correlates of cancer cachexia may underlie disparities. PC incidence and mortality rates were estimated by race/ethnicity, gender, and county using publicly available state-wide cancer registry data that included approximately 2700 Black, 25 200 Non-Hispanic White (NHW), and 3300 Hispanic/Latino (H/L) Floridians diagnosed between 2004 and 2014. Blacks within Florida experienced a significantly (P < 0.05) higher incidence (12.5/100 000) and mortality (10.97/100 000) compared to NHW (incidence = 11.2/100 000; mortality = 10.3/100 000) and H/L (incidence = 9.6/100 000; mortality = 8.7/100 000), especially in rural counties. To investigate radiologic and blood-based correlates of cachexia, we leveraged data from a subset of patients evaluated at two geographically distinct Florida Cancer Centers. In Blacks compared to NHW matched on stage, markers of PC-induced cachexia were more frequent and included greater decreases in core musculature compared to corresponding healthy control patients (25.0% vs 10.1% lower), greater decreases in psoas musculature over time (10.5% vs 4.8% loss), lower baseline serum albumin levels (3.8 vs 4.0 gm/dL), and higher platelet counts (332.8 vs 268.7 k/UL). Together, these findings suggest for the first time that PC and cachexia may affect Blacks disproportionately. Given its nearly universal contribution to illness and PC-related deaths, the early diagnosis and treatment of cachexia may represent an avenue to improve health equity, quality of life, and survival.