Inferior survival of advanced pancreatic cancer patients who received gemcitabine-based chemotherapy but did not participate in clinical trials

Competing Risk Analysis of Outcomes of Unresectable Pancreatic Cancer Patients Undergoing Definitive Radiotherapy

PURPOSE

We investigated potential factors, including clinicopathological features, treatment modalities, neutrophil-to-lymphocyte ratio (NLR), carbohydrate antigen (CA) 19-9 level, tumor responses correlating with overall survival (OS), local progression (LP), and distant metastases (DMs), in patients with locally advanced pancreatic cancer (LAPC) who received definitive radiotherapy (RT).

METHODS

We retrospectively analyzed demographic characteristics; biologically effective doses (BED10, calculated with an α/β of 10) of RT; and clinical outcomes of 57 unresectable LAPC (all pancreatic adenocarcinoma) patients receiving definitive RT using modern techniques with and without systemic therapy between January 2009 and March 2019 at our institution. We used Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 to evaluate the radiographic tumor response after RT. The association between prognostic factors and OS was assessed using the Kaplan-Meier analysis and a Cox regression model, whereas baseline characteristics and treatment details were collected for competing-risk regression of the association with LP and DM using the Fine-Gray model.

RESULTS

A median BED10 of 67.1 Gy resulted in a disease control rate of 87.7%, and the median OS was 11.8 months after a median follow-up of 32.1 months. The 1-year OS rate, cumulative incidences of LP, and DM were 49.2%, 38.5%, and 62.9%, respectively. Multivariate analyses showed that pre-RT NLR ≥3.5 (adjusted hazard ratio [HR] = 8.245, p < 0.001), CA19-9 reduction rate ≥50% (adjusted HR = 0.261, p = 0.005), RT without concurrent chemoradiotherapy (adjusted HR = 5.903, p = 0.004), and administration of chemotherapy after RT (adjusted HR = 0.207, p = 0.03) were independent prognostic factors for OS. Positive lymph nodal metastases (adjusted subdistribution HR [sHR] = 3.712, p = 0.003) and higher tumor reduction after RT (adjusted sHR = 0.922, p < 0.001) were significant prognostic factors for LP, whereas BED10 ≥ 67.1 Gy (adjusted sHR = 0.297, p = 0.002), CA19-9 reduction rate ≥50% (adjusted sHR = 0.334, p = 0.023), and RT alone (adjusted sHR = 2.633, p = 0.047) were significant prognostic factors for DM.

CONCLUSION

Our results indicate that pre-RT NLR and post-RT monitoring of CA19-9 and tumor size reduction can help identify whether patients belong to the good or poor prognostic group of LAPC. The incorporation of new systemic treatments during and after a higher BED10 RT dose for LAPC patients is warranted.

Contribution of nuclear BCL10 expression to tumor progression and poor prognosis of advanced and/or metastatic pancreatic ductal adenocarcinoma by activating NF-κB-related signaling

BACKGROUND

We previously demonstrated that nuclear BCL10 translocation participates in the instigation of NF-κB in breast cancer and lymphoma cell lines. In this study, we assessed whether nuclear BCL10 translocation is clinically significant in advanced and metastatic pancreatic ductal adenocarcinoma (PDAC).

METHOD AND MATERIALS

We analyzed the expression of BCL10-, cell cycle-, and NF-κB- related signaling molecules, and the DNA-binding activity of NF-κB in three PDAC cell lines (mutant KRAS lines: PANC-1 and AsPC-1; wild-type KRAS line: BxPC-3) using BCL10 short hairpin RNA (shBCL10). To assess the anti-tumor effect of BCL10 knockdown in PDAC xenograft model, PANC-1 cells treated with or without shBCL10 transfection were inoculated into the flanks of mice. We assessed the expression patterns of BCL10 and NF-κB in tumor cells in 136 patients with recurrent, advanced, and metastatic PDAC using immunohistochemical staining.

RESULTS

We revealed that shBCL10 transfection caused cytoplasmic translocation of BCL10 from the nuclei, inhibited cell viability, and enhanced the cytotoxicities of gemcitabine and oxaliplatin in three PDAC cell lines. Inhibition of BCL10 differentially blocked cell cycle progression in PDAC cell lines. Arrest at G1 phase was noted in wild-type KRAS cell lines; and arrest at G2/M phase was noted in mutant KRAS cell lines. Furthermore, shBCL10 transfection downregulated the expression of phospho-CDC2, phospho-CDC25C, Cyclin B1 (PANC-1), Cyclins A, D1, and E, CDK2, and CDK4 (BxPC-3), p-IκBα, nuclear expression of BCL10, BCL3, and NF-κB (p65), and attenuated the NF-κB pathway activation and its downstream molecule, c-Myc, while inhibition of BCL10 upregulated expression of p21, and p27 in both PANC-1 and BxPC-3 cells. In a PANC-1-xenograft mouse model, inhibition of BCL10 expression also attenuated the tumor growth of PDAC. In clinical samples, nuclear BCL10 expression was closely associated with nuclear NF-κB expression (p < 0.001), and patients with nuclear BCL10 expression had the worse median overall survival than those without nuclear BCL10 expression (6.90 months versus 9.53 months, p = 0.019).

CONCLUSION

Nuclear BCL10 translocation activates NF-κB signaling and contributes to tumor progression and poor prognosis of advanced/metastatic PDAC.

Postoperative Imaging and Tumor Marker Surveillance in Resected Pancreatic Cancer

Background: Pancreatic cancer is a catastrophic disease with high recurrence and death rates, even in early stages. Early detection and early treatment improve survival in many cancer types but have not yet been clearly documented to do so in pancreatic cancer. In this study, we assessed the benefit on survival resulting from different patterns of surveillance in daily practice after curative surgery of early pancreatic cancer. Methods: Patients with pancreatic ductal adenocarcinoma who had received curative surgery between January 2000 and December 2013 at our institute were retrospectively reviewed. Patients were classified into one of four groups, based on surveillance strategy: the symptom group, the imaging group, the marker group (carbohydrate antigen 19-9 and/or carcinoembryonic antigen), and the intense group (both imaging and tumor marker assessment). Overall survival (OS), relapse-free survival (RFS), and post-recurrence overall survival (PROS) were evaluated. Results: One hundred and eighty-one patients with documented recurrence or metastasis were included in our analysis. The median OS for patients in the symptom group, imaging group, marker group, and intense group were 21.4 months, 13.9 months, 20.5 months, and 16.5 months, respectively (p = 0.670). Surveillance with imaging, tumor markers, or both was not an independent risk factor for OS in univariate and multivariate analyses. There was no significant difference in median RFS (symptom group, 11.7 months; imaging group, 6.3 months; marker group, 9.3 months; intense group, 6.9 months; p = 0.259) or median PROS (symptom group, 6.9 months; imaging group, 7.5 months; marker group, 5.0 months; intense group, 7.8 months; p = 0.953) between the four groups. Multivariate analyses identified poor Eastern Cooperative Oncology Group Performance Status (ECOG PS) (≥1), primary tumor site (tail), and tumor grade (poor differentiation) were poor prognostic factors for OS. Conclusions: Surveillance with regular imaging, tumor marker, or both was not an independent risk factor for OS of pancreatic cancer patients who undergo curative tumor resection.

Clinical characteristics and outcomes of patients enrolled in clinical trials compared with those of patients outside clinical trials in advanced gastric cancer

AIMS

Participating in clinical trials could give cancer patients potential benefits such as experimental treatment, meticulous follow-up, and management of toxicities. We hypothesized that patients participating in clinical trials would achieve better survival outcomes than those not enrolled in trials. We assessed whether the trial effect can improve survival for patients with advanced gastric cancer.

METHODS

We retrospectively enrolled metastatic or recurrent gastric cancer patients who received palliative chemotherapy from January 2010 to December 2012. All patients in this study received fluoropyrimidine and platinum as the first-line palliative chemotherapy. Patients participating in clinical trials were matched 1:1 with patients not enrolled in trial based on propensity-score.

RESULTS

A total of 229 patients were identified, 83 (36.2%) among them participated in 14 clinical trials for advanced gastric cancer. The number of patients enrolled in phase I, II and III trials were 10, 54 and 19, respectively. The median overall survival of the total study patients was 13.0 months (95% confidence interval, 10.7-15.3 months). In the propensity-score matched population, a total of 78 matched pairs of patients were generated. The median overall survival of the 78 patients who participated in the clinical trials was 6 months longer than that of patients not enrolled in trials, although this benefit was marginally significant (15 months vs 9 months, hazard ratio, 0.709; p = 0.068). Participation in clinical trials was a significant factor to predict better overall survival in multivariate analysis (hazard ratio, 0.533, p = 0.001).

CONCLUSION

Trial effect may contribute to prolongation of overall survival in patients who participate in clinical trials for advanced gastric cancer. Physicians may discuss trial effect to encourage participation in clinical trials.

Experimental study on the therapeutic effect and underlining mechanisms of positron in pancreatic cancer cells

The purpose of this study was to assess the potential therapeutic effect of positrons emitted by ¹⁸F-2-Deoxy-2-Fluoro-D-Glucose (¹⁸F-FDG) on pancreatic cancer cells and elucidate its underlying mechanisms. Pancreatic cancer cells were incubated with different radioactive concentrations of ¹⁸F-FDG and evaluated for anti-cancer properties and underlining mechanisms. In addition, three groups of tumor-bearing mice were treated with different doses of ¹⁸F-FDG weekly, the tumor growth rate was calculated, and the mice were imaged by positron emission tomography (PET) with ¹⁸F-FDG before and after treatment. The presence of apoptosis was detected by terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) stain and immunohistochemistry analysis. All treated groups exhibited positron-inhibited proliferation and positron-induced apoptosis compared with the control group in vitro. Further, we noted that higher treatment dose correlated with a better treatment response. In vivo, the high dose administration of ¹⁸F-FDG reduced tumor growth and prolonged the survival of treated mice compared with the control group with no change in the behavior or normal tissues of the mice. Immunohistochemical analysis and TUNEL stain showed more apoptotic cells than that in control group. The results demonstrated that positron radiation inhibited the proliferation and induced apoptosis of pancreatic cancer cells in vitro and in vivo, via an endogenous mitochondria-mediated signaling pathway.

Association of radiotherapy with favorable prognosis in daily clinical practice for treatment of locally advanced and metastatic pancreatic cancer

BACKGROUND AND AIM

Radiotherapy (RT) with or without chemotherapy is currently used in definitive therapy for advanced pancreatic cancer. We sought to evaluate the prognostic significance, pattern of care, and use of RT in locally advanced and metastatic pancreatic cancer.

METHODS

Between 2002 and 2011, patients with invasive pancreatic carcinoma and prior exposure to systemic chemotherapy were included. We used Cox regression model and propensity score matching for prognostic analyses and logistic regression for analyzing the factors impacting the use of RT.

RESULTS

We identified 217 pancreatic cancer patients (74 with unresectable stage II or III and 143 with stage IV). Of all patients, 90.8% had adenocarcinoma, and only 19.2% (42/217) received RT with doses ranging from 50 to 55 Gy in 25 to 28 fractions using modern RT techniques. Logistic regression showed stage (P < 0.001) and initial CA 19-9 level (P = 0.026) were significantly predictive of the choice of RT as a first-line treatment, whereas the second-line use of RT was associated with the response to first-line chemotherapy and longer progression-free survival. Patients with RT had a better median survival than those without it (14.6 vs 8.1 months, P < 0.001). In the multivariate analysis and propensity score matching, RT remained a good prognostic factor for overall survival.

CONCLUSION

The use of RT might be associated with a favorable clinical outcome in patients with locally advanced and metastatic pancreatic cancer. Further exploration of RT as a first-line therapy or second-line therapy for locally advanced or even metastatic pancreatic cancer is warranted.

Perspectives on the combination of radiotherapy and targeted therapy with DNA repair inhibitors in the treatment of pancreatic cancer

Pancreatic cancer is highly lethal. Current research that combines radiation with targeted therapy may dramatically improve prognosis. Cancerous cells are characterized by unstable genomes and activation of DNA repair pathways, which are indicated by increased phosphorylation of numerous factors, including H2AX, ATM, ATR, Chk1, Chk2, DNA-PKcs, Rad51, and Ku70/Ku80 heterodimers. Radiotherapy causes DNA damage. Cancer cells can be made more sensitive to the effects of radiation (radiosensitization) through inhibition of DNA repair pathways. The synergistic effects, of two or more combined non-lethal treatments, led to co-administration of chemotherapy and radiosensitization in BRCA-defective cells and patients, with promising results. ATM/Chk2 and ATR/Chk1 pathways are principal regulators of cell cycle arrest, following DNA double-strand or single-strand breaks. DNA double-stranded breaks activate DNA-dependent protein kinase, catalytic subunit (DNA-PKcs). It forms a holoenzyme with Ku70/Ku80 heterodimers, called DNA-PK, which catalyzes the joining of nonhomologous ends. This is the primary repair pathway utilized in human cells after exposure to ionizing radiation. Radiosensitization, induced by inhibitors of ATM, ATR, Chk1, Chk2, Wee1, PP2A, or DNA-PK, has been demonstrated in preclinical pancreatic cancer studies. Clinical trials are underway. Development of agents that inhibit DNA repair pathways to be clinically used in combination with radiotherapy is warranted for the treatment of pancreatic cancer.

Patient and caregiver awareness of pancreatic cancer treatments and clinical trials

BACKGROUND

The poor prognosis of pancreatic cancer has been well established. For many patients, active treatments can improve patient outcomes, such as overall survival and symptom control. Nevertheless, there is evidence that pancreatic cancer is undertreated, even in patients with resectable disease. In addition, although participation in a clinical trial is recommended by current pancreatic cancer treatment guidelines, recent data suggest that patient participation in ongoing trials is below overall target accrual.

METHODS

A survey was prepared and distributed to patients with pancreatic cancer and caregivers of patients with pancreatic cancer by the Pancreatic Cancer Action Network (funding for the survey was provided by Celgene Corporation). The 70-question survey was completed between July 30, 2013, and September 18, 2013, by respondents in the United States. The goal of this analysis was to evaluate patient and caregiver interactions with physicians about pancreatic cancer treatments and participation in clinical trials.

RESULTS

The survey was completed by 184 patients and 213 caregivers (not necessarily paired). Quality of life, extension of survival, and symptom management were identified as the most important concerns among both patients and caregivers. A large majority of respondents (94.9%) reported that the patient followed the physician's treatment recommendation. Approximately 30% of respondents indicated that the diagnosing physician offered treatment options at the time of diagnosis. Among the respondents who indicated that the physician did not offer treatment options at diagnosis, 20.4% stated that no doctor had ever spoken to them about treatment options. Most respondents (83.1%) reported that the patient received chemotherapy for pancreatic cancer. Approximately half of respondents (49.1%) indicated that they had never discussed clinical trials with a physician. Twelve percent of respondents reported that the patient participated in a clinical trial. In those cases, physicians were listed as the primary source of trial information 80.4% of the time. Familiarity with Patient Central (known as "Patient and Liaison Services" at the time of the study), a support service offered by the Pancreatic Cancer Action Network, was associated with higher rates of receiving treatment (P<0.05), searching the Internet for information on clinical trials (P<0.05), and participating in clinical trials (not statistically significant).

CONCLUSIONS

The results of this study suggest that large numbers of patients and caregivers had never had discussions with physicians about pancreatic cancer treatments or clinical trials. The point about trials takes on even greater importance, considering that patients who participate in clinical trials report better outcomes than those receiving the same treatment outside of clinical trials. Increased discussions with patients could potentially increase treatment and trial participation, possibly improving patient- and caregiver-stated priorities of quality of life, extension of survival, and symptom management.

Diabetes, insulin use, smoking, and pancreatic cancer mortality in Taiwan

The aim of the study was to evaluate the link between diabetes and pancreatic cancer (PC) mortality and the joint effect of smoking and insulin use on PC mortality. A total of 39,988 men and 46,909 women with type 2 diabetes, aged ≥25 years and recruited in 1995-1998, were followed to 2006 for PC mortality. Age-sex-specific mortality rate ratios for diabetic patients versus the general population were calculated. Cox regression was used to evaluate hazard ratios for PC mortality for covariates including age, sex, diabetes duration, body mass index, smoking, insulin use, and area of residence. The interaction and joint effect of smoking and insulin use were also evaluated. A total of 89 men and 63 women died of PC. The mortality rate ratios (95 % CI) showed a significantly higher risk in diabetic patients with a magnitude most remarkable at the youngest age: 1.51 (1.15, 1.98), 2.02 (1.35, 3.03), and 8.36 (5.39, 12.98) for ≥65, 55-64, and 25-54 years old, respectively, for men; and 1.16 (0.84, 1.59), 2.12 (1.39, 3.23) and 3.33 (1.14, 9.68), respectively, for women. In multivariable Cox regression analysis, only age was significantly predictive for PC mortality. Although smoking and insulin use might be associated with a 50 % higher risk when analyzed as individual risk factors, they did not reach statistical significance. The interaction term of smoking and insulin use was also not statistically significant in additional modeling. However, smoking and insulin use jointly increased the risk with an adjusted hazard ratio (95 % CI) of 3.04 (1.37, 6.73) when compared to patients who did not smoke and did not use insulin. Diabetic patients have a significantly higher risk of PC mortality. In patients with type 2 diabetes, smoking and insulin use may jointly increase the risk by threefold.

Sequential gemcitabine and platinum versus first-line combination of gemcitabine and platinum for advanced pancreatic cancer treatment: a retrospective study

OBJECTIVE

The purpose of this study was to investigate the impact of combinational versus sequential gemcitabine and platinum on prognosis of advanced pancreatic cancer.

METHODS

Two hundred and three patients with advanced pancreatic cancer were selected. They were divided into GemP (first-line gemcitabine and platinum), Gem-then-P(sequential gemcitabine and platinum), Gem/other (first-line gemcitabine-based therapy without subsequent platinum),and Gem (first-line gemcitabine-based therapy without subsequent systemic therapy) groups. The Kaplan–Meier method and log-rank test were used for survival analyses. Cox regression model and propensity score matching were used for prognostic analyses.

RESULTS

The median survival was 12.5 months [95 %confidence interval (CI), 11.2-13.7] in the GemP group(N = 65), 8.3 months (95 % CI 5.0-11.7) in the Gem-then-P group (N = 35), 11.6 months (95 % CI 4.6–18.5) in the Gem/other group (N = 26), and 4.7 months (95 % C I3.3-6.0) in the Gem group (N = 77) (P<0.001). Considering the GemP and Gem-then-P groups, performance status, serum creatinine, and response to first-line treatment were independent prognostic factors for overall survival in the multivariate analysis. No specific factors were identified for predicting the choice between GemP and Gem-then-P.

CONCLUSIONS

First-line gemcitabine and platinum-based combinations were not superior to sequential gemcitabine and platinum for overall survival. The best sequence of chemotherapy for advanced pancreatic cancer should be explored in future clinical trials.

Necrolytic migratory erythema and glucagonoma rising from pancreatic head

Glucagonoma syndrome encompasses necrolytic migratory erythema (NME), hyperglucagonemia, diabetes mellitus, anemia, weight loss, glossitis, angular cheilitis, steatorrhea, diarrhea, venous thrombosis, and neuropsychiatric disturbance. Of all the symptoms, NME is a rare skin disorder which is pathognomonic for glucagonoma. We present a 61-year-old woman diagnosed initially as pancreatic head adenocarcinoma with liver metastasis prior to the skin eruption. From the dermatologic finding and other clues, glucagonoma was diagnosed finally.