Factors Affecting Adjuvant Therapy in Stage III Pancreatic Cancer-Analysis of the National Cancer Database

Differences in receipt of multimodality therapy by race, insurance status, and socioeconomic disadvantage in patients with resected pancreatic cancer

BACKGROUND AND METHODS: Racial and socioeconomic disparities in receipt of adjuvant chemotherapy affect patients with pancreatic cancer. However, differences in receipt of neoadjuvant chemotherapy among patients undergoing resection are not well-understood. A retrospective cross-sectional cohort of patients with resected AJCC Stage I/II pancreatic ductal adenocarcinoma was identified from the National Cancer Database (2014-2017). Outcomes included receipt of neoadjuvant versus adjuvant chemotherapy, or receipt of either, defined as multimodality therapy and were assessed by univariate and multivariate analysis.

RESULTS

Of 19 588 patients, 5098 (26%) received neoadjuvant chemotherapy, 9624 (49.1%) received adjuvant chemotherapy only, and 4757 (24.3%) received no chemotherapy. On multivariable analysis, Black patients had lower odds of neoadjuvant chemotherapy compared to White patients (OR: 0.80, 95% CI: 0.67-0.97) but no differences in receipt of multimodality therapy (OR: 0.89, 95% CI: 0.77-1.03). Patients with Medicaid or no insurance, low educational attainment, or low median income had significantly lower odds of receiving neoadjuvant chemotherapy or multimodality therapy.

CONCLUSIONS

Racial and socioeconomic disparities persist in receipt of neoadjuvant and multimodality therapy in patients with resected pancreatic adenocarcinoma.

DISCUSSION

Policy and interventional implementations are needed to bridge the continued socioeconomic and racial disparity gap in pancreatic cancer care.

A Patient With Stage III Locally Advanced Pancreatic Adenocarcinoma Treated With Intra-Arterial Infusion FOLFIRINOX: Impressive Tumoral Response and Death due to Legionella pneumophila Infection: A Unique Case Report

Patients affected by pancreatic ductal adenocarcinoma (PDAC) have very poor prognosis, whereby at a follow-up of 5 years, the mortality rate is very similar to the incidence rate. Globally, around 10% of patients are amenable to radical surgery at the time of diagnosis, which represents the only chance of cure or long-term survival for these patients. Almost 40% of patients with PDAC show locally advanced pancreatic cancer (LAPC). LAPC is not a metastatic disease, although it is not amenable to radical surgery. For these patients, systemic induction chemotherapy with intravenous FOLFIRINOX (5-fluorouracil, folic acid, irinotecan, oxaliplatin) regimen is administered, with the aim of conversion to surgery, although the conversion rate remains low, at approximately 10% to 15%. Pancreatic arterial chemotherapy has been explored to overcome the intrinsic tumor pancreatic resistance to systemic chemotherapy, where an intra-arterial port-a-cath is placed by means of interventional oncology techniques under angiographic guidance in the operating theater. Here, we treated a patient with an intra-arterially modified FOLFIRINOX regimen. Three courses were administered, and the patient experienced no adverse events. At the end of the third course, the patient rapidly developed lung failure due to nosocomial Legionella pneumophila infection, despite the impressive pathological tumor response shown in the autopsy report. This is a first and unique report that demonstrates that pancreatic intra-arterial FOLFIRINOX can be safe and efficacious. We believe that this preliminary result will be confirmed in the next patients to be enrolled and that it provides a glimmer of hope for patients with this lethal disease.

Stage IA Patients With Pancreatic Ductal Adenocarcinoma Cannot Benefit From Chemotherapy: A Propensity Score Matching Study

Purpose: Adjuvant chemotherapy following resection is recommended by clinical practice guidelines for all patients with pancreatic ductal adenocarcinoma (PDAC). This study aimed to evaluate the efficacy of adjuvant chemotherapy among the staging groups of the American Joint Committee on Cancer (AJCC) for PDAC.

Patients and Methods: This retrospective cohort analysis was performed by the Surveillance Epidemiology and End Results (SEER) (2004–2015) database and multi-institutional dataset (2010–2018). Baseline clinicopathologic characteristics of PDAC patients, including age, gender, ethnicity, marital status, education level, county income level, county unemployed rate, insurance status, grade, stage, chemotherapy, and radiotherapy, were collected. Overall survival (OS) was analyzed using the Kaplan–Meier method. The SEER and multi-institutional data were adjusted with 1:1 ratio propensity score matching (PSM).

Results: In total, 6,274 and 1,361 PDAC patients were included from the SEER database and multi-institutional dataset, respectively. Regardless of the count of resected lymph nodes, adjuvant chemotherapy prolonged the long-term OS time for stage IB, IIA, IIB, and III patients in both SEER and multi-institutional cohorts. Nevertheless, adjuvant chemotherapy did not provide additional clinical benefits even after a PSM adjustment for stage IA patients in both SEER and multi-institutional cohorts.

Conclusion: Adjuvant chemotherapy improved the long-term survival of stage IB, IIA, IIB, and III PDAC patients; however, it demonstrated no survival benefit in stage IA PDAC patients. Thus, adjuvant chemotherapy should not be recommended for stage IA PDAC patients. These would significantly reduce the economic burden of society and improve the life quality of stage IA PDAC patients.

Patterns of Care and Outcomes of Adjuvant Chemoradiation for Node-Positive Pancreatic Adenocarcinoma

PURPOSE

The literature has been conflicting on the superiority of adjuvant chemoradiation over chemotherapy for node-positive adenocarcinoma of the pancreas following definitive surgery. We aimed to evaluate the patterns of care and outcomes of these two treatment options using the National Cancer Database (NCDB).

METHODS

Patients diagnosed with non-metastatic, node-positive adenocarcinoma of the pancreas from 2006 to 2014 who received oncologic resection with negative margins were identified in the NCDB. Patient- and clinical-related factors were compared between those who received adjuvant chemotherapy alone (aC) versus adjuvant chemoradiation (aCRT). Univariable and multivariable logistic regression was performed to assess for predictors of adjuvant chemoradiation use. The Kaplan-Meier method was used to assess overall survival (OS) and Cox regression analysis was used to assess impact of covariables on OS.

RESULTS

There were 3609 patients who met the study criteria, of which 2988 (82.8%) received chemotherapy alone and 621 (17.2%) who received chemoradiation. Median follow up for living patients was 33.8 months (IQR 22-51). On multivariable logistic regression, those who received treatment in more recent years of diagnoses (OR 0.21-0.37, p < 0.001) were less likely to receive aCRT over aC. Two-year OS for those who received chemo alone was 44.9% and for chemoradiation was 42.6% (p = 0.169). This finding was sustained on multivariable survival analysis (HR 0.99, p = 0.867).

CONCLUSIONS

Adjuvant chemotherapy alone for adenocarcinoma of the pancreas is the predominant treatment of choice among US hospitals. There was no overall survival benefit noted in those who were treated with adjuvant chemoradiation.

Adjuvant chemotherapy followed by concurrent chemoradiation is associated with improved survival for resected stage I-II pancreatic cancer

Background

This National Cancer Database (NCDB) analysis evaluates the clinical outcomes of postoperative chemotherapy followed by concurrent chemoradiation (C + CRT) compared to concurrent chemoradiation (CRT) alone or adjuvant chemotherapy alone (C) for resected pancreatic cancer.

Methods

The NCDB was queried for primary stage I‐II, cT1‐3N0‐1M0, resected pancreatic adenocarcinoma treated with adjuvant C, CRT, or C + CRT (2004‐2015). Patients treated with C + CRT were compared with those treated with C (cohort C) and CRT (cohort CRT). Baseline patient, tumor, and treatment characteristics were examined. Kaplan‐Meier analysis, multivariable Cox proportional hazards method, forest plot, and propensity score matching were used.

Results

Among 5667 patients, median follow‐up was 34.7, 45.2, and 39.7 months for the C, CRT, and C + CRT cohorts, respectively. By multivariable analysis for all patients, C and CRT had worse OS compared to C + CRT. Treatment interactions were seen among pathologically node‐positive disease. C + CRT was favored in 1‐3 and 4+ positive lymph node diseases when compared to C or CRT alone, but none of the treatment options were significantly favored in node negative disease. Using propensity score matching, 2152 patients for cohort C and 1774 patients for cohort CRT were matched. C + CRT remained significant for improved OS for both cohort C (median OS 23.3 vs 20.0 months) and cohort CRT (median OS 23.4 vs 20.8 months).

Conclusion

This NCDB study using propensity score matched analysis suggests an OS benefit for C + CRT compared to C or CRT alone following surgical resection of pancreatic cancer, particularly for patients with pathologically positive lymph nodes.