Fear of cancer recurrence after curative pancreatectomy: a cross-sectional study in survivors of pancreatic and periampullary tumors

Recurrent disease detection after resection of pancreatic ductal adenocarcinoma using a recurrence-focused surveillance strategy (RADAR-PANC): protocol of an international randomized controlled trial according to the Trials within Cohorts design

BACKGROUND

Disease recurrence remains one of the biggest concerns in patients after resection of pancreatic ductal adenocarcinoma (PDAC). Despite (neo)adjuvant systemic therapy, most patients experience local and/or distant PDAC recurrence within 2 years. High-level evidence regarding the benefits of recurrence-focused surveillance after PDAC resection is missing, and the impact of early detection and treatment of recurrence on survival and quality of life is unknown. In most European countries, recurrence-focused follow-up after surgery for PDAC is currently lacking. Consequently, guidelines regarding postoperative surveillance are based on expert opinion and other low-level evidence. The recent emergence of more potent local and systemic treatment options for PDAC recurrence has increased interest in early diagnosis. To determine whether early detection and treatment of recurrence can lead to improved survival and quality of life, we designed an international randomized trial.

METHODS

This randomized controlled trial is nested within an existing prospective cohort in pancreatic cancer centers in the Netherlands (Dutch Pancreatic Cancer Project; PACAP) and the United Kingdom (UK) (Pancreas Cancer: Observations of Practice and survival; PACOPS) according to the "Trials within Cohorts" (TwiCs) design. All PACAP/PACOPS participants with a macroscopically radical resection (R0-R1) of histologically confirmed PDAC, who provided informed consent for TwiCs and participation in quality of life questionnaires, are included. Participants randomized to the intervention arm are offered recurrence-focused surveillance, existing of clinical evaluation, serum cancer antigen (CA) 19-9 testing, and contrast-enhanced computed tomography (CT) of chest and abdomen every three months during the first 2 years after surgery. Participants in the control arm of the study will undergo non-standardized clinical follow-up, generally consisting of clinical follow-up with imaging and serum tumor marker testing only in case of onset of symptoms, according to local practice in the participating hospital. The primary endpoint is overall survival. Secondary endpoints include quality of life, patterns of recurrence, compliance to and costs of recurrence-focused follow-up, and the impact on recurrence-focused treatment.

DISCUSSION

The RADAR-PANC trial will be the first randomized controlled trial to generate high level evidence for the current clinical equipoise regarding the value of recurrence-focused postoperative surveillance with serial tumor marker testing and routine imaging in patients after PDAC resection. The Trials within Cohort design allows us to study the acceptability of recurrence-focused surveillance among cohort participants and increases the generalizability of findings to the general population. While it is strongly encouraged to offer all trial participants treatment at time of recurrence diagnosis, type and timing of treatment will be determined through shared decision-making. This might reduce the potential survival benefits of recurrence-focused surveillance, although insights into the impact on patients' quality of life will be obtained.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04875325 . Registered on May 6, 2021.

Socioeconomic inequality of health-related quality of life in cancer survivors in South Korea

BACKGROUND

We investigated the inequalities in health-related quality of life (HRQoL) among cancer survivors in Korea, focusing on income and education levels. The slope index of inequality (SII) and relative index of inequality (RII) were utilized to analyze these disparities.

METHODS

Data from the Korea National Health and Nutrition Examination Survey (KNHANES) conducted between 2007 and 2021 was analyzed. The HRQoL was assessed using the EQ-5D questionnaire, which included five problem areas: mobility, self-care, usual activity, pain/discomfort, and anxiety/depression. Logistic regression was employed to calculate the odds ratios (ORs) for each education and income level, indicating the probability of reporting problems. Furthermore, the slope index of inequality (SII) and relative index of inequality (RII) were calculated to evaluate the inequalities in HRQoL.

RESULTS

Among the 3396 cancer survivors, a considerable proportion reported pain/discomfort (29.6%) and mobility problems (21.1%). The logistic regression results demonstrated a higher likelihood of experiencing problems in all five EQ-5D items among individuals with lower income or education levels. Specifically, compared to the high-income group, the adjusted ORs for mobility problems were 2.19, 1.64, and 1.08 for the low, low-medium, and medium-high-income groups, respectively (p-value < 0.05). Notably, significant income inequalities in HRQoL problems were observed, with the greatest disparities seen in self-care and usual activity problems, as indicated by the SII and RII values.

CONCLUSION

Socioeconomic disparities in HRQoL exist among cancer survivors in Korea, particularly related to income levels. Addressing the financial burdens of cancer treatment for individuals with low-income levels may help improve their HRQoL and mitigate these inequalities.

Assessment of the Relationship between Fear of Cancer Recurrence, Spiritual Well-Being, and Mental Health among Cancer Patients: A Cross-Sectional Study

The purpose of this study was to examine the relationship between fear of cancer recurrence, spiritual well-being, and mental health among cancer patients. The study involved 217 patients undergoing chemotherapy. Data were collected with the following instruments: a demographic and clinical information recording form, the fear of cancer recurrence inventory, the Athens insomnia scale, the FACIT-Sp-12 scale for the assessment of spirituality, and the HADS scale for the assessment of mental health. For statistical analysis, SPSS statistical software was used, with the significance threshold set at 0.05;andtl number, t-test, one-way ANOVA, and multiple regression tests were used. The sample consisted of 217 cancer patients with a mean age of 63.7 years (SD = 11.6 years), 39.2% male and 60.8% female. The minimum value on the scale of fear of cancer recurrence was 0 and the maximum was 33 points, with a mean value of 14.1 points (SD = 8.2 points). The hospital scale of anxiety and depression was correlated, both in the dimension of anxiety and in the dimension of depression, significantly and positively with the scale of fear of cancer recurrence. Thus, greater fear of recurrence was associated with greater anxiety and depression. On the contrary, the correlations of anxiety and depression with the dimensions and the overall chronic disease treatment rating scale were significant and negative. So, greater spiritual well-being, in each domain and overall, were associated with less anxiety and depression. Finally, less fear of cancer recurrence was associated with finding greater meaning in life, greater peace, and overall greater spiritual well-being. In summary, fear of cancer recurrence is a predictor of psychological distress in cancer patients. However, spirituality can prevent the development of mental illness and FCR.

Coping in patients with pancreatic cancer: a scoping review and narrative synthesis

INTRODUCTION

Pancreatic cancer is a malignant disease with one of the highest cancer-specific mortality rates. Coping with it probably differs from other malignant diseases. This scoping review was intended to explore and characterise academic literature related to the coping in patients with pancreatic cancer.

METHODS

Eight databases were searched for primary and secondary studies and reviews reporting on coping with pancreatic cancer (adenocarcinoma) in adults in English or German language, regardless of publication date or study design, which were then analysed and summarised by narrative synthesis.

RESULTS

Of 1472 publications identified, 9 articles and book contributions published from 1989 to 2020 in the USA, Europe and Australia met the inclusion criteria. The two main aspects covered were the confrontation with coping tasks, and the reciprocally associated coping with these challenges. In particular, the coping tasks revealed some pancreatic cancer-specific features, such as an increased incidence of depression and anxiety or certain digestive problems, whereas applying of coping strategies seems to be more like the coping behaviours known from the literature for other severe or cancer diseases.

CONCLUSIONS

Patients with pancreatic cancer experience various health issues and face various quality of life changes and coping tasks. Disease-specific contextual factors, usually consisting of late diagnosis at an advanced stage, rapid progression and often poor prognosis, as well as disease-specific challenges are major differences compared with other malignancies or serious illnesses. However, the coping strategies applied do not seem to differ in principle. Currently, no pancreatic cancer-specific coping model exists.

Pancreatic Cancer Surgery: What Matters to Patients?

Pancreatic cancer is a leading cause of cancer-related death, with a poor overall survival rate. Although certain risk factors have been identified, the origins of pancreatic cancer are still not fully understood. Surgical resection remains the primary curative treatment, but pancreatic surgery is still associated with high morbidity and mortality rates, and most patients will experience recurrence. The impact of pancreatic cancer on patients' quality of life is significant, with an important loss of healthy life in affected individuals. Traditional outcome parameters, such as length of hospital stay, do not fully capture what matters to patients during recovery. Patient-centered care is therefore central, and the patient's perspective should be considered in pre-operative discussions. Patient-reported outcome and experience measures (PROMs and PREMs) could play an important role in assessing patient perspectives, but standardized methodology for evaluating and reporting them is needed. This narrative review aims to provide a comprehensive overview of patient perspectives and different patient-reported measures in pancreatic cancer surgery. Understanding the patient perspective is crucial for delivering patient-centered care and improving outcomes for patients with pancreatic cancer.

Predictors of the worry about cancer recurrence among women with breast cancer

INTRODUCTION

Worry about cancer recurrence is identified as the most common psychological burdens experienced by cancer patients and survivors. The present study aimed to determine the predictors of worry about cancer recurrence among women with breast cancer.

MATERIALS AND METHODS

This cross-sectional study was conducted on 166 women with breast cancer undergoing chemotherapy and radiotherapy, who referred to private and public oncology centers in Tabriz, Iran using the convenience sampling. Data collection tools were demographic and disease characteristics questionnaire, cancer worry scale, social support questionnaire, brief illness perception questionnaire, international physical activity questionnaire-short form, and The EORTC-in-patsat32. The data were analyzed using SPSS 25 software. Pearson correlation coefficient, independent t-test, ANOVA, and multivariate linear regression were used.

RESULTS

In the present study, the mean (standard deviation) of score of worry about cancer recurrence was 17.41 (7.88), ranging from 8-32. The results revealed that the type of surgery, illness perception, satisfaction with care, and place of treatment were the most important predictors of worry about cancer recurrence, which explained 44.3% of the variance.

CONCLUSION

The enhancement of satisfaction with care and training coping strategies among individuals with high perceived severity of the illness contribute to the reduction of worry about cancer recurrence and adaptation to breast cancer.

The Imperative of Assessing Quality of Life in Patients Presenting to a Pancreaticobiliary Surgery Clinic

OBJECTIVE

The objective of this study was to determine baseline health-related quality of life (QoL) in patients with pancreatic adenocarcinoma, periampullary cancers, and benign pancreaticobiliary (PB) conditions at the time of the first visit to a PB surgery clinic, and to explore the relationship between QoL, demographics, clinical parameters, complications, and survival.

SUMMARY BACKGROUND DATA

Few studies have examined baseline QoL measures, the impact of comorbidities, age, sex, and smoking on subsequent postoperative complications and survival in patients with pancreatic adenocarcinoma, related PB cancers, and with benign PB conditions.

METHODS

Data were collected from scheduled patients at a PB surgery clinic between 2013 and 2018. The Brief Pain Inventory, Fact-Hepatobiliary Scale, and Facit-Fatigue questionnaires were administered. QoL parameters were compared between PB cancer patients and those with benign disease.

RESULTS

A total of 462 individuals with PB cancers and benign diseases exhibited baseline physical well-being, functional well-being, fatigue, and overall QoL at or below the 75th percentile of wellness at the time of the first office visit. Younger age, smoking, and mental health comorbidities contributed significantly to decreased QoL. PA patients were 7 times more likely to die in the follow-up period than the benign disease group. Black patients had higher pain scores and were 3 times more likely to have a postsurgery complication. Sex differences were identified regarding fatigue, pain, and overall QoL.

CONCLUSIONS

This large cohort of PB cancer and benign disease patients exhibited significantly impaired baseline QoL. GI problems, weight loss, smoking, cardiovascular, pulmonary disease, and history of anxiety and depression contributed significantly to reduced QoL. The study sheds a cautionary light on the burden of PB disease at the time of surgical evaluation and its relationship to diminished QoL.

Women's psychosexual experiences following radical radiotherapy for gynaecological cancer: A qualitative exploration

PURPOSE

To explore psychosexual experiences of women following radical radiotherapy for gynaecological cancer.

METHODS

Seven women who had completed radical radiotherapy for gynaecological cancer were interviewed. Interviews were semi-structured, and data were analyzed using an interpretative phenomenological analysis (IPA) approach.

RESULTS

Five superordinate themes were constructed: (1) No desire for sex since completing treatment; (2) Fear; (3) Unmet information and support needs; (4) Partner support and needs; and (5) Communication. Fear of adverse consequences following sex inhibited return to sexual activity after treatment. Misconceptions and lack of knowledge were evident. Communicating sexual issues was a difficulty that transcended personal relationships, also evident in professional medical relationships.

CONCLUSION

Simple measures, beginning with facilitating understanding and acceptance of psychosexual experiences, can help those experiencing psychosexual problems following radical radiotherapy. Encouraging discussion, providing options and practical knowledge, and clarifying misconceptions about risks from sex after cancer could improve outcomes for gynaecological cancer patients.

What is the prevalence of fear of cancer recurrence in cancer survivors and patients? A systematic review and individual participant data meta-analysis

OBJECTIVE

Care for fear of cancer recurrence (FCR) is considered the most common unmet need among cancer survivors. Yet the prevalence of FCR and predisposing factors remain inconclusive. To support targeted care, we provide a comprehensive overview of the prevalence and severity of FCR among cancer survivors and patients, as measured using the short form of the validated Fear of Cancer Recurrence Inventory (FCRI-SF). We also report on associations between FCR and clinical and demographic characteristics.

METHODS

This is a systematic review and individual participant data (IPD) meta-analysis on the prevalence of FCR. In the review, we included all studies that used the FCRI-SF with adult (≥18 years) cancer survivors and patients. Date of search: 7 February 2020. Risk of bias was assessed using the Joanna Briggs Institute critical appraisal tool.

RESULTS

IPD were requested from 87 unique studies and provided for 46 studies comprising 11,226 participants from 13 countries. 9311 respondents were included for the main analyses. On the FCRI-SF (range 0-36), 58.8% of respondents scored ≥13, 45.1% scored ≥16 and 19.2% scored ≥22. FCR decreased with age and women reported more FCR than men. FCR was found across cancer types and continents and for all time periods since cancer diagnosis.

CONCLUSIONS

FCR affects a considerable number of cancer survivors and patients. It is therefore important that healthcare providers discuss this issue with their patients and provide treatment when needed. Further research is needed to investigate how best to prevent and treat FCR and to identify other factors associated with FCR. The protocol was prospectively registered (PROSPERO CRD42020142185).

Health-Related Quality of Life (HRQoL) in Neuroendocrine Tumors: A Systematic Review

Therapeutic advancements in neuroendocrine tumors (NETs) have improved survival outcomes. This study aims to review the impact of the current therapeutics on health-related quality of life (HRQoL) in NET patients. A literature review was performed utilizing PubMed, The Cochrane Library, and EMBASE, using the keywords "Carcinoid", "Neuroendocrine tumor", "NET", "Quality of life", "Chemotherapy", "Chemoembolization", "Radiofrequency ablation", "Peptide receptor radionucleotide therapy", "PRRT", "Surgery", "Everolimus", "Octreotide", "Lanreotide", "Sunitinib", and "Somatostatin analog". Letters, editorials, narrative reviews, case reports, and studies not in English were excluded. Out of 2375 publications, 61 studies met our inclusion criteria. The commonly used instruments were EORTC QLQ-C30, FACT G, and EORTC- QLQ GI.NET-21. HRQoL was assessed in all pivotal trials that led to approvals of systemic therapies. All systemic therapies showed no worsening in HRQoL. The NETTER-1 study was the only study to show a statistically significant improvement in HRQoL in several domains. The trial examining sunitinib versus placebo in pancreatic NETs showed no change in QoL, except for worsening of diarrhea. In addition to clinical outcomes, patient-reported outcomes are a key element in making appropriate treatment decisions. HRQoL data should be readily provided to patients to assist in shared decision-making.

Quality of Life Instruments and Trajectories After Pancreatic Cancer Resection: A Systematic Review

ABSTRACT

This systematic review aimed to investigate the instruments available to measure quality of life (QOL) after pancreatic cancer surgery and to describe short- and long-term QOL outcomes. A comprehensive literature search was completed using PubMed, Embase, and Medline from inception to March 2019. Studies investigating QOL outcomes in patients undergoing pancreatic cancer surgery who were 18 years or older were included. The main outcomes of interest were QOL instruments and short (≤6 months) and long term (>6 months) QOL outcomes. The overarching domains of physical, psychosocial, overall QOL, symptoms, and other were used to summarize QOL outcomes. Thirty-five studies reporting on 3573 patients were included. Fifteen unique QOL instruments were identified, of which 4 were disease-specific instruments. Most of the included studies reported no changes in QOL at short- and long-term follow-ups for the overarching domains. No difference in QOL outcomes was reported between different surgical approaches, except laparoscopic versus open distal pancreatectomy, and pancreaticoduodenectomy versus distal pancreatectomy. There are a wide range of instruments available to measure QOL outcomes in pancreatic cancer surgical patients, although only few are disease-specific. Most of the included studies reported no significant changes in QOL outcomes at short- or long-term follow-ups.

Factors Influencing Exercise Following Pancreatic Tumor Resection

BACKGROUND

We previously demonstrated associations between exercise during pancreatic cancer treatment and quality of life and physical fitness prior to pancreatectomy. In this study, we quantified exercise among survivors following pancreatic tumor resection and characterized concordance with established guidelines.

METHODS

We quantified exercise frequency, duration, and intensity among survivors who underwent pancreatectomy for adenocarcinoma or a neuroendocrine tumor at our center from 2000 to 2017 and compared them with American College of Sports Medicine Guidelines for Cancer Survivors. Additional surveys measured motivation to exercise, barrier self-efficacy, quality of life, and fatigue. Multivariable models were constructed to evaluate associations between clinicodemographic and psychosocial variables and guideline concordance, and between guideline concordance and quality of life and fatigue.

RESULTS

Of 504 eligible survivors, 262 (52%) returned surveys. Only 62 participants (24%) reported meeting both aerobic and strengthening guidelines; 103 (39%) reported meeting neither. Adjusted analyses demonstrated that higher autonomous motivation was associated with higher aerobic and strengthening guideline concordance (both p < 0.01). Higher barrier self-efficacy and older age were associated with higher aerobic guideline concordance (p < 0.01). We identified no significant associations between guideline concordance and tumor type, time since surgery, or recent cancer therapy (all p > 0.05). We found favorable associations between aerobic guideline concordance and both quality of life and fatigue (both p < 0.001).

CONCLUSIONS

Less than one-quarter of participants exercised sufficiently to meet national exercise guidelines following pancreatectomy. To maximize exercise and related benefits, interventions should help survivors increase intrinsic motivation and overcome barriers to exercise.

Spotlight on the Fear of Cancer Recurrence Inventory (FCRI)

Fear of cancer recurrence (FCR) is a pervasive concern for people living with cancer. The rapidly expanding FCR literature has been weakened somewhat by use of miscellaneous FCR measures of varying quality. The Fear of Cancer Recurrence Inventory (FCRI) has been widely used in observational and intervention studies and the FCRI severity subscale, also known as the FCRI-Short Form (FCRI-SF), is often used to identify potential cases of clinically significant FCR. Given the FCRI's increasing use in research and clinical practice, we aimed to provide an overview, critique, and suggested improvements of the FCRI. Studies citing the original FCRI validation paper were identified and synthesised using narrative and meta-analytic methods. The 42-item FCRI has demonstrated a reasonably robust 7-factor structure across evaluations in multiple languages, although certain subscales (eg, Coping) demonstrate sub-optimal reliability. Confirmation of the cross-cultural equivalence of several FCRI translations is needed. Meta-analysis of FCRI-SF scores revealed a combined weighted mean score of 15.7/36, a little above the lowest proposed cut-off score (≥13) for clinical FCR. Depending on the FCRI-SF cut-off used, between 30.0% and 53.9% of the cancer population (ie, patients and survivors) appear to experience sub-clinical or clinical FCR. Higher FCRI scores were associated with younger age and female gender, pain/physical symptoms and psychological morbidity, consistent with the FCR literature generally. Issues regarding the application and interpretation of the FCRI remain. Whether the FCRI is well suited to assessing fear of progression as well as recurrence is unclear, the meaningfulness of the FCRI total score is debatable, and the use of the FCRI-SF to screen for clinical FCR is problematic, as items do not reflect established characteristics of clinical FCR. Refinement of the FCRI is needed for it to remain a key FCR assessment tool in future research and clinical practice.

A New Surveillance Algorithm After Resection of Colorectal Liver Metastases Based on Changes in Recurrence Risk and RAS Mutation Status

BACKGROUND

The optimal surveillance strategy after resection of colorectal liver metastases (CLM) is unknown. We evaluated changes in recurrence risk after CLM resection and developed a surveillance algorithm.

METHODS

Patients undergoing CLM resection during 1998 to 2015 were identified from a prospectively compiled database and analyzed if they had the potential for follow-up longer than the longest observed time to recurrence in this cohort. Changes in recurrence risk and risk factors for recurrence were evaluated. All statistical tests were 2-sided.

RESULTS

Among 2,105 patients who were initially identified and underwent CLM resection, the latest recurrence was observed at 87 months; 1,221 consecutive patients from 1998 through 2011 with the potential for at least 87 months of follow-up were included. The risk of recurrence was highest at 0 to 2 years after CLM resection, lower at 2 to 4 years after CLM resection, and steadily lower after 4 years after CLM resection. Factors associated with increased recurrence risk at the time of surgery were primary lymph node metastasis (hazard ratio [HR], 1.54; 95% CI, 1.21-1.97; P<.001), multiple CLM (HR, 1.31; 95% CI, 1.06-1.63; P=.015), largest liver metastasis diameter >5 cm (HR, 1.64; 95% CI, 1.23-2.19; P<.001), and RAS mutation (HR, 1.29; 95% CI, 1.04-1.59; P=.020). In patients without recurrence at 2 years, the only factor still associated with increased recurrence risk was RAS mutation. In those patients, the recurrence rate at 4 years was 59.3% in patients with RAS mutation versus 27.8% in patients with RAS wild-type (P=.019).

CONCLUSIONS

For patients who have undergone CLM resection, we propose surveillance every 3 to 4 months during years 0 to 2, every 3 to 4 months (if mutant RAS) versus every 4 to 6 months (if RAS wild-type) during years 2 to 4, and every 6 to 12 months if recurrence-free at 4 years.

Ten-year impact of pancreaticoduodenectomy on bowel function and quality of life of patients with ileal pouch-anal anastomosis for familial adenomatous polyposis

BACKGROUND

Patients with familial adenomatous polyposis (FAP) carry a risk of duodenal adenocarcinoma. These patients, who already have an ileal pouch-anal anastomosis (IPAA), sometimes require pancreaticoduodenectomy (PD). This work aims to evaluate the long-term consequences of the combination of PD + IPAA.

METHODS

All patients with IPAA due to FAP who underwent PD from 1991 to 2017 were included (PD + IPAA group). Patients were matched 1:1 according to age, sex, ASA score and presence of colorectal cancer. Fecal continence and quality of life (QoL) were assessed using the Wexner score and the EORTC-QLQ-C30 questionnaire.

RESULTS

Thirty-two PD + IPAA patients were matched with thirty-two IPAA-only patients. In each group, the response rate to the questionnaire was 78% (25/32). No differences were noted between PD + IPAA and IPAA-only groups in terms of daytime fecal frequency (6.0 vs 6.0; p = 0.362), Wexner score (3/20 vs 4/20; p = 0.984) and global QoL score (83.3/100 vs 83.3/100; p = 0.401). In the PD + IPAA group, 26% of patients developed diabetes a median period of 10.0 years after PD. The global QoL for these patients was significantly altered (p = 0.011), while daytime fecal frequency was unaffected (p = 0.092) as fecal continence (p = 0.475).

CONCLUSION

In FAP patients with IPAA, PD does not affect bowel function or QoL.

Priority Rankings of Patient-Reported Outcomes for Pancreatic Ductal Adenocarcinoma: A Comparison of Patient and Physician Perspectives

Background: Pancreatic ductal adenocarcinoma (PDAC) is associated with high symptom burden. However, treatment decisions currently depend heavily on physician interpretation of clinical parameters and may not consider patients’ health preferences. The NIH Patient-Reported Outcomes Measurement Information System (PROMIS) initiative standardized a set of patient-reported outcomes for use in chronic diseases. This study identifies preference rankings among patients with PDAC and physicians for PROMIS domains and compares the priorities of patients and their providers. Methods: We condensed the 96 NIH PROMIS adult domains into 31 domains and created a Maximum Difference Scaling questionnaire. Domain preference scores were generated from the responses of patients with PDAC and physicians, which were compared using Maximum Difference Scaling software across demographic and clinical variables. Results: Participants included 135 patients with PDAC (53% male; median age, 68 years) and 54 physicians (76% male; median years of experience, 10). Patients selected physical functioning (PF) as their top priority, whereas physicians identified pain as most important. PF, ability to perform activities of daily living, and symptom management were within the top 5 domains for both patients and physicians, and varied only slightly across age, sex, and ethnicity. However, several domains were ranked significantly higher by patients than by physicians, including but not limited to PF; ability to do things for yourself, family, and friends; ability to interact with others to obtain help; and sleep quality. Physicians ranked pain, anxiety, and depression higher than patients did. Conclusions: Our findings suggest that patients with PDAC value PF and engaging in daily and social activities the most, whereas physicians prioritize symptoms such as pain. Patient-reported outcomes need to become more integrated into PDAC care and research to better identify unmet patient needs, inform treatment decisions, and develop therapies that address outcomes valued by patients.

Health anxiety and illness-related fears across diverse chronic illnesses: A systematic review on conceptualization, measurement, prevalence, course, and correlates

BACKGROUND

Patients with chronic diseases commonly report fears of illness or symptoms recurring or worsening. These fears have been addressed from an illness-specific perspective (e.g., fear of cancer recurrence), a generic illness perspective (e.g., fear of progression), and a psychiatric perspective (DSM-5 illness anxiety disorder and somatic symptom disorder). The broader concept of health anxiety (HA) can also be applied to patients with a chronic disease. This review was conducted to investigate the conceptual, theoretical, measurement-overlap, and differences between these distinct perspectives. We also aimed to summarize prevalence, course, and correlates of these fears in different chronic illnesses.

METHODS

We used PsycINFO, PubMED, CINAHL, Web of Science, SCOPUS, and PSYNDEX to conduct a systematic review of studies pertaining to these fears in chronic illness published from January 1996 to October 2017. A total of 401 articles were retained.

RESULTS

There were commonalities across different conceptualizations and diseases: a high prevalence of clinical levels of fears (>20%), a stable course over time, and a deleterious impact on quality of life. Reviewed studies used definitions, models, and measures that were illness-specific, with only a minority employing a psychiatric perspective, limiting cross-disease generalizability. There appears to be some applicability of DSM-5 disorders to the experience of fear of illness/symptoms in patients with a chronic illness. While conceptualizing HA on a continuum ranging from mild and transient to severe may be appropriate, there is a lack of agreement about when the level of fear becomes 'excessive.' The definitions, models, and measures of HA across chronic illnesses involve affective, cognitive, behavioral, and perceptual features.

CONCLUSIONS

The concept of HA may offer a unifying conceptual perspective on the fears of illness/symptoms worsening or returning commonly experienced by those with chronic disease.

The relationship between fears of cancer recurrence and patient age: A systematic review and meta-analysis

BACKGROUND

Fears of cancer recurrence (FCR) is one of the most prevalent concerns and a common unmet need reported by cancer patients. Patient age is a demographic variable that has been linked to FCR, among others. Although it is recognised by researchers that age and FCR may be negatively correlated, the strength of this correlation has yet to be established.

AIM

The aims of this study were to (a) conduct a meta-analysis to investigate the overall association of patient age in years with FCR across studies from 2009 to February 2019 and (b) scrutinise for patterns of these effect sizes across studies.

METHODS AND RESULTS

Peer-reviewed papers were gathered from the literature via online databases (PubMed, EMBASE, MEDLINE, and PsycINFO). Systematic review guidelines including a quality assessment were applied to the 31 selected studies (pooled participant N size = 19 777). The meta-analysis demonstrated a significant negative association between age and FCR (ES = -0.12; 95% CI, -0.17, -0.07). Meta-regression revealed the association of patient age and FCR significantly reduced over the last decade. A significant effect (β = -0.17, P = 0.005) of breast cancer versus other cancers on this age by FCR association was also identified.

CONCLUSION

The reliable and readily accessible personal information of age of patient can be utilised as a weak indicator of FCR level especially in the breast cancer field, where the majority of studies were drawn. The suggestion that age and FCR association may be attenuated in recent years requires confirmation.

Long-term Quality of Life and Gastrointestinal Functional Outcomes After Pancreaticoduodenectomy

OBJECTIVE

To perform a comprehensive assessment of long-term quality of life (QOL) and gastrointestinal (GI) function in patients following pancreaticoduodenectomy (PD).

SUMMARY OF BACKGROUND DATA

Survival after PD has greatly improved and thus has resulted in a larger population of survivors, yet long-term QOL and GI function after PD is largely unknown.

METHODS

Patients were identified from a global online support group. QOL was measured using the Short Form-36, while GI function was assessed using the Gastrointestinal Symptom Rating Scale. QOL and GI function were analyzed across subgroups based on time after PD. QOL was compared with preoperative measurements and with established values of a general healthy population (GHP). Multivariate linear regression was used to identify predictors of QOL.

RESULTS

Of the 7605 members of the online support group, 1102 responded to the questionnaire with 927 responders meeting inclusion criteria. Seven hundred seventeen (77.3%) of these responders underwent PD for malignancy. Mean age was 57 ± 12 years and 327 (35%) were male. At the time of survey, patients were 2.0 (0.7, 4.3) years out from surgery, with a maximum 30.7-year response following PD. Emotional and physical domains of QOL improved with time and surpassed preoperative levels between 6 months and 1 year after PD (both P < 0.001). Each GI symptom worsened over time (all P < 0.001). Independent predictors of general QOL in long-term survivors (> 5 years) included total GSRS score [β = -1.70 (-1.91, -1.50)], female sex [β = 3.58 (0.67, 6.46)], and being a cancer survivor [β = 3.93 (0.60, 7.25)].

CONCLUSIONS

Long-term QOL following PD improves over time, however never approaches that of a GHP. GI dysfunction persists in long-term survivors and is an independent predictor of poor QOL. Long-term physical, psychosocial, and GI functional support after PD is encouraged.

Postoperative surveillance of pancreatic cancer patients

BACKGROUND

The aim of this study is to collect the best available evidence for diagnostic modalities, frequency, and duration of surveillance after resection for pancreatic ductal adenocarcinoma (PDAC).

METHODS

PDAC guidelines published after 2015 were collected. Furthermore, a systematic search of the literature on postoperative surveillance was performed in PubMed and Embase from 2000 to 2019. Articles comparing different diagnostic modalities and frequencies of postoperative surveillance in PDAC patients with regard to survival, quality of life, morbidity and cost-effectiveness were selected.

RESULTS

The literature search resulted in 570 articles. A total of seven guidelines and twelve original clinical studies were eventually evaluated. PDAC guidelines increasingly recommend a combination of tumor marker testing and computed tomography (CT) imaging every three to six months during the first two years after resection. These guidelines are, however, based on expert opinion and other low-level evidence. Prospective studies comparing different surveillance strategies are lacking. According to recent studies, surveillance with tumor markers and imaging at regular intervals results in the detection of PDAC recurrence before the onset of symptoms and more frequent administration of further therapy, such as chemotherapy or radiotherapy.

CONCLUSION

Current evidence for recurrence-focused surveillance after PDAC resection is limited and contradictory. Consequently, recommendations on surveillance are conflicting. To define the clinical merit of recurrence-focused surveillance, patients who are most likely to benefit from early detection and treatment of PDAC recurrence need to be identified. To this purpose, well-designed prospective studies are needed, accounting for both economical and psychosocial implications of surveillance.

Psychological Outcomes and Quality of Life in Relation to Pancreatectomy: A Systematic Review

This review aimed to inventory and analyze previous studies regarding quality of life (QoL) and psychological outcomes in relation to pancreatectomy. PubMed and PsycInfo databases were reviewed using the Preferred Reporting Items for Systematic review and Meta-Analysis guidelines. Thirteen studies were selected, 9 of which focused on the QoL after surgery. Quality of life significantly improved 3 to 6 months after surgery. Regarding the postoperative experience, one study reported high fear of recurrence of cancer, whereas another emphasized various expressions of patient needs. One study explained how strategy and ability to adapt are not related to the type, the cause, nor the physical condition, but are mainly influenced by the age and the subjective experience of the patients. A last study showed that depression did not affect survival rate after surgery. Our systematic review found only few studies regarding the psychological condition after pancreatectomy and highlights the need to describe and characterize the patients' psychological characteristics in this setting.

Primary Care Versus Oncology-Based Surveillance Following Adjuvant Chemotherapy in Resected Pancreatic Cancer

INTRODUCTION

High level evidence to guide surveillance following curative intent treatment for pancreatic cancer is lacking and this has likely resulted in wide variations in practice. We aim to describe patterns of surveillance and evaluate their impact on outcomes.

METHODS

A total of 147 adult patients who received at least one cycle of adjuvant gemcitabine or 5-fluorouracil-based chemotherapy at any one of five British Columbia Cancer Agency centers between 2001 and 2015 were included. Surveillance strategies were classified into two categories: discharged to primary care physicians (PCPs) or follow-up at cancer centers (CC) that included regular clinical assessments, laboratory testing, and/or diagnostic imaging.

RESULTS

Median age at diagnosis was 64 (range 38-85) years and 48% were men. More patients were followed by CC than by PCPs (66 vs. 44%). Among the measured prognostic factors, only patients with advanced tumor stage (T3/4) were more likely to be followed by cancer specialists (78 vs. 62%, P = 0.03), while other patient and disease characteristics were balanced between the two groups. In the entire cohort, 100 (68%) patients had a documented recurrence. Patients followed by CC were more likely to receive palliative chemotherapy at recurrence than those followed by PCPs (58 vs. 34%, respectively, P = 0.03). The median overall survival (OS) was 2.82 (95% CI 2.17-3.32) years in the CC group and 3.35 (95% CI 2.85-5.06) years in the PCP group while the median relapse-free survival (RFS) was 1.4 (95% CI 1.37-1.77) and 2.4 (95% CI 2.07-4.59) years, respectively. On multivariate analysis, there was no significant difference in OS between CC and PCP-based surveillance (HR 1.23; 95% CI 0.74-2.04, P = 0.40); however, RFS favored the PCP group (HR 1.62; 95% CI 1.01-2.56, P = 0.04, for the CC group).

CONCLUSION

In this population-based analysis, surveillance tests and imaging performed by CC detected recurrences earlier when compared to follow-up by PCPs, but this did not result in OS differences. Patients with more advanced tumors were more likely to be seen at CC. PCPs may play a larger role in the follow-up care of selected low risk patients with resected pancreatic cancer.

Using photography to explore psychological distress in patients with pancreatic cancer and their caregivers: a qualitative study

PURPOSE

The quality of life (QOL) experiences of patients with pancreatic cancer and their caregivers is poorly understood. Psychological distress is high, but few studies examine the factors associated with psychological distress. The purpose of this study is to gain a richer understanding of the factors associated with psychological distress from patient and caregiver perspectives.

METHODS

Twenty participants (13 patients, 7 caregivers) completed group discussions on the experiences of living with pancreatic cancer. Using photovoice methods, participants took photographs and provided narratives depicting the distress they experienced. Participant-produced photographs and group discussion transcripts were analyzed to identify key themes using thematic analysis.

RESULTS

Commonalities between patient and caregiver sources of distress emerged despite their distinct roles. Findings revealed four major areas of distress: diagnosis of an unexpected advanced cancer, changes in roles and identity, management of weight loss and gastrointestinal problems, and fear of the future. Participants also discussed unique perspectives such as the stigma of pancreatic cancer and caregiver guilt.

CONCLUSIONS

Photovoice provides a unique insight into the lives of patients with pancreatic cancer and their caregivers. Our findings contribute to the gap in the current literature by providing a better understanding of the factors surrounding pancreatic cancer distress. We also identify several clinical recommendations to improve cancer care delivery and areas for future research.

Quality of Life in Patients With Pancreatic Cancer and Their Caregivers: A Systematic Review

Little is known about quality of life (QOL) of patients with pancreatic cancer and their caregivers compared with adults with other cancers. This systematic review summarizes the available evidence base, identifies its limitations, and recommends directions for research and clinical application. A systematic review was conducted of research on QOL in adults with pancreatic cancer and their caregivers. Quality of life was examined in the following specific domains: psychological, physical, social, sexual, spiritual, and general. Of the 7130 articles reviewed, 36 studies met criteria for inclusion. Compared with healthy adults or population norms, adults with pancreatic cancer had worse QOL across all domains. Compared with patients with other cancer types, patients with pancreatic cancer evidenced worse psychological QOL. Physical and social QOL were either similar or more compromised than in patients with other cancers. Limited data preclude conclusions about sexual, spiritual, and caregiver QOL. Patients with pancreatic cancer evidence decrements in multiple QOL domains, with particular strain on psychological well-being. Methodological limitations of available studies restrict definitive conclusions. Future research with well-defined samples, appropriate statistical analyses, and longitudinal designs is needed. Findings from this review support the merits of distress screening, integration of mental health professionals into medical teams, and attention to caregiver burden.

Psychometric testing of the Fear of Cancer Recurrence Inventory-caregiver Chinese version in cancer family caregivers in Taiwan

OBJECTIVE

The purposes of this study were to develop a Chinese version of the Fear of Cancer Recurrence Inventory-caregiver (FCRI-c Chinese) and assess the psychometrics of this test in the family caregivers (FCs) of Taiwanese patients with head and neck cancer.

METHODS

An instrument testing study was conducted at a major medical center in Taiwan. Head and neck cancer patients and their major FCs were recruited as dyads from the radiation outpatient department. The FCRI-c Chinese was tested for internal consistency reliability, test-retest reliability, and construct validity (including theoretically supported correlation, discriminant validity, and factor structure).

RESULTS

We recruited 300 patient-caregiver dyads. The test had good internal consistency (Cronbach α = .94) and a 2-week test-retest reliability of .88. Confirmatory factor analysis indicated an acceptable fit of the model to the data. The construct validity was also satisfactory, as indicated by the significant positive correlations of the test with depression and anxiety in FCs, and the significant negative correlation of the test with patients' quality of life. A significantly higher test score was present in FCs caring for patients with metastasis and patients who completed treatment a long time ago.

CONCLUSIONS

The FCRI-c Chinese is a valid instrument for examination of the fear of cancer recurrence in the FCs of patients with head and neck cancer. Clinicians can use this multidimensional instrument to assess important clinical care issues and improve the quality of care provided by FCs.

Systematic review on the impact of pancreatoduodenectomy on quality of life in patients with pancreatic cancer

BACKGROUND

Patients undergoing pancreatoduodenectomy for pancreatic cancer have a high risk of major postoperative complications and a low survival rate. Insight in the impact of pancreatoduodenectomy on quality of life (QoL) is therefore of great importance. The aim of this systematic review was to assess QoL after pancreatoduodenectomy for pancreatic cancer.

METHODS

A systematic review of the literature was performed according to the PRISMA guidelines. A systematic search of all the English literature available in PubMed and Medline was performed. All studies assessing QoL with validated questionnaires in pancreatic cancer patients undergoing pancreatoduodenectomy were included.

RESULTS

After screening a total of 788 articles, the full texts of 36 articles were assessed, and 17 articles were included. QoL of physical and social functioning domains decreased in the first 3 months after surgery. Recovery of physical and social functioning towards baseline values took place after 3-6 months. Pain, fatigue and diarrhoea scores deteriorated postoperatively, but eventually resolved after 3-6 months.

CONCLUSION

Pancreatoduodenectomy for malignant disease negatively influences QoL in the physical and social domains at short term. It will eventually recover to baseline values after 3-6 months. This information is valuable for counselling and expectation management of patients undergoing pancreatoduodenectomy.

Role of rapid kV-switching dual-energy CT in assessment of post-surgical local recurrence of pancreatic adenocarcinoma

PURPOSE

The purpose of this study is to evaluate the performance of material-specific iodine (MS-I) images generated by rapid kV-switching single-source dual-energy computed tomography (rsDECT) for distinguishing post-operative changes from local tumor recurrence in patients on follow-up for pancreatic adenocarcinoma after surgical resection.

METHODS

In this IRB-approved HIPPA-compliant study, retrospective review of 51 patients who underwent surgical resection of pancreatic adenocarcinoma was conducted and were followed up using contrast-enhanced rsDECT (Discovery CT 750HD, GE Healthcare, Milwaukee, WI). Independent qualitative assessment for presence of local tumor recurrence was performed by two radiologists who evaluated 65 keV (single-energy CT-equivalent interpretation) and 65 keV with MS-I (rsDECT interpretation) in separate sessions. Quantitative analysis of Hounsfield unit (HU, on 65 keV) and normalized iodine concentration (NIC on MS-I images; iodine concentration ratio in post-operative tissue to aorta) was measured. Follow-up imaging, temporal change of CEA and CA 19-9 or biopsy served as reference standard for presence and absence of local recurrence. Sensitivity and specificity of readers and quantitative parameters was calculated and receiver operating characteristic curves and Fisher's exact test were generated. A p value < 0.05 was considered statistically significant.

RESULTS

A total of 51 patients (27 females, 24 males) with mean age of 64 years built the final cohort. Local recurrence was absent in 23 (Group A) and present in 28 (Group B) patients. The follow-up imaging was performed within 7 months of rsDECT. For both readers, the addition of MS-I increased the specificity for tissue characterization and improved reader confidence as compared to 65 keV (specificity: 80% and 56%, respectively) images alone. Quantitative analysis revealed a significantly lower NIC (0.28 vs. 0.35; p < 0.05) for non-recurrent tissue. However, HU was not significantly different for non-recurrent and recurrent tissue (0.63 vs. 0.70; p > 0.05).

CONCLUSION

In inherently complex cases of post-operative pancreatic adenocarcinoma, MS-I images from rsDECT can be a useful adjunct to conventional scans in characterizing loco-regional soft tissue.

Fear of cancer recurrence and its predictors among cervical cancer survivors

Objective

To identify the characteristics of fear of cancer recurrence (FCR) in cervical cancer survivors (CCSs) and investigate the relationship of FCR with demographic and medical characteristics, level of quality of life (QOL), and psychological distress. We also aimed to determine the predictors of FCR.

Methods

The short version of the Fear of Progression Questionnaire (FoP-Q-SF), the Hospital Anxiety and Depression Scale (HADS), and the Functional Assessment of Cancer Therapy-Cervical (FACT-Cx) questionnaire were administered to 699 CCSs who had complete treatment at Songklanagarind Hospital between 2006 and 2016. Analysis was performed to determine potential predictors associated with FCR.

Results

Among the 12 items of the FoP-Q-SF, the 3 greatest fears were 1) worrying about what would happen to their family; 2) being afraid of pain; and 3) fear of disease progression. The prevalences of anxiety and depression disorder were 20.46% and 9.44%, respectively. CCSs who had FCR at the 5th quintile were more likely to have medical co-morbidities, low FACT-Cx scores in all domains and a high HADS scores (anxiety and depression disorder). Multivariate analysis showed that only anxiety disorder (odds ratio [OR]=4.99; p<0.001) and low FACT-Cx score (total) (OR=6.14; p<0.001) were identified as independent predictors for FCR at the 5th quintile.

Conclusion

FCR is an important problem in cervical cancer which should be addressed during post-treatment care. Only anxiety disorder and low QOL were independently associated with high FCR.

The relationship between cancer patient's fear of recurrence and chemotherapy: A systematic review and meta-analysis

OBJECTIVE

The study aim was to provide an overview of the current evidence available on the link between chemotherapy (CTX) and fear of cancer recurrence (FoR).

METHODS

PubMED, Medline, Embase, PsycINFO and Web of Science databases were searched to identify relevant studies. Two authors independently selected and assessed the studies regarding eligibility criteria. Meta-analysis of suitable studies was conducted, and quality rated.

RESULTS

Forty eligible studies were included in the systematic review and twenty-nine of them were included in further meta-analysis. Meta-analysis of the available data confirmed a weak relationship between CTX and FoR (29 studies, 30,176 patients, overall r=0.093, 95% CI: 0.062, 0.123, P˂0.001).

CONCLUSIONS

The meta-analysis demonstrates a weak but significant relationship between cancer patient's FoR and the receipt of chemotherapy. However, these results should be interpreted with caution. Further investigation is warranted to explore possible mechanisms of FoR increase in patients who receive chemotherapy. Longitudinal studies assessing the trajectory of FoR during chemotherapy are also warranted.

Systematic review reveals lack of quality in reporting health-related quality of life in patients with gastroenteropancreatic neuroendocrine tumours

BACKGROUND

Gastroenteropancreatic neuroendocrine tumours (GEP-NET) are often slow-growing and patients may live for years with metastasised disease. Hence, along with increasing overall and progression-free survival, treatments aim at preserving patients' well-being and health-related quality of life (HRQoL). However, studies on systematic HRQoL assessment in patients with GEP-NET are scarce. Therefore, the purpose of the current review is to systematically evaluate the methodological quality of the identified studies.

METHODS

A targeted database search was performed in PubMed, EMBASE, and CENTRAL. Data extraction was conducted by two independent researchers according to predefined criteria. For study evaluation, the Minimum Standard Checklist for Evaluating HRQoL Outcomes in Cancer Clinical Trials and the CONSORT Patient-Reported Outcome extension were adapted.

RESULTS

The database search yielded 48 eligible studies. We found the awareness for the need of HRQoL measurement to be growing and application of cancer-specific instruments gaining acceptance. Overall, studies were too heterogeneous in terms of patient characteristics and treatment interventions to draw clear conclusions for clinical practice. More importantly, a range of methodological shortcomings has been identified which were mainly related to the assessment and statistical analysis, as well as the reporting and interpretation of HRQoL data.

CONCLUSION

Despite an increasing interest in HRQoL in GEP-NET patients, there is still a lack of knowledge on this issue. A transfer of HRQoL results into clinical practice is hindered not only by the scarceness of studies, but also by the often limited quality of HRQoL processing and reporting.

Does finding early recurrence improve outcomes, and at what cost?

The putative goal of surveillance is the early detection of recurrence while both the cancer and patient are still treatable. To be cost and clinically effective, surveillance requires a tailored approach based on stage, tumor biology, conditional survival, and available treatment options. Although surveillance is the major component of care for cancer patients after potentially curative treatment, current guidelines for surveillance lack the high-level data seen on the treatment side of the patient care continuum. J. Surg. Oncol. 2016;114:329-335. © 2016 Wiley Periodicals, Inc.

Clinical Impact of Structured Follow-up After Pancreatic Surgery

OBJECTIVES

Structured follow-up after surgery for pancreatic ductal adenocarcinoma (PDAC) remains controversial and is currently not recommended due to a supposed lack of therapeutic consequences. Furthermore, it is not clear whether noncancer patients after pancreas resection need to be seen in the clinic on a regular basis. The present study analyzed how follow-up after pancreatic surgery affected postoperative treatment and long-term outcomes.

METHODS

Data of all postoperative visits in a specialized outpatient clinic for pancreatic diseases were analyzed for a 1-year period with regard to symptoms, diagnostic procedures, and therapeutic consequences.

RESULTS

Six hundred eighteen patients underwent 940 postoperative follow-ups. Nearly half of them needed a change of medication due to altered pancreatic function. In 74 (40%) of 184 resected PDAC patients, recurrence (local or systemic) was detected during follow-up, although only 19 of these had shown associated symptoms (26%). In all patients with recurrence, a cancer-directed treatment was induced. Eleven (69%) of 16 patients with isolated local recurrence were referred for reresection.

CONCLUSIONS

Follow-up examinations are a substantial part of the clinical management after pancreas resections. Follow-up is particularly important for PDAC because recurrence is often asymptomatic, but its detection allows for therapeutic interventions and potentially improved prognosis. This should be implemented in future guidelines.

A qualitative study of patient and clinician attitudes regarding surveillance after a resection of pancreatic and peri-ampullary cancer

BACKGROUND

After surgical resection of pancreatic adenocarcinoma, most patients will develop recurrence within 2 years. Intense follow-up is often recommended; however, its impact on survival is unknown. Patient and clinician attitudes towards follow-up were qualitatively assessed along with the perceived benefits and challenges.

METHODS

A semi-structured interview guide was developed. Purposive sampling identified patients who were in active surveillance or had developed recurrence. Clinicians involved in patient care were also interviewed. Interviews were conducted until saturation was reached and themes were derived using standard qualitative methods.

RESULTS

A total of 15 patients and seven clinicians were interviewed. Patient themes included a limited understanding of disease prognosis, a desire for reassurance, a desire to know if and when recurrence occurred and minimal difficulties with follow-up. Clinician themes included expectation that patients are aware of the recurrence risk, a desire to provide reassurance, support for intense follow-up and perceived patient challenges in follow-up. Overall, the dominant theme was one of disconnect between patients and clinicians in the understanding of the disease and its prognosis.

DISCUSSION

Patients have an intense need for reassurance and obtain this through follow-up appointments with their oncologists. Consequently, they express few difficulties with the process. Clinicians recognize this desire for reassurance. Patients' understanding and expectations contrast starkly with clinicians' perspectives regarding prognosis.

Pancreatic cancer-specific cell death induced in vivo by cytoplasmic-delivered polyinosine-polycytidylic acid

Polyinosine-polycytidylic acid [pIC] is a synthetic dsRNA that acts as an immune agonist of TLR3 and RLR to activate dendritic and natural killer cells that can kill tumor cells. pIC can also trigger apoptosis in pancreatic ductal adenocarcinoma cells (PDAC) but its mechanism of action is obscure. In this study, we investigated the potential therapeutic activity of a formulation of pIC with polyethylenimine ([pIC](PEI)) in PDAC and investigated its mechanism of action. [pIC](PEI) stimulated apoptosis in PDAC cells without affecting normal pancreatic epithelial cells. Mechanistically, [pIC](PEI) repressed XIAP and survivin expression and activated an immune response by inducing MDA-5, RIG-I, and NOXA. Phosphorylation of AKT was inhibited by [pIC](PEI) in PDAC, and this event was critical for stimulating apoptosis through XIAP and survivin degradation. In vivo administration of [pIC](PEI) inhibited tumor growth via AKT-mediated XIAP degradation in both subcutaneous and quasi-orthotopic models of PDAC. Taken together, these results offer a preclinical proof-of-concept for the evaluation of [pIC](PEI) as an immunochemotherapy to treat pancreatic cancer.

Intensity of follow-up after pancreatic cancer resection

The prognosis of patients diagnosed with pancreatic adenocarcinoma remains dismal. Of the 15-20 % of patients who are candidates for potentially curative resection, 66-92 % will develop recurrent disease. Although guidelines for surveillance in the postoperative setting exist, they are not evidence based, and there is wide variability of strategies utilized. Current surveillance guidelines as suggested by the National Comprehensive Cancer Network (NCCN) include routine history and physical, measurement of serum cancer-associated antigen 19-9 (CA19-9) levels, and computed tomographic imaging at 3- to 6-month intervals for the first 2 years, and annually thereafter. However, the lack of prospective clinical data examining the efficacy of different surveillance strategies has led to a variability of the intensity of follow-up and a lack of consensus on its necessity and efficacy. Recent therapeutic advances may have the potential to significantly alter survival after recurrence, but a careful consideration of current surveillance strategies should be undertaken to optimize existing approaches in the face of high recurrence and low survival rates.

Predictors of fear of recurrence in patients one year after cancer rehabilitation: a prospective study

BACKGROUND

Fear of cancer recurrence (FCR) or cancer progression is one of the most frequent distressing psychological symptoms in cancer patients. In contrast to anxiety disorders according to the ICD-10 or DSM-IV, FCR describes an emotional response to the real threat of a life-threatening illness. Elevated levels of FCR can become dysfunctional, causing considerable disruption in social functioning, and affect well-being and quality of life (QoL). We examined the prevalence and course of FCR in cancer patients during and after a rehabilitation program, and investigated associations between demographic, medical and psychosocial factors. We further aimed to identify predictors of FCR one year after cancer rehabilitation.

METHODS

A total of eligible N = 1281 patients (77.5% participation rate) were consecutively recruited on average 11 months post-diagnosis and assessed at the beginning (t1) (1148), at the end (t2) (1060) and 12 months after rehabilitation (t3) (n = 883). Participants completed validated measures assessing FCR, anxiety, depression, QoL, social support, and a range of cancer- and treatment-related characteristics.

RESULTS

At t1, 18.1% of our sample was classified as having high levels of FCR and 66.6% showed moderate levels of FCR. Fear of recurrence decreased over time (p < 0.001) (η² = .095), however, at follow-up 17.2% of our sample showed high levels of FCR and 67.6% had moderate levels of FCR. Linear regression analysis (stepwise backward) including demographic, medical and psychosocial factors, revealed that lower social class, having skin cancer, colon cancer or hematological cancer, palliative treatment intention, pain and a higher number of physical symptoms, depression, lower social support and adverse social interactions predicted FCR one year after rehabilitation (R² adjusted = 0.34) (p < 0.001).

CONCLUSION

Our data provide evidence that elevated levels of FCR represent a continuing problem in cancer patients. The need to enhance cancer rehabilitation and survivorship programs including interventions tailored to specific problems such as FCR is emphasized.

Follow-up after curative surgery for pancreatic ductal adenocarcinoma: asymptomatic recurrence is associated with improved survival

AIM

There is no consensus on the optimal follow-up schedule of patients after surgery for pancreatic cancer. In this retrospective study, recurrence and survival were investigated for patients presenting with either symptomatic or asymptomatic recurrence. Patient, tumor and treatment characteristics that predicted the length of postrecurrence survival were identified.

METHODS

Clinical records of 164 patients who underwent a pancreatic resection (R0/R1) for pancreatic ductal adenocarcinoma from January 2000 to December 2010 were retrieved. Patients underwent a systematic follow-up program. Patient, tumor and treatment characteristics were compared between patients with asymptomatic and symptomatic recurrence.

RESULTS

Of 164 consecutive patients, 144 patients (88%) had recurrence (29 asymptomatic, 115 symptomatic). The most frequent reported symptoms were abdominal pain, fatigue/weakness, back pain, weight loss, nausea/loss of appetite and jaundice. Median time to recurrence was 12.0 months for asymptomatic and 7.0 months for symptomatic patients (P = 0.036). Median postrecurrence survival was 10.0 months for asymptomatic and 4.0 months for symptomatic patients (P < 0.0001). Median overall survival was 24.5 months for asymptomatic and 11.0 months for symptomatic patients (P < 0.0001). Symptomatic recurrence, disease free survival <12 months, and no adjuvant chemotherapy were the only independent predictors of poor postrecurrence survival. 72% of asymptomatic and 37% of symptomatic patients received oncological treatment.

CONCLUSIONS

Patients with asymptomatic pancreatic cancer recurrence have improved recurrence-free, postrecurrence and overall survival. Symptoms when recurrence is diagnosed are a good surrogate marker of biological aggressiveness. Detection of asymptomatic recurrence may facilitate patient eligibility for investigational studies or other forms of treatment.

Frequency and intensity of postoperative surveillance after curative treatment of pancreatic cancer: a cost-effectiveness analysis

BACKGROUND

Few data exist to guide oncologic surveillance following curative treatment of pancreatic cancer. We sought to identify a rational, cost-effective postoperative surveillance strategy.

METHODS

We constructed a Markov model to compare the cost-effectiveness of 5 postoperative surveillance strategies. No scheduled surveillance served as the baseline strategy. Clinical evaluation and carbohydrate antigen (CA) 19-9 testing without/with routine computed tomography and chest X-ray at either 6- or 3-month intervals served as the 4 comparison strategies of increasing intensity. We populated the model with symptom, recurrence, treatment, and survival data from patients who had received intensive surveillance after multimodality treatment at our institution between 1998 and 2008. Costs were based on Medicare payments (2011 US dollars).

RESULTS

The baseline strategy of no scheduled surveillance was associated with a postoperative overall survival (OS) of 24.6 months and a cost of $3837/patient. Clinical evaluation and CA 19-9 assay every 6 months until recurrence was associated with a 32.8-month OS and a cost of $7496/patient, with an incremental cost-effectiveness ratio (ICER) of $5364/life-year (LY). Additional routine imaging every 6 months incrementally increased total cost by $3465 without increasing OS. ICERs associated with clinic visits every 3 months without/with routine imaging were $127,680 and $294,696/LY, respectively. Sensitivity analyses changed the strategies' absolute costs but not the relative ranks of their ICERs.

CONCLUSIONS

Increasing the frequency and intensity of postoperative surveillance of patients after curative therapy for pancreatic cancer beyond clinical evaluation and CA 19-9 testing every 6 months increases cost but confers no clinically significant survival benefit.