Disparities in Surgical Treatment of Resectable Pancreatic Adenocarcinoma at Minority Serving Hospitals

INTRODUCTION

Minority serving hospitals (MSH) are those serving a disproportionally high number of minority patients. Previous research has demonstrated that treatment at MSH is associated with worse outcomes. We hypothesize that patients treated at MSH are less likely to undergo surgical resection of pancreatic adenocarcinoma compared to patients treated at non-MSH.

METHODS

Patients with resectable pancreatic cancer were identified using the National Cancer Database. Institutions treating Black and Hispanic patients in the top decile were categorized as an MSH. Factors associated with the primary outcome of definitive surgical resection were evaluated using multivariable logistic regression. Univariate and multivariable survival analysis was performed.

RESULTS

Of the 75,513 patients included in this study, 7.2% were treated at MSH. Patients treated at MSH were younger, more likely to be uninsured, and higher stage compared to those treated at non-MSH (P < 0.001). Patients treated at MSH underwent surgical resection at lower rates (MSH 40% versus non-MSH 44.5%, P < 0.001). On multivariable logistic regression, treatment at MSH was associated with decreased likelihood of undergoing definitive surgery (odds ratio 0.91, P = 0.006). Of those who underwent surgical resection, multivariable survival analysis revealed that treatment at an MSH was associated with increased morality (hazard ratio 1.12, P < 0.001).

CONCLUSIONS

Patients with resectable pancreatic adenocarcinoma treated at MSH are less likely to undergo surgical resection compared to those treated at non-MSH. Targeted interventions are needed to address the unique barriers facing MSH facilities in providing care to patients with pancreatic adenocarcinoma.

The Impact of Race on Pancreatic Cancer Treatment and Survival in the Nationwide Veterans Affairs Healthcare System

OBJECTIVES

Among patients with pancreatic cancer, studies show racial disparities at multiple steps of the cancer care pathway. Access to healthcare is a frequently cited cause of these disparities. It remains unclear if racial disparities exist in an integrated, equal access public system such as the Veterans Affairs healthcare system.

METHODS

We identified all patients diagnosed with pancreatic adenocarcinoma in the national Veterans Affairs Central Cancer Registry from January 2010 to December 2018. We examined the independent association between race and 3 endpoints: stage at diagnosis, receipt of treatment, and survival while adjusting for sociodemographic factors and medical comorbidities.

RESULTS

We identified 8529 patients with pancreatic adenocarcinoma, of whom 79.5% were White and 20.5% were Black. Black patients were 19% more likely to have late-stage disease and 25% less likely to undergo surgical resection. Black patients had 13% higher mortality risk compared with White patients after adjusting for sociodemographic characteristics and medical comorbidities. This difference in mortality was no longer statistically significant after additionally adjusting for cancer stage and receipt of potentially curative treatment.

CONCLUSIONS

Equal access to healthcare might have reduced but failed to eliminate disparities. Dedicated efforts are needed to understand reasons underlying these disparities in an attempt to close these persistent gaps.

Socioeconomic Mediation of Racial Segregation in Pancreatic Cancer Treatment and Outcome Disparities

OBJECTIVE

To understand the mediating effect of socioeconomic factors on the association between residential segregation and racial disparities in pancreatic cancer (PC).

BACKGROUND

Black patients with PC present at a later stage and have worse mortality than White patients. These disparities have been explained by the level of residential segregation.

METHODS

Data were obtained from Surveillance, Epidemiology, and End-Results (SEER) and included all Black and White patients who were diagnosed with PC between 2005 and 2015. The primary exposure variable was the Index of Dissimilarity, a validated measure of segregation. County-level socioeconomic variables from the US Census were assessed as mediators. The primary outcomes were advanced stage at diagnosis, surgical resection for localized disease, and overall mortality. Generalized structural equation modeling was used to assess the mediation of each of the socioeconomic variables.

RESULTS

Black patients in the highest levels of segregation saw a 12% increased risk [relative risk=1.12; 95% confidence interval (CI): 1.08, 1.15] of presenting at an advanced stage, 11% decreased likelihood of undergoing surgery (relative risk=0.89; 95% CI: 0.83, 0.94), and 8% increased hazards of death (hazard ratio=1.08; 95% CI: 1.03, 1.14) compared with White patients in the lowest levels. The Black share of the population, insurance status, and income inequality mediated 58% of the total effect on the advanced stage. Poverty and Black income immobility mediated 51% of the total effect on surgical resection. Poverty and Black income immobility mediated 50% of the total effect on overall survival.

CONCLUSIONS

These socioeconomic factors serve as intervention points for legislators to address the social determinants inherent to the structural racism that mediate poor outcomes for Black patients.

Review of genetic and pharmacogenetic differences in cytotoxic and targeted therapies for pancreatic cancer in African Americans

Pancreatic ductal adenocarcinoma (PDAC) is currently the third leading cause of cancer mortality and the incidence is projected to increase by 2030. Despite recent advances in its treatment, African Americans have a 50-60% higher incidence and 30% higher mortality rate when compared to European Americans possibly resulting from differences in socioeconomic status, access to healthcare, and genetics. Genetics plays a role in cancer predisposition, response to cancer therapeutics (pharmacogenetics), and in tumor behavior, making some genes targets for oncologic therapeutics. We hypothesize that the germline genetic differences in predisposition, drug response, and targeted therapies also impact PDAC disparities. To demonstrate the impact of genetics and pharmacogenetics on PDAC disparities, a review of the literature was performed using PubMed with variations of the following keywords: pharmacogenetics, pancreatic cancer, race, ethnicity, African, Black, toxicity, and the FDA-approved drug names: Fluoropyrimidines, Topoisomerase inhibitors, Gemcitabine, Nab-Paclitaxel, Platinum agents, Pembrolizumab, PARP-inhibitors, and NTRK fusion inhibitors. Our findings suggest that the genetic profiles of African Americans may contribute to disparities related to FDA approved chemotherapeutic response for patients with PDAC. We recommend a strong focus on improving genetic testing and participation in biobank sample donations for African Americans. In this way, we can improve our current understanding of genes that influence drug response for patients with PDAC.

Eligibility Criteria Perpetuate Disparities in Enrollment and Participation of Black Patients in Pancreatic Cancer Clinical Trials

PURPOSE

Clinical trials determine safety and efficacy of cancer therapeutics and establish standards of care. Minority patient participation in cancer clinical trials is dismal. We aimed to determine the impact of eligibility criteria on disparities in pancreatic ductal adenocarcinoma (PDAC) clinical trial candidacy.

METHODS

Traditional PDAC trial eligibility criteria were obtained from ClinicalTrials.gov. Patients with PDAC who sought care at Virginia Commonwealth University Health from 2010 to 2019 were included. Clinical data were obtained from billing codes and discrete values in the electronic medical record. Eligibility criteria differences between racial groups were determined using chi-squared tests and unconditional maximum likelihood-based odds ratios.

RESULTS

Among 676 patients, most identified as Black or White race (42.5% and 51.6%, respectively). Using traditional criteria, Black patients were more likely to be ineligible for participation compared with White patients (42.4% v 33.2%, P = .023) secondary to hypoalbuminemia (14.1% v 7.9%, P = .023), HIV (3.1% v 0.3%, P = .010), hepatitis B (1.7% v 0%, P = .043), and hepatitis C (9.1% v 3.4%, P = .005). Black patients were also numerically more likely to be ineligible because of renal dysfunction, recent coronary stenting, and uncontrolled diabetes mellitus. Prior cancer treatment excluded fewer Black than White patients (9.1% v 14.0%, P = .072), most attributable to lower rates of neoadjuvant chemotherapy received. Strategic eligibility criteria revisions could equalize ineligibility rates between Black and White patients (26.8% v 24.8%, P = .581).

CONCLUSION

Traditional eligibility criteria differentially exclude Black patients from participating in PDAC clinical trials. These criteria perpetuate disparities, limit generalizability, and are often not medically justifiable. Revised criteria may improve participant diversity, without compromising safety or study results.

Treatment Inequity: Examining the Influence of Non-Hispanic Black Race and Ethnicity on Pancreatic Cancer Care and Survival in Wisconsin

INTRODUCTION

We investigated race and ethnicity-based disparities in first course treatment and overall survival among Wisconsin pancreatic cancer patients.

METHODS

We identified adults diagnosed with pancreatic adenocarcinoma in the Wisconsin Cancer Reporting System from 2004 through 2017. We assessed race and ethnicity-based disparities in first course of treatment via adjusted logistic regression and overall survival via 4 incremental Cox proportional hazards regression models.

RESULTS

The study included 8,490 patients: 91.3% (n = 7,755) non-Hispanic White; 5.1% (n = 437) non-Hispanic Black, 1.8% (n = 151) Hispanic, 0.6% Native American (n = 53), and 0.6% Asian (n = 51) race and ethnicities. Non-Hispanic Black patients had lower odds of treatment than non-Hispanic White patients for full patient (OR, 0.52; 95% CI, 0.41-0.65) and Medicare cohorts (OR, 0.40; 95% CI, 0.29-0.55). Non-Hispanic Black patients had lower odds of receiving surgery than non-Hispanic White patients (full cohort OR, 0.67 [95% CI, 0.48-0.92]; Medicare cohort OR, 0.57 [95% CI, 0.34-0.93]). Non-Hispanic Black patients experienced worse survival than non-Hispanic White patients in the first 2 incremental Cox proportional hazard regression models (model II HR, 1.18; 95% CI, 1.06-1.31). After adding insurance and treatment course, non-Hispanic Black and non-Hispanic White patients experienced similar survival (HR, 0.98; 95% CI, 0.88-1.09).

CONCLUSION

Non-Hispanic Black patients were almost 50% less likely to receive any treatment and 33% less likely to receive surgery than non-Hispanic White patients. After including treatment course, non-Hispanic Black and non-Hispanic White patient survival was similar. Increasing non-Hispanic Black patient treatment rates by addressing structural factors affecting treatment availability and employing culturally humble approaches to treatment discussions may mitigate these disparities.

Broadening Diversity in PDAC Trials

Findings from a simulated pancreatic cancer trial indicate that some common eligibility criteria, including infectious comorbidities, disproportionately disqualify more Black than white patients from being enrolled. The researchers proposed alternative criteria, showing that the changes could eliminate the imbalance in eligibility.

Racial/ethnic disparities in weight or BMI change in adulthood and pancreatic cancer incidence: The multiethnic cohort

INTRODUCTION

Compared to non-Hispanic Whites, Japanese Americans, Native Hawaiians, and African Americans have higher incidences of pancreatic cancer (PCa) that are not entirely explained by rates of obesity but may be explained by weight changes throughout adulthood.

METHODS

The multiethnic cohort is a population-based prospective cohort study that has followed 155,308 participants since its establishment between 1993 and 1996. A total of 1,328 incident cases with invasive PCa were identified through 2015. We conducted separate multivariable Cox proportional hazards models for self-reported weight-change and BMI-change (age 21 to cohort entry) to determine the association with PCa risk, adjusting for potential confounders including weight or BMI at age 21.

RESULTS

The mean age at cohort entry was 59.3 years (SD 8.9). An increased risk of PCa was associated with: 1) weight (HR per10 lbs = 1.06; 95% CI = 1.03-1.09) or BMI (HR per kg/m2  = 1.04; 95% CI = 1.02-1.05) at age 21; and 2) weight (HR per 10 lbs = 1.03; 95% CI = 1.01-1.05) or BMI (HR = 1.02; 95% CI = 1.00-1.03) at cohort entry. We found increased risk of PCa between weight (HR per 10 lbs = 1.03; 95% CI = 1.01-1.05) and BMI (HR per 5 kg/m2  = 1.08; 95% CI = 1.01-1.15) change from age 21 to baseline. There were significant interactions between race/ethnicity and weight (p = 0.008) or BMI (p = 0.03) at baseline, and weight (p = 0.02) or BMI (p = 0.02) change. Weight and BMI change through adulthood significantly increased the risk of PCa for Japanese Americans and Latinos, but not for African American, White, or Hawaiian participants.

CONCLUSION

Our findings indicate that weight or BMI gain has a significant and independent impact on PCa risk, specifically among Latinos and Japanese Americans.

Prognostic Impact of Tumor Size on Pancreatic Neuroendocrine Tumor Recurrence May Have Racial Variance

OBJECTIVE

The incidence of pancreatic neuroendocrine tumors (PNETs) has increased over the last decade. Black patients have worse survival outcomes. This study investigates whether oncologic outcomes are racially disparate at a single institution.

METHODS

Retrospective analysis was performed on 151 patients with resected PNETs between 2010 and 2019.

RESULTS

More White males and Black females presented with PNETs (P = 0.02). White patients were older (65 years vs 60 years; P = 0.03), more likely to be married (P < 0.01), and had higher median estimated yearly incomes ($28,973 vs $17,767; P < 0.01) than Black patients. Overall and disease-free survival were not different. Black patients had larger median tumor sizes (30 mm vs 23 mm; P = 0.02). Tumor size was predictive of recurrence only for White patients (hazard ratio, 1.02; P = 0.01). Collectively, tumors greater than 20 mm in size were more likely to have recurrence (P = 0.048), but this cutoff was not predictive in either racial cohort independently.

CONCLUSIONS

Black patients undergoing curative resection of PNETs at our institution presented with larger tumors, but that increased size is not predictive of disease-free survival in this population.

Racial Differences in Gastroenteropancreatic Neuroendocrine Tumor Treatment and Survival in the United States

OBJECTIVES

The objective of this study was to evaluate racial differences in cancer treatment and survival in gastroenteropancreatic neuroendocrine tumor (GEP-NET) patients.

METHODS

Using the Surveillance, Epidemiology, and End Results Registry, we identified patients with GEP-NETs of the stomach, small intestine (SI), colon, rectum, appendix, and pancreas diagnosed between 1973 and 2014. Demographic, cancer, and treatment information were collected and compared using χ2 tests. Multivariable logistic and Cox regression were used to determine disparities in receiving treatment and overall survival.

RESULTS

We identified 19,031 GEP-NET patients: 2839 were non-Hispanic Blacks, 12,832 non-Hispanic Whites, 2098 Hispanics, and 1262 Asians. African Americans and Hispanics with SI and pancreatic NETs were less likely to be treated with surgery (odds ratio, 0.6; 95% confidence interval [CI], 0.46-0.69; odds ratio, 0.71; 95% CI, 0.51-0.99, respectively). African American race was not an independent predictor of survival; there was a strong trend in stomach, SI, and pancreas NETs (hazard ratio [HR], 1.31; 95% CI, 1-1.7; HR, 1.2; 95% CI, 0.99-1.45; HR, 1.22; 95% CI, 1-1.48, respectively).

CONCLUSIONS

Our study provides evidence of racial disparities in treatment and survival across GEP-NET primary sites and racial groups. Further studies should be performed to improve our understanding of the reason for these disparities.

Replication and Genetic Risk Score Analysis for Pancreatic Cancer in a Diverse Multiethnic Population

BACKGROUND

Genome-wide association studies (GWAS) have identified several SNPs associated with pancreatic cancer. No studies yet have attempted to replicate these SNPs in US minority populations. We aimed to replicate the associations of 31 GWAS-identified SNPs with pancreatic cancer and build and test a polygenic risk score (PRS) for pancreatic cancer in an ethnically diverse population.

METHODS

We evaluated 31 risk variants in the Multiethnic Cohort and the Southern Community Cohort Study. We included 691 pancreatic ductal adenocarcinoma (PDAC) cases and 13,778 controls from African-American, Japanese-American, Latino, Native Hawaiian, and white participants. We tested the association between each SNP and PDAC, established a PRS using the 31 SNPs, and tested the association between the score and PDAC risk.

RESULTS

Eleven of the 31 SNPs were replicated in the multiethnic sample. The PRS was associated with PDAC risk [OR top vs. middle quintile = 2.25 (95% confidence interval, 1.73-2.92)]. Notably, the PRS was associated with PDAC risk in all ethnic groups except Native Hawaiian (OR per risk allele ranged from 1.33 in Native Hawaiians to 1.91 in African Americans; P heterogeneity = 0.12).

CONCLUSIONS

This is the first study to replicate 11 of the 31 GWAS-identified risk variants for pancreatic cancer in multiethnic populations, including African Americans, Japanese Americans, and Latinos. Our results also suggest a potential utility of PRS with GWAS-identified risk variants for the identification of individuals at increased risk for PDAC across multiple ethnic groups.

IMPACT

PRS can potentially be used to stratify pancreatic cancer risk across multiple ethnic groups.

Association of Glycated Hemoglobin Levels With Risk of Pancreatic Cancer

IMPORTANCE

New-onset diabetes after the age of 50 years is a potential indicator of pancreatic cancer. Understanding the associations between hyperglycemia, diabetes, and pancreatic cancer, including pancreatic ductal adenocarcinoma, is key to developing an approach to early detection.

OBJECTIVE

To assess the association of elevation in glycated hemoglobin (HbA1c) with the risk of pancreatic cancer.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted using data collected from an integrated health care system in California. A total of 851 402 patients aged 50 to 84 years who had HbA1c measurements taken between 2010 and 2014 were identified as the base cohort, with 12 contemporaneous cohorts created based on varying HbA1c thresholds (ie, 6.1%, 6.3%, 6.5%, and 6.7%) and prior diabetes status. Data analysis was conducted from August 2018 to September 2019.

MAIN OUTCOMES AND MEASURES

New cases of pancreatic cancer identified through cancer registry and California death files during a 3-year period. Three-year risk, incidence rate, sensitivity, number of patients needed to screen to detect 1 case, timing, and stage at diagnosis were determined.

RESULTS

Among 851 402 patients in the base cohort, 447 502 (52.5%) were women, 255 441 (30.0%) were Hispanic participants, 383 685 (45.1%) were non-Hispanic white participants, 100 477 (11.8%) were Asian participants, and 88 969 (10.4%) were non-Hispanic black participants, with a median (interquartile range) age of 62 (56-69) years and a median (interquartile range) HbA1c level of 6.0% (5.7%-6.6%). The incidence rate of pancreatic cancer was 0.45 (95% CI, 0.43-0.49) per 1000 person-years. After excluding prior diabetes as well as confirmation of new-onset hyperglycemia based on an HbA1c level of 6.5%, a total of 20 012 patients remained, with 74 of 1041 pancreatic ductal adenocarcinoma cases (7.1%) from the base cohort included. The rate of pancreatic cancer was 0.72 (95% CI, 0.32-1.42) per 1000 person-years among Asian patients, 0.83 (95% CI, 0.35-1.71) per 1000 person-years among non-Hispanic black patients, 0.84 (95% CI, 0.48-1.37) per 1000 person-years among Hispanic patients, and 2.37 (95% CI, 1.75-3.14) per 1000 person-years among non-Hispanic white patients. Overall, 42 of 74 cancers (56.8%) were diagnosed within 1 year of the index laboratory test. Among 1041 total cases, 708 (68.0%) had staging information available, of whom 465 (65.7%) had stage III or IV disease at diagnosis. In the base cohort, the number needed to undergo evaluation to identify a single case of pancreatic ductal adenocarcinoma was 818 (95% CI, 770-869), with estimates ranging from 206 (95% CI, 160-264) to 600 (95% CI, 540-666) in the subcohorts.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that screening patients for pancreatic cancer based solely on elevation in HbA1c level is unlikely to represent an effective strategy. Future efforts to identify a high-risk population based on changes in glycemic parameters should account for racial/ethnic differences.

C-reactive protein/albumin ratio is a prognostic indicator in Asians with pancreatic cancers: A meta-analysis

BACKGROUND

The prognostic value of C-reactive protein/albumin ratio (CAR) in pancreatic cancer remains controversial. This study aimed to determine the potential role of CAR as a prognostic indicator in pancreatic cancer.

METHODS

A comprehensive literature search up to December 2018 was conducted using PubMed, Web of Science, and other databases. The hazard ratio (HR) with 95% confidence interval (CI) was employed to quantitatively assess CAR as a prognostic indicator in patients with pancreatic cancer.

RESULTS

Eleven studies with 2047 pancreatic cancer patients were selected for the analysis. Ten out of 11 studies included only Asian patients. The pooled results showed that a higher CAR value was significantly associated with a poor overall survival of pancreatic cancer patients (random-effects model: HR = 1.86; 95% CI = 1.53-2.26). Sensitivity analysis indicated the stability of the overall pooled results. Subgroup analysis and meta-regression analysis revealed that the country under study, cut-off value of CAR, treatment of patients, and the period of follow-up did not affect the prognostic value of CAR in pancreatic cancer patients (P > .05). No publication bias was noted across the studies (P = .933).

CONCLUSION

This meta-analysis suggests that CAR is associated with the survival of pancreatic cancer patients of Asian ethnicity, and a higher CAR may be a potential prognostic indicator in pancreatic cancers.

Differences in Pancreatic Cancer Incidence Rates and Temporal Trends Across Asian Subpopulations in California (1988-2015)

OBJECTIVE

Ethnic disparities in pancreatic cancer (PanCan) incidence exist, but little is known about incidence trends in heterogeneous Asian Americans. We examined PanCan incidence and temporal patterns among detailed ethnic populations, including Asian American subgroups.

METHODS

A total of 71,099 invasive exocrine PanCan cases were identified using the California Cancer Registry between 1988 and 2015. Cases were grouped into mutually exclusive groups of non-Hispanic (NH) white, NH black, Hispanic, NH Asian/Pacific Islander (API), and NH American Indian/Alaska Native (AIAN). Asians were further identified by specific ethnicity.

RESULTS

The age-adjusted incidence rates (AAIRs, per 100,000) of PanCan varied significantly across racial/ethnic groups, ranging from the highest of 10.4 in NH blacks to 7.6 in NH whites, 7.1 in Hispanics, 6.2 in NH APIs, and to the lowest of 5.2 in NH AIAN. Despite the relatively low rate in the NH APIs, the rates across Asian subgroups varied significantly, with rates similar to NH whites in Japanese (8.1) and Koreans (7.5) to the low rate in South Asians (4.4).

CONCLUSIONS

Significant heterogeneity of PanCan incidence in disaggregated Asian Americans is a novel finding. These results fill a gap regarding PanCan burden in Asian Americans and underscore the importance of disaggregating ethnic populations in cancer research.

Disparities in Care: Impact of Socioeconomic Factors on Pancreatic Surgery: Exploring the National Cancer Database

Studies have shown high-volume institutions have decreased mortality and increased survival for pancreatectomy. However, not all patients can travel to high-volume centers. Socioeconomic factors may influence treatment decisions. The goal of this study is to examine socioeconomic factors that determine where a patient is treated and how that location affects outcome. This is a retrospective study of the National Cancer Database of patients diagnosed with pancreatic cancer from 2004 to 2014. The primary outcome was to examine socioeconomic factors that predicted where a patient underwent their pancreatectomy. Patients treated at academic programs (APs) had to travel a mean distance of 80.9 miles, whereas patients treated at community programs (CPs) had to travel 31.7 miles (P < 0.0001). Spanish and Hispanic patients were less likely to travel to an AP (69% had surgery at an AP versus 76% of non-Hispanic patients, P < 0.001). Patients with higher comorbidities were also more likely to have care at CPs. Patients who had pancreatic cancer surgery at CPs were more likely to be Hispanic or with higher medical comorbidities. Those who had surgery at AP traveled further distances but had better perioperative outcomes and had an improvement in overall survival.

Clinicopathological features and prognosis factors for survival in elderly patients with pancreatic neuroendocrine tumor: A STROBE-compliant article

To investigate the features and prognosis of the elderly patients with pancreatic neuroendocrine tumor (pNET).The patients diagnosed with pNETs between 2004 and 2014 were identified from the Surveillance Epidemiology and End Results database. The ethical approval was waived because the present study was analysis of the data from Surveillance Epidemiology and End Results database.A total of 4608 patients with "one primary only" histologically pNETs were confirmed and 653 were older than 75 years. Cancer-specific survival (CSS) and overall survival (OS) were examined. The elderly patients (≥75 years) have disadvantage in CSS and OS compared with younger cohort. Multivariate logistic regression revealed that the elderly patients have increased poorly differentiated composition, and decreased proportion of Black patients, receipt of surgery, married status, and number of removed lymph node. Multivariate Cox regression analysis demonstrated worse differentiation. Patients of T3-4 and M1 stage were associated with poor CSS, while patients of being female, tumor locating at pancreatic body/tail, receipt of surgery, and being married were associated with better CSS in the elderly patients. Meanwhile, patients with higher histological grade and M1 stage have poor OS, while patients with the characteristics of female, being married, tumor location at pancreatic body/tail and tumor surgery have better OS. Distant metastatic elderly patients underwent primary site surgery had better CSS and OS than the patients without surgery.The elderly patients have increased possibility of poorly differentiated tumor, and decreased proportion of Black patients, surgery of primary site, number of removed lymph node and married status. Worse differentiation and tumor metastasis were independent risk factors for both CSS and OS, while primary tumor located in body/tail of pancreas, female patients, surgery of tumor primary site, and being married were protective factors.

Prediction model for pancreatic cancer risk in the general Japanese population

Genome-wide association studies (GWASs) have identified many single nucleotide polymorphisms (SNPs) that are significantly associated with pancreatic cancer susceptibility. We sought to replicate the associations of 61 GWAS-identified SNPs at 42 loci with pancreatic cancer in Japanese and to develop a risk model for the identification of individuals at high risk for pancreatic cancer development in the general Japanese population. The model was based on data including directly determined or imputed SNP genotypes for 664 pancreatic cancer case and 664 age- and sex-matched control subjects. Stepwise logistic regression uncovered five GWAS-identified SNPs at five loci that also showed significant associations in our case-control cohort. These five SNPs were included in the risk model and also applied to calculation of the polygenic risk score (PRS). The area under the curve determined with the leave-one-out cross-validation method was 0.63 (95% confidence interval, 0.60–0.66) or 0.61 (0.58–0.64) for versions of the model that did or did not include cigarette smoking and family history of pancreatic cancer in addition to the five SNPs, respectively. Individuals in the lowest and highest quintiles for the PRS had odds ratios of 0.62 (0.42–0.91) and 1.98 (1.42–2.76), respectively, for pancreatic cancer development compared with those in the middle quintile. We have thus developed a risk model for pancreatic cancer that showed moderately good discriminatory ability with regard to differentiation of pancreatic cancer patients from control individuals. Our findings suggest the potential utility of a risk model that incorporates replicated GWAS-identified SNPs and established demographic or environmental factors for the identification of individuals at increased risk for pancreatic cancer development.

Disparities in cancer outcomes across age, sex, and race/ethnicity among patients with pancreatic cancer

Age, sex, and racial/ethnic disparities exist, but are understudied in pancreatic adenocarcinoma (PDAC). We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to determine whether survival and treatment disparities persist after adjusting for demographic and clinical characteristics. Our study included PDAC patients diagnosed between 1992 and 2011. We used Cox regression to compare survival across age, sex, and race/ethnicity within early-stage and late-stage cancer subgroups, adjusting for marital status, urban location, socioeconomics, SEER region, comorbidities, stage, lymph node status, tumor location, tumor grade, diagnosis year, and treatment received. We used logistic regression to compare differences in treatment received across age, sex, and race/ethnicity. Among 20,896 patients, 84% were White, 9% Black, 5% Asian, and 2% Hispanic. Median age was 75; 56% were female and 53% had late-stage cancer. Among early-stage patients in the adjusted Cox model, older patient subgroups had worse survival compared with ages 66-69 (HR > 1.1, P < 0.01 for groups >69); no survival differences existed between sexes. Black (HR = 1.1, P = 0.01) and Hispanic (HR = 1.2, P < 0.01) patients had worse survival compared with White. Among late-stage cancer patients, patients over age 84 had worse survival than those aged 66-69 (HR = 1.1, P < 0.01), and males (HR = 1.08, P < 0.01) had worse survival than females; there were no racial/ethnic differences. Older age and minority race/ethnicity were associated with lower likelihood of receiving chemotherapy, radiation, and/or surgery. Age and racial/ethnic disparities in survival outcomes and treatment received exist for PDAC patients; these disparities persist after adjusting for differences in demographic and clinical characteristics.

Pancreatic Cancer Mortality in China: Characteristics and Prediction

OBJECTIVES

During the last decade, the mortality rate of pancreatic cancer in China has significantly increased. We analyzed data for the period 1991-2014 to investigate the distribution of mortality rates and predict trends for the next 5 years.

METHODS

We obtained the pancreatic mortality data from the Chinese cancer annual report. Trend surface analysis was applied to study the geographical distribution. We used curve estimation, time series, grey box modeling, and joinpoint regression to predict the mortality rate.

RESULTS

Standardized pancreatic cancer mortality rate increased during 1991-2014 and might peak in the ensuing 5 years in China. The mortality rate was higher among elderly people and in urban and northeast/eastern areas than among young people and in rural and middle/western areas.

CONCLUSIONS

Pancreatic cancer mortality shows an increasing trend, which is related to the socioeconomic development of China and the ageing of the population. Prevention strategies should be aimed at urban men 45 years or older, especially those residing in higher-mortality rate areas.

QuickStats: Age-Adjusted Death Rates* for Top Five Causes of Cancer Death,(†) by Race/Hispanic Ethnicity - United States, 2014

In 2014, the top five causes of cancer deaths for the total population were lung, colorectal, female breast, pancreatic, and prostate cancer. The non-Hispanic black population had the highest age-adjusted death rates for each of these five cancers, followed by non-Hispanic white and Hispanic groups. The age-adjusted death rate for lung cancer, the leading cause of cancer death in all groups, was 42.1 per 100,000 standard population for the total population, 45.4 for non-Hispanic white, 45.7 for non-Hispanic black, and 18.3 for Hispanic populations.

Functional single nucleotide polymorphisms within the cyclin-dependent kinase inhibitor 2A/2B region affect pancreatic cancer risk

The CDKN2A (p16) gene plays a key role in pancreatic cancer etiology. It is one of the most commonly somatically mutated genes in pancreatic cancer, rare germline mutations have been found to be associated with increased risk of developing familiar pancreatic cancer and CDKN2A promoter hyper-methylation has been suggested to play a critical role both in pancreatic cancer onset and prognosis. In addition several unrelated SNPs in the 9p21.3 region, that includes the CDNK2A, CDNK2B and the CDNK2B-AS1 genes, are associated with the development of cancer in various organs. However, association between the common genetic variability in this region and pancreatic cancer risk is not clearly understood. We sought to fill this gap in a case-control study genotyping 13 single nucleotide polymorphisms (SNPs) in 2,857 pancreatic ductal adenocarcinoma (PDAC) patients and 6,111 controls in the context of the Pancreatic Disease Research (PANDoRA) consortium. We found that the A allele of the rs3217992 SNP was associated with an increased pancreatic cancer risk (ORhet=1.14, 95% CI 1.01-1.27, p=0.026, ORhom=1.30, 95% CI 1.12-1.51, p=0.00049). This pleiotropic variant is reported to be a mir-SNP that, by changing the binding site of one or more miRNAs, could influence the normal cell cycle progression and in turn increase PDAC risk. In conclusion, we observed a novel association in a pleiotropic region that has been found to be of key relevance in the susceptibility to various types of cancer and diabetes suggesting that the CDKN2A/B locus could represent a genetic link between diabetes and pancreatic cancer risk.

Characteristics of Venous Thromboembolism in Pancreatic Adenocarcinoma in East Asian Ethnics: A Large Population-Based Observational Study

Pancreatic cancer (PC) is known to be frequently associated with venous thromboembolism (VTE). Although treatment and prophylaxis strategies for VTE in PC patients were updated recently, these were mainly based on data from Western populations and were not verified in East Asian ethnic populations.We investigated the clinical characteristics of VTE in East Asian PC patients. We reviewed electronic medical records (EMR) of 1334 patients diagnosed with pancreatic adenocarcinoma from 2005 to 2010 at single tertiary hospital in Korea. All the patients with newly diagnosed VTE were classified by anatomical site and manifestation of symptoms. The primary outcomes of interest were 2-year cumulative incidence of VTE events. Cox proportional hazards models were used to analyze associations between risk factors and clinical outcomes.A total of 1115 patients were eligible for enrollment. The 2-year cumulative VTE incidence was 9.2%. Major risk factors associated with VTE event were advanced cancer stage, major surgery, and poor performance status. Risk factors associated with mortality after PC diagnosis included advanced cancer stage, poor performance score, leukocytosis, and lower albumin level. The overall VTE did not affected mortality. However in subgroup analysis, symptomatic VTE and deep vein thrombosis/pulmonary thromboembolism (DVT/PTE) showed worse prognosis than incidental or intra-abdominal VTE.The overall incidence of VTE events in Korean PC patients was lower than previous studies. Advanced cancer stage was the most important factor for VTE event and mortality. Unlike Western population group, VTE event did not affect overall prognosis after PC diagnosis. However, symptomatic VTE and DVT/PTE showed higher mortality after VTE event.

Current status and progress of pancreatic cancer in China

Cancer is currently one of the most important public health problems in the world. Pancreatic cancer is a fatal disease with poor prognosis. As in most other countries, the health burden of pancreatic cancer in China is increasing, with annual mortality rates almost equal to incidence rates. The increasing trend of pancreatic cancer incidence is more significant in the rural areas than in the urban areas. Annual diagnoses and deaths of pancreatic cancer in China are now beyond the number of cases in the United States. GLOBOCAN 2012 estimates that cases in China account for 19.45% (65727/337872) of all newly diagnosed pancreatic cancer and 19.27% (63662/330391) of all deaths from pancreatic cancer worldwide. The population’s growing socioeconomic status contributes to the rapid increase of China’s proportional contribution to global rates. Here, we present an overview of control programs for pancreatic cancer in China focusing on prevention, early diagnosis and treatment. In addition, we describe key epidemiological, demographic, and socioeconomic differences between China and developed countries. Facts including no nationwide screening program for pancreatic cancer, delay in early detection resulting in a late stage at presentation, lack of awareness of pancreatic cancer in the Chinese population, and low investment compared with other cancer types by government have led to backwardness in China’s pancreatic cancer diagnosis and treatment. Finally, we suggest measures to improve health outcomes of pancreatic cancer patients in China.

Association of cholesterol with risk of pancreatic cancer: A meta-analysis

AIM: To evaluate the effect of dietary cholesterol and serum total cholesterol (TC) on the risk of pancreatic cancer.

METHODS: A literature search was performed up to June 2014 in PubMed, EMBASE, China National Knowledge Infrastructure and China Biology Medical literature database for relevant articles published in English or Chinese. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated with a random-effects model.

RESULTS: We included 14 published articles with 439355 participants for dietary cholesterol, and 6 published articles with 1805697 participants for serum TC. For the highest vs lowest category of dietary cholesterol, the pooled RR (95%CI) of pancreatic cancer was 1.308 (1.097-1.559). After excluding two studies (RR > 3.0), the pooled RR (95%CI) was 1.204 (1.050-1.380). In subgroup analysis stratified by study design, the pooled RRs (95%CIs) were 1.523 (1.226-1.893) for case-control studies and 1.023 (0.871-1.200) for cohort studies. The association of dietary cholesterol with the risk of pancreatic cancer was significant for studies conducted in North America [1.275 (1.058-1.537)] and others [2.495 (1.565-3.977)], but not in Europe [1.149 (0.863-1.531)]. No significant association [1.003 (0.859-1.171)] was found between the risk of pancreatic cancer and serum TC.

CONCLUSION: Dietary cholesterol may be associated with an increased risk of pancreatic cancer in worldwide populations, except for Europeans. The results need to be confirmed further.

Cancers associated with BRCA1 and BRCA2 mutations other than breast and ovarian

BACKGROUND

Previous studies have reported additional cancers associated with BRCA mutations; however, the type, magnitude of risk, and sex differences remain to be clarified. The purpose of this study was to evaluate the incidence of cancers other than breast and ovarian cancer in known mutation carriers.

METHODS

An institutional review board-approved study identified 1072 patients who had genetic counseling at the authors' institution and tested positive for a deleterious BRCA mutation. The expected number of cancer cases was calculated from the number of individuals in the study sample multiplied by the cancer incidence rates for the general population. The expected and observed numbers of cases were calculated in 5-year intervals to accommodate different age-related incidence rates. Standardized incidence ratios (SIRs) for each cancer type were calculated.

RESULTS

Among the 1072 mutation carriers, 1177 cancers of 30 different cancer types were identified. Individuals with a BRCA1 mutation did not have a significant increase in cancers other than breast and ovarian cancer; however, a trend in melanoma was observed. Individuals with a BRCA2 mutation had significantly higher numbers of observed cases versus expected cases for pancreatic cancer in both men and women (SIR, 21.7; 95% confidence interval [CI], 13.1-34.0; P < .001) and for prostate cancer in men (SIR, 4.9; 95% CI, 2.0-10.1; P = .002).

CONCLUSIONS

The results of this study uphold the current recommendations for hereditary breast and ovarian cancer screening of cancers other than breast and ovarian cancer by the National Comprehensive Cancer Network. Larger cohorts and collaborations are needed to further verify these findings.

Meta analysis of the association of cholesterol with pancreatic carcinoma risk

PURPOSE

Pancreatic carcinoma is a malignant tumor with poor prognosis. This metaanalysis was conducted to investigate if there exists any association of cholesterol with pancreatic carcinoma risk.

METHODS

A literature search was performed in Cochrane Central Library, PubMed, MEDLINE, EMBASE, CNKI (China National Knowledge Infrastructure), China Biology Medical literature database (CBM), and WangFang database for relevant available articles. Dietary cholesterol and serum levels of total cholesterol (TC) were assessed and compared. Pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated.

RESULTS

A total 19 articles coming from Europe, Asia and north America were assessed in this study. There was a significant difference between highest and lowest dietary cholesterol intake for pancreatic carcinoma risk (RR=1.31, 95% CI:1.10 to 1.56, p=0.01). Moreover, in subgroup analysis, there was a significant difference between highest and lowest dietary cholesterol intake for pancreatic carcinoma risk for case-control studies (RR=1.52, 95% CI:1.23 to 1.90, p=0.04). However, no significant difference was noticed between highest and lowest dietary cholesterol intake for pancreatic carcinoma risk for cohort studies (RR=1.02, 95% CI:0.87 to 1.20, p=0.51). The meta analysis results showed a significant difference between highest and lowest dietary cholesterol for pancreatic carcinoma in Europeans (RR=1.15, 95% CI:0.86 to 1.53, p=0.05). Moreover, compared to the low serum level of TC, the high level serum TC was associated with pancreatic carcinoma risk (RR=1.00, 95% CI:0.86-1.17, p=0.03). There was a significant difference between high and low levels of serum TC for pancreatic carcinoma risk in Europeans (RR=1.03, 95% CI: 0.72 to 1.48, p=0.04).

CONCLUSION

Dietary or serum cholesterol may be associated with risk for increased pancreatic carcinoma.

Clinical characteristics and prognostic factors of gastroenteropancreatic neuroendocrine tumors: a single center experience in China

BACKGROUND/AIMS

Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are a unique subgroup of tumors in the digestive system but with great clinical heterogeneity. The information on clinical characteristics and prognostic factors of Chinese patients is rather limited.

METHODOLOGY

We retrospectively analyzed the clinical features, prognostic factors of this disease in a consecutive cohort (N=294) between January 2007 and December 2012.

RESULTS

Functioning tumors accounted for 9.2%. Rectum was the most predominant GEP-NETs locations. Abdominal pain occurred in 46.5% patients which was the most common initial symptom. G1, G2 and G3 tumors accounted for 41.5%, 34.7% and 23.8%, respectively. Endoscopy provided the highest detection rate of 95.7%. Consistence between endoscopic ultrasound guided fine needle aspiration biopsy (EUS-FNAB) and surgically obtained histological Ki-67 index was 36.4%. Serum CgA test showed a 80.0% consistence with the tissue biopsy. The median follow up duration was 2.8 years (0.02-5.90 years), the median survival was 4.8 years, overall 5-year survival rate was 69.6%. We found colonic localization, tumor size larger than 20 mm, G3 tumor and metastasis were associated with worse outcome (p<0.05).

CONCLUSION

We found both consistence and differences in GEP-NETs characteristics between our study and previous reports.

Case-control study of diabetes-related genetic variants and pancreatic cancer risk in Japan

AIM: To examine whether diabetes-related genetic variants are associated with pancreatic cancer risk.

METHODS: We genotyped 7 single-nucleotide polymorphisms (SNPs) in PPARG2 (rs1801282), ADIPOQ (rs1501299), ADRB3 (rs4994), KCNQ1 (rs2237895), KCNJ11 (rs5219), TCF7L2 (rs7903146), and CDKAL1 (rs2206734), and examined their associations with pancreatic cancer risk in a multi-institute case-control study including 360 cases and 400 controls in Japan. A self-administered questionnaire was used to collect detailed information on lifestyle factors. Genotyping was performed using Fluidigm SNPtype assays. Unconditional logistic regression methods were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between these diabetes-associated variants and pancreatic cancer risk.

RESULTS: With the exception of rs1501299 in the ADIPOQ gene (P = 0.09), no apparent differences in genotype frequencies were observed between cases and controls. Rs1501299 in the ADPIOQ gene was positively associated with pancreatic cancer risk; compared with individuals with the AA genotype, the age- and sex-adjusted OR was 1.79 (95%CI: 0.98-3.25) among those with the AC genotype and 1.86 (95%CI: 1.03-3.38) among those with the CC genotype. The ORs remained similar after additional adjustment for body mass index and cigarette smoking. In contrast, rs2237895 in the KCNQ1 gene was inversely related to pancreatic cancer risk, with a multivariable-adjusted OR of 0.62 (0.37-1.04) among individuals with the CC genotype compared with the AA genotype. No significant associations were noted for other 5 SNPs.

CONCLUSION: Our case-control study indicates that rs1501299 in the ADIPOQ gene may be associated with pancreatic cancer risk. These findings should be replicated in additional studies.

Association between Helicobacter pylori infection and pancreatic cancer development: a meta-analysis

BACKGROUND

Pancreatic cancer is one of the most troublesome malignancies with dismal prognosis. H. pylori has been recognized as a type I carcinogen. Several studies have evaluated the association between H. pylori infection and pancreatic cancer development, however, the conclusions are inconsistent.

METHODS

Literature search was carried out in PubMed, EMBASE, Cochrane Library and CNKI databases to identify eligible researches. We performed overall meta-analysis of all studies included and subgroup analysis based on regional distribution. Quality of the studies (assessed by Newcastle-Ottawa quality assessment scale for case-control studies) and CagA+ strains of H. pylori were taken into consideration, and we conducted additional analyses including high-quality researches and those concerning CagA+ H. pylori respectively.

RESULTS

9 studies involving 3033 subjects (1083 pancreatic cancer cases, 1950 controls) were included. Summary OR and 95%CI of the overall meta-analysis of all included studies were 1.47 and 1.22-1.77, pooled data of the 4 high-quality studies were OR 1.28, 95%CI 1.01-1.63. OR of the 5 studies examined CagA+ strains was 1.42, corresponding 95%CI was 0.79 to 2.57. Summary estimates of subgroup analysis based on regional distribution are as follows, Europe group: OR 1.56, 95%CI 1.15-2.10; East Asia group: OR 2.01, 95%CI 1.33-3.02; North America group: OR 1.17, 95%CI 0.87-1.58. There was not obvious heterogeneity across the 9 studies. No publication bias was detected.

CONCLUSION

H. pylori infection is significantly, albeit weakly, associated with pancreatic cancer development. The association is prominent in Europe and East Asia, but not in North America. CagA+ H. pylori strains appear not to be associated with pancreatic cancer. However, more studies, especially prospective studies, are needed to validate our results.

Chromogranin A is a reliable biomarker for gastroenteropancreatic neuroendocrine tumors in an Asian population of patients

PURPOSE

To evaluate the significance of plasma chromogranin A (CgA) levels in patients with gastroenteropancreatic neuroendocrine tumors (GEP-NET) in terms of disease status and treatment responses.

MATERIALS AND METHODS

Forty-four GEP-NET patients comprising 15 disease-free patients and 29 patients with active disease, as well as 26 healthy participants were enrolled in this study between April 2010 and April 2011. Clinicopathological factors were collected and serial plasma CgA levels were measured.

RESULTS

Plasma CgA levels were significantly higher in GEP-NET patients with active disease than in disease-free patients (p = 0.011) or healthy participants (p = 0.001). No difference in CgA levels was observed in terms of primary tumor location, tumor grade, and functional status in patients with active disease. CgA values at 94 U/l distinguished healthy individuals or disease-free patients from patients with active disease. Sensitivity and specificity rates were 86 and 88%, respectively. CgA levels at 110 U/l differentiated patients without recurrence from those with recurrence, with a sensitivity rate of 100% and a specificity rate of 80%. Patients (5/5, 100%) with stable disease and who showed partial response after treatment had a more than 20% decrease in CgA levels compared with the baseline values. Patients (6/6, 100%) with progressive disease showed a less than 20% decrease or increase in CgA levels.

CONCLUSION

The plasma CgA level is a reliable biomarker for GEP-NET. We conclude that changes in CgA levels are associated with disease status and treatment responses.

Survival in population-based pancreatic cancer patients: San Francisco Bay area, 1995-1999

Patient vital status generally is passively obtained by cancer registries, and no previous population-based studies have used extensive active follow-up to compute a more accurate overall survival rate for pancreatic cancer. Therefore, the authors used multiple active and passive follow-up methods to determine vital status and date of death for 1,954 pancreatic cancer patients diagnosed from 1995 to 1999 in a large population-based study in the San Francisco Bay Area, California. Survival rates were estimated by using Kaplan-Meier methods. Hazard ratios and 95% confidence intervals were estimated by using multivariable Cox proportional-hazards models. Vital status was confirmed for >99% of 1,954 patients. The overall 5-year survival rate was 1.3% and was greater in patients who were younger and who had localized disease, well-differentiated tumors, and surgical resection. Shorter survival was associated with older age at diagnosis, male sex, distant/metastatic disease, and poorly differentiated tumors. Longer survival was observed for Asian/Pacific Islanders compared with non-Hispanic whites and for any active treatment regardless of tumor stage. With an almost complete follow-up, the authors observed a low overall 5-year survival rate. Although the results provide further evidence of poor survival among patients with pancreatic cancer, the data also suggest that within-stage-of-disease patients survived somewhat longer with therapy.

Pancreatic cancer susceptibility loci and their role in survival

Pancreatic cancer has one of the worst mortality rates of all cancers. Little is known about its etiology, particularly regarding inherited risk. The PanScan project, a genome-wide association study, identified several common polymorphisms affecting pancreatic cancer susceptibility. Single nucleotide polymorphisms (SNPs) in ABO, sonic hedgehog (SHH), telomerase reverse transcriptase (TERT), nuclear receptor subfamily 5, group A, member 2 (NR5A2) were found to be associated with pancreatic cancer risk. Moreover the scan identified loci on chromosomes 13q22.1 and 15q14, to which no known genes or other functional elements are mapped. We sought to replicate these observations in two additional, independent populations (from Germany and the UK), and also evaluate the possible impact of these SNPs on patient survival. We genotyped 15 SNPs in 690 cases of pancreatic ductal adenocarcinoma (PDAC) and in 1277 healthy controls. We replicated several associations between SNPs and PDAC risk. Furthermore we found that SNP rs8028529 was weakly associated with a better overall survival (OS) in both populations. We have also found that NR5A2 rs12029406_T allele was associated with a shorter survival in the German population. In conclusion, we found that rs8028529 could be, if these results are replicated, a promising marker for both risk and prognosis for this lethal disease.

The hypofunctional effect of P335L single nucleotide polymorphism on SSTR5 function

BACKGROUND

Somatostatin receptor subtype 5 (SSTR5) mediates the inhibitory effect of somatostatin on insulin expression/secretion and cell proliferation. A number of single nucleotide polymorphisms (SNPs) of SSTR5 have been identified, including P335L, a nonsynonymous SNP located in the protein C-terminal region and encrypted by the codon CCG (proline) or the codon CTG (leucine). In the present study we sought to determine the distribution of the SSTR5 P335L SNP in a cohort of pancreatic cancer patients and whether the P335L SNP affected cellular function of SSTR5 in human pancreatic cancer.

METHODS

The P335L germline genotype of 246 patients with pancreatic cancer (213 Caucasians, 16 Hispanics, and 17 African Americans) and 17 human pancreatic cell lines was determined with the TaqMan SNP Genotyping assay. Human SSTR5 leucine variant (L335) was generated by performing site-directed mutagenesis using SSTR5 proline variant (P335) as a template. Transient transfections were performed in HEK293, Mia PaCa-2, and β-TC-6 cells using Lipofectamine 2000. The expression of SSTR5 L335 was determined with a mouse monoclonal anti-SSTR5 L335 antibody generated in our laboratory. The cell proliferation rate was measured by performing MTS assays. Insulin concentration was measured by performing ELISA assays.

RESULTS

Genotyping of the patients' blood indicated that the frequency of the T allele (CT and TT genotypes) in codon 335 of SSTR5 in Caucasians, Hispanics, and African Americans was 52, 69, and 35%, respectively, which was race-dependent. Statistical analysis indicated that association between the frequency of the T allele and the existence of pancreatic cancer in each race missed significance perhaps due to limited sample size. In 17 tested human pancreatic cancer cell lines, 5 (Capan-2, HPAF-II, Panc03.27, Panc-1, and -3) were homozygous (TT genotype) and 9, including Mia PaCa-2, were heterozygous (CT genotype). Overexpression of SSTR5 L335 in Mia PaCa-2 cells enhanced cell proliferation compared to overexpression of SSTR5 P335. Overexpression of SSTR5 P335 enhanced the inhibitory effect of SSTR5 agonist RPL-1980 on cell proliferation of Mia PaCa-2 cells and glucose-stimulated insulin secretion from mouse insulinoma cells, while overexpression of SSTR5 L335 blocked the inhibitory effect of RPL-1980. Overexpression of SSTR5 L335 enhanced PDX-1 expression in Mia PaCa-2 cells. A specific monoclonal antibody was generated to detect SSTR5 P335L.

CONCLUSION

SSTR5 P335L SNP widely exists in the human population, in patients with pancreatic cancer, and is race-dependent. The SNP is also present in selected human pancreatic cancer cell lines. In contrast to SSTR5 P335, overexpression of the SSTR5 L335 variant resulted in cellular proliferation and PDX-1 overexpression in human pancreatic cancer cells. Its overexpression blocked the inhibitory effect of an SSTR5-specific analog on human pancreatic cancer cell proliferation and on glucose-stimulated insulin secretion from mouse insulinoma cells. These data suggest that SSTR5 P335L is a hypofunctional protein with a potentially harmful effect on function, as well as potential latent effect, and therefore it could affect the clinical response to somatostatin analog therapy for patients with pancreatic cancer.

Correlates of circulating 25-hydroxyvitamin D: Cohort Consortium Vitamin D Pooling Project of Rarer Cancers

Low vitamin D status is common globally and is associated with multiple disease outcomes. Understanding the correlates of vitamin D status will help guide clinical practice, research, and interpretation of studies. Correlates of circulating 25-hydroxyvitamin D (25(OH)D) concentrations measured in a single laboratory were examined in 4,723 cancer-free men and women from 10 cohorts participating in the Cohort Consortium Vitamin D Pooling Project of Rarer Cancers, which covers a worldwide geographic area. Demographic and lifestyle characteristics were examined in relation to 25(OH)D using stepwise linear regression and polytomous logistic regression. The prevalence of 25(OH)D concentrations less than 25 nmol/L ranged from 3% to 36% across cohorts, and the prevalence of 25(OH)D concentrations less than 50 nmol/L ranged from 29% to 82%. Seasonal differences in circulating 25(OH)D were most marked among whites from northern latitudes. Statistically significant positive correlates of 25(OH)D included male sex, summer blood draw, vigorous physical activity, vitamin D intake, fish intake, multivitamin use, and calcium supplement use. Significant inverse correlates were body mass index, winter and spring blood draw, history of diabetes, sedentary behavior, smoking, and black race/ethnicity. Correlates varied somewhat within season, race/ethnicity, and sex. These findings help identify persons at risk for low vitamin D status for both clinical and research purposes.

Flavonols and pancreatic cancer risk: the multiethnic cohort study

Only a few prospective studies have investigated flavonols as risk factors for cancer, none of which has included pancreatic cancer. The latter is usually fatal, rendering knowledge about prevention particularly important. The authors estimated intakes of three flavonols-quercetin, kaempferol, and myricetin-for 183,518 participants in the Multiethnic Cohort Study and examined associations with incidence of pancreatic cancer. Baseline data were collected in Hawaii and California in 1993-1996. Diet was assessed by using a quantitative food frequency questionnaire. During 8 years of follow-up, 529 cases of exocrine pancreatic cancer occurred. Multivariate Cox regression models were calculated to estimate relative risks. Intake of total flavonols was associated with a reduced pancreatic cancer risk (relative risk for the highest vs. lowest quintile = 0.77, 95% confidence interval: 0.58, 1.03; p trend = 0.046). Of the three individual flavonols, kaempferol was associated with the largest risk reduction (relative risk = 0.78, 95% confidence interval: 0.58, 1.05; p trend = 0.017). Total flavonols, quercetin, kaempferol, and myricetin were all associated with a significant inverse trend among current smokers (relative risks for the highest vs. lowest quartile = 0.41, 0.55, 0.27, 0.55, respectively) but not never or former smokers. This study provides evidence for a preventive effect of flavonols on pancreatic cancer, particularly for current smokers.

Race, socioeconomic status, treatment, and survival time among pancreatic cancer cases in California

BACKGROUND

Poor survival in pancreatic adenocarcinoma is associated with African-American race and also with low socioeconomic status (SES). However, it is not known whether the observed poor survival of African-American pancreatic adenocarcinoma cases is due to SES itself and/or treatment disparities. We set out to determine this using the large, population-based California Cancer Registry (CCR) database as a model.

METHODS

We conducted a case-only analysis of CCR data (1989-2003), including descriptive analysis of relevant clinical variables and SES. The SES variable used has been derived from principle component analysis of census block level CCR data linked to census data to address seven major indicators of SES. Overall survival univariate analyses were conducted using the Kaplan-Meier method. Multivariate survival analyses were done using Cox proportional hazards ratios (HR).

RESULTS

Incident cases of pancreatic cancer (24,735) were analyzed. Among adenocarcinomas, after adjustment for age, year of diagnosis, and gender, African-Americans [HR, 1.14; 95% confidence interval (95% CI), 1.08-1.21] and Hispanics (HR, 1.06; 95% CI, 1.01-1.11) had an increased risk of death compared with Caucasians. These differences persisted after adjustment for stage. However, after further adjustment for SES, surgery, radiation, and chemotherapy, the risk of death for African-Americans (HR, 1.00; 95% CI, 0.94-1.06) and Hispanics (HR, 0.97; 95% CI, 0.93-1.02) was not statistically different from Caucasians.

CONCLUSIONS

Differences in treatment and SES likely account for the observed poor survival of African-Americans and Hispanics among pancreatic adenocarcinoma cases. These data highlight the importance of improving access to care for ethnic minority pancreatic cancer patients.

Vegetable intake and pancreatic cancer risk: the multiethnic cohort study

Investigators studying associations between vegetable intake and pancreatic cancer risk have reported inconsistent findings to date. To further explore these associations, the authors analyzed data on 183,522 participants enrolled in the Hawaii-Los Angeles Multiethnic Cohort Study in 1993-1996. Intakes of total vegetables, light green, dark green, yellow-orange, and cruciferous vegetables, tomato products, and legumes were estimated from a quantitative food frequency questionnaire. After an average of 8.3 years of follow-up, 529 pancreatic cancer cases were identified. Multivariate-adjusted Cox proportional hazards models were created. All statistical tests were two-sided. Overall, total vegetable intake was not associated with pancreatic cancer risk, nor was intake of vegetable subgroups. Current smokers, who were at increased risk of pancreatic cancer (relative risk = 1.78, 95% confidence interval: 1.40, 2.27), had a decreased risk with higher intake of dark green vegetables (for comparison of extreme quartiles, relative risk = 0.50, 95% confidence interval: 0.27, 0.92; p-trend = 0.029). The inverse association for dark green vegetables was also seen in African Americans (p-trend = 0.043). In stratified analyses, inverse associations with total vegetables, light green vegetables, and legumes were significant in overweight/obese subjects. In conclusion, the authors found no evidence for an inverse association between vegetable intake and pancreatic cancer overall, but inverse associations in high-risk persons suggest the need for further investigation.

The epidemiology of pancreatic cancer in the United States: changes below the surface

BACKGROUND

Pancreatic cancer is the fourth leading cause of cancer death in the United States.

AIM

To examine temporal changes in the incidence and survival of patients with pancreatic adenocarcinoma.

METHODS

Using data from nine registries of the Surveillance, Epidemiology and End Results programme, age-adjusted incidence rates per 100 000 and survival rates were calculated for pancreatic cancer between 1977 and 2001.

RESULTS

We identified 58 655 cases of pancreatic cancer. The age-adjusted incidence rate remained stable during the study period (11.3 in 1977-1981 and 10.9 in 1997-2001). Overall, men were 30% more affected than women (age-adjusted incidence rate of 13.0 in men and 9.8 in women). The age-adjusted incidence rates were almost 50% higher among Blacks (16.4) than Whites (10.8) and people of other races (9.8). Over time the proportions of patients with localized disease decreased from 12.3% to 7.4% and those with regional disease increased from 18.6% to 25.8%, while metastatic disease remained stable (52.5% vs. 49.8%). The 1-year relative survival increased from 15.2% in 1977-1981 to 21.6% in 1997-2001.

CONCLUSIONS

The incidence of pancreatic cancer is stable. A shift from localized to regional disease was observed over time. The overall survival remains poor despite important improvements among patients with early stage disease.

A Geographic Correlation Study of the Incidence of Pancreatic and other Cancers in Whites

Ecologic analyses of cancer incidence rates may be helpful to formulate hypotheses on risk factors and mechanisms of poorly known neoplasms, such as pancreatic cancer. We calculated sex-specific pair-wise and partial (after adjustment for lung cancer incidence) correlations between the incidence of pancreatic cancer and that of 23 other cancers in two international sets of cancer incidence data: the recorded or estimated incidence for 2000 in 38 European countries and the recorded incidence in Whites for 1993-1997 in 35 cancer registries from North America and Oceania. In both sexes and datasets, a strong, highly significant correlation was present between the incidence of pancreatic cancer and that of lung and kidney cancer. For the latter, correlation coefficients in the European data were 0.71 in men and 0.74 in women (both p<0.0001); in the cancer registry data they were 0.57 (p=0.0004) in men and 0.45 (p=0.007) in women. The results on kidney cancer were not modified by adjustment for the correlation with lung cancer, were confirmed by the application of spatial regression models and, with the exception of men in the cancer registry data, were confirmed in sensitivity analyses restricted to the populations with data of best quality. Weaker, less consistent correlations were found for colorectal, endometrial, ovarian and bladder cancers. Tobacco smoking is a plausible explanation of the association between pancreatic and lung cancer; the association with kidney cancer likely reflects additional common etiologic and pathogenetic factors of the two neoplasms.

Phase II study of fixed dose rate gemcitabine with cisplatin for metastatic adenocarcinoma of the pancreas

PURPOSE

Although gemcitabine remains the standard of care for patients with advanced pancreatic cancer, additional improvements may be realized by combining therapeutic agents with synergistic activity, and optimizing drug delivery using pharmacokinetic principles such as fixed dose rate (FDR) infusion. The objectives of this study were to determine safety and efficacy in patients with metastatic pancreatic cancer treated with FDR gemcitabine in combination with low-dose cisplatin.

PATIENTS AND METHODS

Chemotherapy-naive patients with metastatic pancreatic adenocarcinoma were treated with a combination of gemcitabine 1,000 mg/m2 at 10 mg/m2/min together with cisplatin 20 mg/m2 on days 1 and 8 of a 21-day cycle. Patient follow-up was performed using computerized tomographic scans and serial CA 19-9 measurements.

RESULTS

A total of 51 patients were enrolled onto the study, with a median follow-up time of 215 days. Twenty-two of 40 patients (55.0%) with a baseline serum CA 19-9 level > or = 2x the upper limit of normal demonstrated a > or = 50% biomarker decline during treatment. Nine of 47 patients (19.1%) with measurable disease achieved a partial response, and 28 patients (59.6%) had disease stabilization for at least two treatment cycles. Median time to progression was 3.9 months and median survival was 7.1 months, with an estimated 1-year survival rate of 29%. The most frequently reported grade 3 or 4 adverse events were neutropenia (52.9%) and thrombocytopenia (15.7%). Most patients were switched to an every-other-week dosing schedule.

CONCLUSION

The combination of FDR gemcitabine and cisplatin is well tolerated and appears to be an acceptable, albeit not clearly superior, alternative to other gemcitabine/platinum regimens for the treatment of metastatic pancreatic cancer.

Meat and fat intake as risk factors for pancreatic cancer: the multiethnic cohort study

BACKGROUND

Meat intake has been associated with risk of exocrine pancreatic cancer, but previous findings have been inconsistent. This association has been attributed to both the fat and cholesterol content of meats and to food preparation methods. We analyzed data from the prospective Multiethnic Cohort Study to investigate associations between intake of meat, other animal products, fat, and cholesterol and pancreatic cancer risk.

METHODS

During 7 years of follow-up, 482 incident pancreatic cancers occurred in 190,545 cohort members. Dietary intake was assessed using a quantitative food frequency questionnaire. Associations for foods and nutrients relative to total energy intake were determined by Cox proportional hazards models stratified by gender and time on study and adjusted for age, smoking status, history of diabetes mellitus and familial pancreatic cancer, ethnicity, and energy intake. Statistical tests were two-sided.

RESULTS

The strongest association was with processed meat; those in the fifth quintile of daily intake (g/1000 kcal) had a 68% increased risk compared with those in the lowest quintile (relative risk = 1.68, 95% confidence interval = 1.35 to 2.07; Ptrend < .01). The age-adjusted yearly incidence rates per 100,000 persons for the respective quintiles were 41.3 and 20.2. Intakes of pork and of total red meat were both associated with 50% increases in risk, comparing the highest with the lowest quintiles (both Ptrend < .01). There were no associations of pancreatic cancer risk with intake of poultry, fish, dairy products, eggs, total fat, saturated fat, or cholesterol. Intake of total and saturated fat from meat was associated with statistically significant increases in pancreatic cancer risk but that from dairy products was not.

CONCLUSION

Red and processed meat intakes were associated with an increased risk of pancreatic cancer. Fat and saturated fat are not likely to contribute to the underlying carcinogenic mechanism because the findings for fat from meat and dairy products differed. Carcinogenic substances related to meat preparation methods might be responsible for the positive association.

[Comparison of pBcl-2 and pBax expression in primary invasive ductal pancreatic cancer between Chinese and Japanese patients]

OBJECTIVE

To clarify the clinicopathologic significance of the expression of the Bcl-2 protein (pBcl-2) and the Bax protein (pBax), and their clinical implications in Chinese and Japanese patients with human invasive ductal carcinomas (IDCs) of the pancreas.

METHODS

The study included 59 Chinese and 65 Japanese patients with IDCs of the pancreas. pBcl-2 and pBax expression were immuno-stained with streptavidin-biotin (SAB) method.

RESULTS

pBcl-2 (+) was seen in 35.6% of Chinese and in 23.1% of Japanese patients. pBax (+) was seen in 49.2% of Chinese and 64.7% of Japanese patients. A comparison between them showed that there were significant differences in the male patients, in the patients with the moderately differentiated cancer, and in the elderly patients (chi squared = 4.447, P = 0.035; chi squared = 4.114, P = 0.043; chi squared = 6.657, P = 0.010 respective). In both Chinese and Japanese patients, those with pBcl-2 positive expression had a significantly higher survival rate than those with negative one (chi squared = 9.99, P = 0.0016; chi squared = 7.63, P = 0.0058). The group with pBax positive expression had a significantly higher survival rate in Japanese patients (chi squared = 9.37, P = 0.0022). Japanese patients whose tumors exhibited pBcl-2 and pBax positive immunostaining survived significantly longer than Chinese patients did (chi squared = 4.48, P = 0.0342; chi squared = 5.23, P = 0.023).

CONCLUSIONS

The expressions of both pBcl-2 and pBax are high found in Chinese and Japanese patients. The pBcl-2 positive expression implies a better prognosis in both Chinese and Japanese patients with IDCs of the pancreas. The effect of pBax expression on prognosis is different between Chinese and Japanese patients.

Impact of ethnicity on outcome in pancreatic carcinoma

CONTEXT

Ethnicity is an important factor known to impact the biology and outcome of many cancers. In pancreatic cancer, African Americans are thought to have a higher incidence and poorer prognosis than Whites.

PATIENTS

A total 645 pancreatic cancer patients were identified in the database, of which, 530 patients were eligible for this study and retained for the statistical analysis. Of the 530 patients, 137 (25.8%) were Blacks, 393 (74.2%) were Whites, 275 (51.9%) were males and 255 (48.1) were females. Ages ranged from 21 to 93 years with values of 62.3+/-13.3 years, 64.2+/-11.6 years, 63.1+/-10.9 and 64.3+/-13.3 (mean+/-SD) for Blacks, Whites, males, and females, respectively. Overall, 132 patients out of 415 (31.8%) were seen in stage I, 61 (14.7%) in stage II, 105 (25.3%) in stage III, 117 (28.2%) in stage IV, while 115 patients (21.7%) had missing stage.

RESULTS

There were no significant differences between Blacks and Whites with respect to distributions across stages (P=0.422). Adenocarcinoma was the most common histology in both ethnicities with poor differentiation in 47.4% of Blacks and 57.0% of Whites. Overall, 125 (23.6%) received surgery alone, 54 (10.2%) surgery with chemotherapy, 5 (0.9%) surgery with external radiation therapy, 10 (1.9%) external radiation therapy alone, 68 (12.8%) chemotherapy alone, 58 (10.9%) chemo-external radiation therapy, and 210 (39.6%) no therapy. Overall, only 22 patients survived at 5-yr (4.2%). Median survival was 8.0 months for Blacks (95% CI: 6.4-10.2) and 8.1 months for Whites (95% CI: 7.1-9.7) and there was no significant difference in survival between Blacks and Whites (P=0.971). There were more survivors in females (43/255, 16.9%) than in males (25/275, 9.1%; P=0.009), and females had significantly greater survival times as compared to males (P=0.022).

CONCLUSIONS

Pancreatic cancer is a disease of both ethnicities with a slight male predominance among Whites and female predominance among Blacks. We did not find any significant difference in the treatment specific outcome and survival between Blacks and Whites.

Risk of pancreatic adenocarcinoma: disparity between African Americans and other race/ethnic groups

BACKGROUND

African Americans have a higher incidence of pancreatic adenocarcinoma compared with non-Hispanic whites. Whether other clinical differences exist between these two groups is not well known.

METHODS

The authors conducted a population-based retrospective analysis of all patients with pancreatic adenocarcinoma in both a regional and a statewide database between 1988 and 1998. Their goal was to evaluate differences in incidence rates, clinical presentation, including age at diagnosis, gender, and tumor characteristics, and treatment among race/ethnic groups.

RESULTS

African Americans had a higher age-adjusted incidence rate of pancreatic adenocarcinoma (8.78) compared with non-Hispanic whites (5.89), Hispanics (5.09), Asians (4.75), and all race/ethnicities combined (5.82). African Americans also presented at a later stage of disease and received less surgery than all other race/ethnicities, despite equal availability of medical insurance. The analyses also revealed gender differences. In general, males maintained a higher incidence rate of pancreatic adenocarcinoma than females across all race/ethnicities. In all race/ethnic groups, females were diagnosed at an older age and an earlier stage of disease than males. The proportional hazard mortality ratio for females age < 60 was significantly less than that for males in the same age group (P < 0.02), even after accounting for stage and treatment.

CONCLUSIONS

African Americans in California had a higher incidence rate of pancreatic adenocarcinoma, had a slightly higher risk of presenting with advanced-stage disease and with nonresectable tumors (i.e., tumors located in the body or tail of the pancreas), and underwent less surgical treatment than all other race/ethnicities. Younger females in all race/ethnic groups had a survival advantage over males of the same age.