Journal of Gastrointestinal Surgery

, Volume 18, Issue 1, pp 113–123 | Cite as

Trends in the Treatment of Resectable Pancreatic Adenocarcinoma

  • Siavash Raigani
  • John Ammori
  • Julian Kim
  • Jeffrey M. HardacreEmail author
2013 SSAT Plenary Presentation



Multiple prospective, randomized trials have demonstrated that the addition of adjuvant therapy after surgical resection of pancreatic cancer improves survival compared to surgery alone. However, the optimal type of adjuvant therapy, chemotherapy alone, or chemotherapy combined with chemoradiation therapy remains controversial. Our aim was to examine the treatment trends for surgically resectable (stages I and II) pancreatic cancer in the USA using the National Cancer Database.


The National Cancer Database (NCDB) is a national oncology outcomes database for over 1,500 Commission on Cancer accredited cancer programs. Patients diagnosed with stage I–II pancreatic adenocarcinoma between 2003 and 2010 were selected from the NCDB Hospital Comparison Benchmark Reports. Attention was paid to the initial treatment regimen, such as surgery alone, surgery plus chemotherapy, or surgery plus chemoradiation. In addition, data on hospital setting (teaching hospitals vs. community hospitals) were collected and analyzed. The Cochran–Armitage test for trend was used to assess changes in treatment over time.


Fifty-nine thousand ninety-four patients with stage I–II pancreatic adenocarcinoma were included in the analysis. Between 2003 and 2010, the use of surgery alone as first course treatment of stage II disease decreased significantly at both teaching hospitals and community hospitals among patients who underwent surgery (P < 0.0001 for both cases). In the same period, the use of chemotherapy in addition to surgery as treatment of stage I and II disease increased at least twofold at both hospital settings (P < 0.0001 for all cases). Treatment with surgery plus chemoradiation decreased significantly for both stages in both hospital settings (P < 0.0001 for all cases). Nonsurgical treatment for stage II disease was surprisingly high and significantly increased over time (P < 0.001 for both hospital types), ranging from approximately 30–37 % at teaching hospitals and 39–47 % at community hospitals.


Data from the NCDB from 2003 to 2010 illustrate changes in the adjuvant treatment of pancreatic cancer. The use of chemotherapy alone as adjuvant therapy increased whereas the use of multimodality therapy decreased. In addition, there remains an alarmingly high rate of nonsurgical therapy for stage I and II disease.


Pancreatic cancer Surgery Adjuvant therapy 



The author (SR) would like to thank the Case Western Reserve University School of Medicine for providing support with the Dean’s Summer Research Award for first-year medical students.


  1. 1.
    Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin 2012; 62:10–29.PubMedCrossRefGoogle Scholar
  2. 2.
    Stocken DD, Büchler MW, Dervenis C, Bassi C, Jeekel H, Klinkenbijl JH, Bakkevold KE, Takada T, Amano H, Neoptolemos JP, Pancreatic Cancer Meta-analysis Group. Meta-analysis of randomised adjuvant therapy trials for pancreatic cancer. Br J Cancer 2005;92:1372.PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Kalser MH, Ellenberg SS. Pancreatic cancer. Adjuvant combined radiation and chemotherapy following curative resection. Arch Surg 1985;120:899–903.PubMedCrossRefGoogle Scholar
  4. 4.
    Neoptolemos JP, Dunn JA, Stocken DD, Almond J, Link K, Beger H, Bassi C, Falconi M, Pederzoli P, Dervenis C, Fernandez-Cruz L, Lacaine F, Pap A, Spooner D, Kerr DJ, Friess H, Büchler MW, European Study Group for Pancreatic Cancer. Adjuvant chemoradiotherapy and chemotherapy in resectable pancreatic cancer: a randomised controlled trial. Lancet 2001;358:1576–85.PubMedCrossRefGoogle Scholar
  5. 5.
    Oettle H, Post S, Neuhaus P, Gellert K, Langrehr J, Ridwelski K, Schramm H, Fahlke J, Zuelke C, Burkart C, Gutberlet K, Kettner E, Schmalenberg H, Weigang-Koehler K, Bechstein WO, Niedergethmann M, Schmidt-Wolf I, Roll L, Doerken B, Riess H. Adjuvant chemotherapy with gemcitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial. JAMA 2007;297:267–77.PubMedCrossRefGoogle Scholar
  6. 6.
    Regine WF, Winter KA, Abrams RA, Safran H, Hoffman JP, Konski A, Benson AB, Macdonald JS, Kudrimoti MR, Fromm ML, Haddock MG, Schaefer P, Willett CG, Rich TA. Fluorouracil vs gemcitabine chemotherapy before and after fluorouracil-based chemoradiation following resection of pancreatic adenocarcinoma: a randomized controlled trial. JAMA 2008;299:1019–26.PubMedCrossRefGoogle Scholar
  7. 7.
    Neoptolemos JP, Stocken DD, Bassi C, Ghaneh P, Cunningham D, Goldstein D, Padbury R, Moore MJ, Gallinger S, Mariette C, Wente MN, Izbicki JR, Friess H, Lerch MM, Dervenis C, Oláh A, Butturini G, Doi R, Lind PA, Smith D, Valle JW, Palmer DH, Buckels JA, Thompson J, McKay CJ, Rawcliffe CL, Büchler MW, European Study Group for Pancreatic Cancer. Adjuvant chemotherapy with fluorouracil plus folinic acid vs gemcitabine following pancreatic cancer resection: a randomized controlled trial. JAMA 2010;304:1073–81.PubMedCrossRefGoogle Scholar
  8. 8.
    National Comprehensive Cancer Network Guidelines Version 2.2012 - Pancreatic Adenocarcinoma. Available at (Accessed March 28, 2013).
  9. 9.
    Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992;45:613–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Klinkenbijl JH, Jeekel J, Sahmoud T, van Pel R, Couvreur ML, Veenhof CH, Arnaud JP, Gonzalez DG, de Wit LT, Hennipman A, Wils J. Adjuvant radiotherapy and 5-fluorouracil after curative resection of cancer of the pancreas and periampullary region: phase III trial of the EORTC gastrointestinal tract cancer cooperative group. Ann Surg 1999;230:776–84.PubMedCrossRefGoogle Scholar
  11. 11.
    Yeo CJ, Abrams RA, Grochow LB, Sohn TA, Ord SE, Hruban RH, Zahurak ML, Dooley WC, Coleman J, Sauter PK, Pitt HA, Lillemoe KD, Cameron JL. Pancreaticoduodenectomy for pancreatic adenocarcinoma: postoperative adjuvant chemoradiation improves survival. A prospective, single-institution experience. Ann Surg 1997;225:621–36.PubMedCrossRefGoogle Scholar
  12. 12.
    Seufferlein T, Bachet JB, Van Cutsem E, Rougier P; ESMO Guidelines Working Group. Pancreatic adenocarcinoma: ESMO-ESDO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncology 2012;23:33–40.CrossRefGoogle Scholar
  13. 13.
    Hardacre JM, Mulcahy M, Small W, Talamonti M, Obel J, Krishnamurthi S, Rocha-Lima CS, Safran H, Lenz HJ, Chiorean EG. Addition of algenpantucel-L immunotherapy to standard adjuvant therapy for pancreatic cancer: a phase 2 study. J Gastrointest Surg 2013;17:94–101.PubMedCrossRefGoogle Scholar
  14. 14.
    Piperdi M, McDade TP, Shim JK, et al. A neoadjuvant strategy for pancreatic adenocarcinoma increases the likelihood of receiving all components of care: lessons from a single-institution database. Journal of the International Hepato Pancreato Biliary Association 2010;12:204–210.CrossRefGoogle Scholar
  15. 15.
    Sohn TA, Yeo CJ, Cameron JL, Koniaris L, Kaushal S, Abrams RA, Sauter PK, Coleman J, Hruban RH, Lillemoe KD. Resected adenocarcinoma of the pancreas-616 patients: results, outcomes, and prognostic indicators. J Gastrointest Surg 2000;4:567–79.PubMedCrossRefGoogle Scholar
  16. 16.
    Hardacre JM. Is there a learning curve for pancreaticoduodenectomy after fellowship training? HPB Surg 2010;2010:230287.PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Aloia TA, Lee JE, Vauthey JN, Abdalla EK, Wolff RA, Varadhachary GR, Abbruzzese JL, Crane CH, Evans DB, Pisters PW.Delayed recovery after pancreaticoduodenectomy: a major factor impairing the delivery of adjuvant therapy? J Am Coll Surg 2007;204:347–55.PubMedCrossRefGoogle Scholar
  18. 18.
    Sener SF, Fremgen A, Menck HR, Winchester DP. Pancreatic cancer: a report of treatment and survival trends for 100,313 patients diagnosed from 1985–1995, using the National Cancer Database. J Am Coll Surg 1999;189:1–7.PubMedCrossRefGoogle Scholar
  19. 19.
    Bilimoria KY, Bentrem DJ, Ko CY, Tomlinson JS, Stewart AK, Winchester DP, Talamonti MS. Multimodality therapy for pancreatic cancer in the U.S.: utilization, outcomes, and the effect of hospital volume. Cancer 2007;110:1227–34.PubMedCrossRefGoogle Scholar
  20. 20.
    Bilimoria KY, Bentrem DJ, Ko CY, Stewart AK, Winchester DP, Talamonti MS. National failure to operate on early stage pancreatic cancer. Ann Surg 2007;246:173–80.PubMedCrossRefGoogle Scholar
  21. 21.
    Lee S, Tzeng CD, Chang GJ, Fleming JB, Lee JE, Katz MH, Jeffrey RL, Hetz SP. Race does not impact pancreatic cancer treatment and survival in an equal access federal health care system. Presented at Society of Surgical Oncology Cancer Symposium, March 6–9, 2013.Google Scholar
  22. 22.
    Riall TS, Lillemoe KD. Underutilization of surgical resection in patients with localized pancreatic cancer. Ann Surg 2007;246:181–2.PubMedCrossRefGoogle Scholar
  23. 23.
    Gordon TA, Bowman HM, Tielsch JM, Bass EB, Burleyson GP, Cameron JL. Statewide regionalization of pancreaticoduodenectomy and its effect on in-hospital mortality. Ann Surg 1998;228:71–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349:2117–2127.PubMedCrossRefGoogle Scholar
  25. 25.
    Fong Y, Gonen N, Rubin D, Radzyner M, Brennan MF. Long-term survival is superior after resection for cancer in high-volume centers. Ann Surg 2005;242:540–547.PubMedGoogle Scholar
  26. 26.
    Straus SG, Chen AH, Yee H Jr, Kushel MB, Bell DS. Implementation of an electronic referral system for outpatient specialty care. AMIA Annu Symp Proc 2011;2011:1337–46.PubMedGoogle Scholar
  27. 27.
    Kim-Hwang JE, Chen AH, Bell DS, Guzman D, Yee HF Jr, Kushel MB. Evaluating electronic referrals for specialty care at a public hospital. J Gen Intern Med 2010;25:1123–8.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2013

Authors and Affiliations

  • Siavash Raigani
    • 1
  • John Ammori
    • 1
  • Julian Kim
    • 1
  • Jeffrey M. Hardacre
    • 1
    Email author
  1. 1.Department of Surgery, Division of Surgical Oncology, University Hospitals Seidman Cancer CenterCase Western Reserve UniversityClevelandUSA

Personalised recommendations