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Trends in the Treatment of Resectable Pancreatic Adenocarcinoma

  • 2013 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

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.

Methods

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.

Results

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.

Conclusion

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.

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Acknowledgments

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.

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Authors and Affiliations

  1. Department of Surgery, Division of Surgical Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44106, USA

    Siavash Raigani, John Ammori, Julian Kim & Jeffrey M. Hardacre

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  1. Siavash Raigani
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  2. John Ammori
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  3. Julian Kim
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  4. Jeffrey M. Hardacre
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Corresponding author

Correspondence to Jeffrey M. Hardacre.

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Discussant

Dr. John Allendorf (New York, New York): We know that the patients with pancreatic cancer who do the best and live the longest are the ones who undergo surgical resection and we often lament that only 15 % of patients present with resectable disease. But, Dr. Hardacre and soon to be Dr. Raigani remind us that actually far fewer patients than this actually get to an operating room. Even more startling is the finding that there has been no improvement in the years that have elapsed since Drs. Bilimori and Talamonti brought this to our attention. The authors of this paper should be commended for not letting this issue rest.

I have three questions:

1. Most of the work done on this issue utilizes the national cancer database. Have the authors considered querying other large national databases or large institutional databases to corroborate their findings using similar methods?

2. The overriding bias in this paper, likely held by many of us in the room, is that the reported rate if surgery is unacceptably low. However, the target, acceptable, or appropriate rate of surgical treatment is certainly less than 100 %. Could the authors comment on what they think the appropriate target rate for surgical resection ought to be?

3. Many patients who are radiographically stage I or II by initial CT scan will later be found to be stage III or stage IV by additional imaging or at surgical exploration. So, how does and at what point does the patient get assigned to a stage in the database and how might this affect your results?

Closing Discussant

Mr. Siavash Raigani: Thank you Dr. Allendorf for your comments and questions. We originally set out on this project to assess trends in the adjuvant treatment of pancreatic cancer. We had noticed at our institution that more patients seemed to be getting chemotherapy in the adjuvant setting instead of multimodality therapy. We were therefore interested in seeing if this was a more widespread phenomenon. Our data have shown that it is, but they have also shown the persistence of an inability to get patients with resectable pancreatic cancer the therapy that has the greatest impact on outcome.

With regard to your first question, we are not aware of other national databases that would be able to provide the information needed to corroborate or refute our results. Should anyone know of such a database, we would certainly be interested in doing so.

With regard to staging, the NCDB uses a combined AJCC stage group, which includes the pathologic stage group augmented by the clinical stage group where the pathologic stage is not recorded. This combination minimizes the number of cases without an AJCC stage and avoids exclusion of nonsurgical cases from review.

Finally, you asked what we think an appropriate utilization of surgical resection would be. In this study, ∼20 % of the patients were age 80 or greater. Of that group, one would think that 50–75 % are not appropriate for pancreatic resection. This brings us to 85–90 % of the entire study population. If we subtracted another 5–10 % for patients not amenable to resection, we enter the 75–85 % range, which we think is a reasonable target for a resection rate.

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Raigani, S., Ammori, J., Kim, J. et al. Trends in the Treatment of Resectable Pancreatic Adenocarcinoma. J Gastrointest Surg 18, 113–123 (2014). https://doi.org/10.1007/s11605-013-2335-x

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  • DOI: https://doi.org/10.1007/s11605-013-2335-x

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