Underuse of surgical resection among elderly patients with early-stage pancreatic cancer

doi:10.1016/j.surg.2015.04.031

Surgery

Volume 158, Issue 5, November 2015, Pages 1226-1234

https://doi.org/10.1016/j.surg.2015.04.031 Get rights and content

Background

Although surgery improves the health care quality and outcomes of patients with early-stage pancreatic cancer, these patients' operative resection rate has been historically low. We sought to identify factors that are associated with operative resection in this patient population.

Methods

In this retrospective population-based study, we used Texas Cancer Registry–linked and Surveillance and Epidemiology End Results Program–linked Medicare data to study factors potentially associated with operative resection in patients age ≥66 years who had been diagnosed with localized pancreatic cancer between January 1, 2001, and December 31, 2009. Variables were assessed using multivariate logistic regression and Cox proportional hazards regression models. We used Kaplan–Meier analysis to assess the effect of operative resection on survival rate.

Results

Of 1,501 patients with localized pancreatic cancer, only 340 (22.7%) underwent operation. Patients were more likely to undergo surgery if they were young, had small tumors, had low-grade tumors, and had nodal negativity (P < .05). Compared with patients who did not undergo surgery, patients who underwent surgery had a significantly higher 5-year overall survival rate (25.0 vs 2.3%; P < .0001) and had a higher median survival time (24.3 vs 5.8 months).

Conclusion

The rate of operative resection of early-stage pancreatic cancer did not increase significantly from 2001 to 2009. Although we identified several variables associated with operative resection, why the percentage of patients with localized pancreatic cancer who undergo definitive surgery is so low remains unclear.

Section snippets

Data

We used Texas Cancer Registry (TCR)-linked and SEER registry–linked Medicare databases in this retrospective population-based study. The TCR is a statewide, population-based registry of patient and tumor data. The National Cancer Institute's SEER Program consists of 18 nationwide population-based registries of cancer cases among 28% of the US population.

The Institutional Review Board of The University of Texas MD Anderson Cancer Center approved this study by granting an exemption in the absence

Results

We identified 1,501 patients with localized pancreatic cancer, of whom 340 (23%) underwent operative resection (Table I). The resection rate increased from 23% in 2001 to 30% in 2009 (P = .4048) but the year-to-year changes in the rate were inconsistently positive or negative within this interval (Fig 1). Of the 1,161 patients who did not undergo operative resection, 576 (50%) received nonoperative treatment with chemotherapy and/or radiotherapy, and 585 (50%) received no anticancer treatment.

Discussion

Operative resection is widely considered the only curative treatment for patients with early-stage pancreatic cancer and therefore has been recommended by the NCCN and European Society for Medical Oncology as a primary treatment option for these patients.4, 5 Nevertheless, multiple studies have shown that the surgery is grossly underused. Bilimoria et al,¹⁰ using the National Cancer Data Base, demonstrated the underuse of pancreatectomy among patients with early-stage disease between 1995 and

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Pancreatic cancer has a high case fatality and relatively short survival after diagnosis. Treatment is paramount to improving survival, but studies on the effects of standard treatment by surgery or chemotherapy on survival in U.S. healthcare settings is limited. Further, variability in access to care may impact treatment and outcomes for patients. We aimed to assess the relationship between standard treatment(s) and survival of pancreatic adenocarcinoma in a population with access to comprehensive healthcare.
We used the Military Cancer Epidemiology (MilCanEpi) database, which includes data from the Department of Defense cancer registry and medical encounter data from the Military Health System (MHS), to study a cohort of 1408 men and women who were diagnosed with pancreatic adenocarcinoma between 1998 and 2014. Treatment with surgery or chemotherapy in relation to overall survival was examined in multivariable time-dependent Cox regression models.
Overall, 75 % of 441 patients with early-stage and 51 % of 967 patients with late-stage pancreatic adenocarcinoma received treatment. In early-stage disease, surgery alone or surgery with chemotherapy were both associated with statistically significant 52 % reduced risks of death, but chemotherapy alone was not. In late-stage disease, surgery alone, chemotherapy alone, or both surgery and chemotherapy significantly reduced the risk of death by 42 %, 25 %, and 52 %, respectively.
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Those patients who underwent resection enjoyed significantly longer survival, with median survival time of 24.3 months compared to 5.8 months. This suggests that patients who could be enjoying extended lifespan due to surgical resection may not be receiving the option due to age alone.149 Similarly, among those who undergo resection, there are decreased rates of adjuvant chemotherapy delivery in the elderly population, which is associated with decreased median survival.150
Age as a prognostic indicator for adjuvant therapy in patients who underwent pancreatic resections for cancer
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There are a number of considerations that should be taken into account when treating older patients with pancreatic cancer. A study of Texas Cancer Registry-linked and Surveillance and Epidemiology End Results Program-linked Medicare data showed that only 8.5% of older patients (age ≥ 81) with localized pancreatic cancer underwent surgical resection, compared with 29.6% of patients younger than 81 years [30]. Although the safety of surgical resection has been demonstrated in older patients [31–33], surgery carries increased risk of intraoperative complications, postoperative morbidity, and mortality in this population [17–19,34].
In pancreatic cancer, the greatest increase in survival is attained by surgical resection followed by adjuvant chemotherapy. Although surgical complications and functional status are recognized as independent factors for halting adjuvant therapy in patients that undergo pancreatic resections, other elements may play a role in deciding which patients get treated postoperatively. Here we determined demographic and clinical characteristics of patients receiving adjuvant chemotherapy, with the primary intent to investigate if age alone affects rates of adjuvant therapy.
National Cancer Database (NCDB) was queried for patients that underwent surgery for pancreatic cancer. Groups were divided into: adjuvant chemotherapy (n = 17,924) and no adjuvant chemotherapy (n = 12,947). Basic demographics and treatment characteristics were analyzed. Age was compared with an independent means test; other comparisons used Chi-square test of independence.
There was a statistical difference in age (adjuvant therapy 64.86 ± 9.89 vs. no therapy 67.78 ± 11.22, p < 0.001), insurance type, facility type, and cancer stage for patients that received adjuvant therapy and those that did not. Average age of patients not receiving chemotherapy was significantly older at each pathologic stage. Subset analysis of patients treated with chemotherapy showed that the majority of patients received single agent regimens (62%), at an average of 59 days following surgery, and at academic cancer programs (52%).
Regardless of postoperative complications and functional status, age alone appears to affect rates of adjuvant therapy in patients with resected pancreatic cancer. Older patients should be offered tailored regimens that would allow them to complete the intended extent of treatment.
Determinants of survival and attempted resection in patients with non-metastatic pancreatic cancer: An Australian population-based study
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Our results may, however, indicate that in some cases older patients may be considered to have non-resectable disease by default and without adequate staging or review by an expert team. In the absence of poor performance status or significant comorbidities age is not necessarily a contraindication to surgery [40] and may indicate a nihilistic attitude amongst some clinicians [41]. This emphasises the importance of a full staging work up so that patients can make informed decisions about their treatment, irrespective of their age.
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Data were collected for 786 eligible patients. Disease was considered locally advanced for 561 (71%) patients, 510 (65%) were classified as having potentially resectable disease and 365 (72%) of these had an attempted resection. Along with age, comorbidities and tumour stage, increasing remoteness of residence was associated with poorer survival. Remoteness of residence and review by a hepatobiliary surgeon were factors influencing the decision to offer surgery.
This study indicated disparity in survival dependent on patients' residential location and access to a specialist hepatobiliary surgeon. Accurate clinical staging is a critical element in assessing surgical resectability and it is therefore crucial that all patients have access to specialised clinical services.
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To develop a composite score for the quality of care for patients with pancreatic cancer in Australia; to determine whether it was affected by patient and health service-related factors; to assess whether the score and survival were correlated.
We reviewed medical records of patients diagnosed with pancreatic cancer during July 2009 – June 2011 and notified to the Queensland and New South Wales cancer registries.
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Proportional quality of care scores were assigned to 1571 patients. Scores for patients living in rural areas were significantly lower than for those in major cities (adjusted difference, 11%; 95% CI, 8–13%); they were higher for patients in the least socio-economically disadvantaged areas (v most disadvantaged areas: 8% higher; 95% CI, 6–11%), who were younger, had better Eastern Cooperative Oncology Group performance status, or who first presented to a hospital with a high pancreatic case volume. Higher scores were associated with improved survival; after adjusting for patient-related factors, each 10 percentage point increase in the score reduced the risk of dying by 6% (hazard ratio, 0.94; 95% CI, 0.91–0.97).
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PancreasUnderuse of surgical resection among elderly patients with early-stage pancreatic cancer

Background

Methods

Results

Conclusion

Section snippets

Data

Results

Discussion

Surg Oncol Clin N Am

Surg Oncol Clin N Am

Ann Oncol

J Chronic Dis

J Clin Epidemiol

Surgery

Am J Surg

J Am Coll Surg

J Gastrointest Surg

J Gastrointest Surg

HPB (Oxford)

Pancreas
Underuse of surgical resection among elderly patients with early-stage pancreatic cancer