Surgery Still Underused in Early Pancreatic Cancer

Megan Brooks

March 21, 2014

PHOENIX — Surgery is potentially curable for patients with early-stage pancreatic cancer, yet it remains underused in the United States, new research shows.

Using the Surveillance, Epidemiology, and End Results (SEER) database, researchers found that surgery for localized pancreatic adenocarcinoma has not increased in the past 2 decades.

"While not all patients with localized disease are candidates for curative resection, there is an opportunity for educating patients and physicians about the potential benefits of surgery," senior study author Julian Kim, MD, chief of surgical oncology at University Hospitals Case Medical Center Seidman Cancer Center in Cleveland, said in a statement.

Dr. Julian Kim

The study results were presented here at the Society of Surgical Oncology 67th Annual Cancer Symposium.

Worse Survival

Pancreatic cancer is the fourth leading cause of cancer-related death United States, killing more than 35,000 Americans annually. Pancreatic cancer is typically aggressive and has nonspecific initial symptoms, making it difficult to catch early, the researchers point out.

Conventional therapies have little impact on prognosis and disease outcome. Surgical resection, when possible, is currently the only chance for a cure. Without resection, overall median survival is 4 to 6 months, with an estimated 5-year survival rate of 0.4% to 5.0%.

 
The use of surgery has remained flat.
 

In a previous study, Dr. Kim and his colleagues looked at patterns of care in patients with pancreatic cancer to determine whether chemotherapy and radiation therapy are being incorporated into modern treatment plans in addition to surgery.

"To our surprise, even though there was increased utilization of chemotherapy and radiation over the past several years, the use of surgery has remained flat," Dr. Kim told Medscape Medical News.

New Study

The purpose of the current study was to "confirm this finding using the SEER database and to identify factors associated with patients not undergoing surgery to see where there might be opportunities to increase utilization," Dr. Kim explained.

The study involved 6742 patients diagnosed with SEER historic stage A localized pancreatic adenocarcinoma from 1988 to 2010; 1715 (25.4%) of these received surgical treatment.

On multivariate analysis, patients were less likely to have undergone surgery if they were older than 50 years, black, unmarried, living outside the eastern United States, had pancreatic head or body lesions, had higher tumor grades, or had tumors measuring more than 2 cm (P < .0001).

Patients who did not undergo surgery had significantly worse disease-specific survival than those who did (6 vs 27 months; P < .0001). Surgery was independently associated with survival (hazard ratio, 3.09; 95% confidence interval, 2.82 - 3.38).

Strategies to Increase Use

"In general, despite the fact that surgery is the only potential curative treatment for pancreatic cancer, surgery for cancer of the head of the pancreas — the Whipple procedure — has traditionally been thought of as one with a high complication rate and risk of perioperative death," Dr. Kim told Medscape Medical News.

"However, with more modern surgical techniques and improved anesthesia and postoperative care pathways, success rates are improving and patients previously considered to be poor surgical candidates are now tolerating the procedures surprisingly well," he said.

Several strategies could boost rates of surgery for appropriate patients, Dr. Kim said.

 
All patients with pancreatic cancer who have been told that they are not surgical candidates should seek a second opinion.
 

The primary strategy to increase the use of this surgery is to make physicians and patients aware of the results. "All patients with pancreatic cancer who have been told that they are not surgical candidates should seek a second opinion from an experienced pancreatic surgeon or multidisciplinary pancreatic cancer oncology team," he explained.

"While many patients will not be candidates for surgery, there are likely many patients who are not receiving the benefits of surgery simply because they are not being evaluated by experienced teams of physicians," Dr. Kim said.

"Another strategy will be to increase the quality of pancreas cancer surgery in community hospitals. Our group at University Hospitals is developing a model to accomplish this that can be exported to other regions," he added.

Society of Surgical Oncology (SSO) 67th Annual Cancer Symposium: Abstract P392. Presented March 13, 2014.

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