The prognostic role of time to diagnosis and presenting symptoms in patients with pancreatic cancer

Diagnostic delay at diagnosis and time-to-treatment influence overall survival of pancreatic cancer patients

BACKGROUND

Pancreatic adenocarcinoma (PDAC) presents with nonspecific symptoms, leading to long diagnostic delays and time-to-treatment. Data on the effects of diagnostic delay and time-to-treatment on the prognosis of PDAC patients are limited, dated and heterogeneous.

AIMS

To investigate whether diagnostic delay, time-to-treatment, or diagnostic delay + time-to-treatment (overall delay) impact overall survival (OS) and whether they differ in patients followed up at a tertiary referral center compared to community hospitals.

METHODS

This was a single-center prospective cohort of consecutive patients with PDAC, recording demographics, presenting symptoms, stage, treatments, and survival.

RESULTS

A total of 282 patients were included. Diagnostic delay>49 days was significantly associated with a higher risk of death in univariate (HR 1.627; 95 % CI 1.15-2.28; p = 0.005) but not in multivariate analysis, whereas overall delay>104 days was significantly associated with a higher risk of death in both univariate (HR 1.83; 95 %CI 1.29-2.61; p = 0.0008) and multivariate (HR, 1.63; 95 % CI, 1.13-2.34; p = 0.008) analyses. Patients who were entirely cared for in tertiary center presented a significantly shorter median time-to-treatment (49 vs. 56 days; p = 0.048) than those in community hospitals.

CONCLUSION

Prolonged diagnostic and overall delays seem to impair the survival of patients with PDAC. While diagnostic delay might be reduced with higher awareness of specific warning symptoms, the overall delay can be reduced through specific and faster dedicated therapeutic pathways in referral centers.

Cultures derived from pancreatic cancer xenografts with long-term gemcitabine treatment produce chemoresistant secondary xenografts: Establishment of isogenic gemcitabine-sensitive and -resistant models

In attempts to establish sophisticated models to reproduce the process of acquired drug resistance, we transformed normal human pancreatic ductal epithelial cells by introducing genes for multiple cellular factors. We also created isogenic gemcitabine-sensitive and -resistant models by short- and long-term gemcitabine treatment, respectively. These models demonstrated differences in drug resistance in vivo, but not in vitro. Gemcitabine treatment also induced squamous transdifferentiation in xenografts in mice. The transcription factor p63 was identified as a possible resistance-determining factor but was unlikely to be solely responsible for the resistance to gemcitabine. This system would prove useful to discover novel molecular targets to overcome chemotherapy resistance, by allowing the evaluation of molecules of interest in xenograft models after in vitro genetic ablation.

Integrating allele-specific PCR with CRISPR-Cas13a for sensitive KRAS mutation detection in pancreatic cancer

BACKGROUND

The clustered regulatory interspaced short palindromic repeats (CRISPR)-Cas13a system has strong potential for highly sensitive detection of exogenous sequences. The detection of KRASG12 point mutations with low allele frequencies may prove powerful for the formal diagnosis of pancreatic ductal adenocarcinoma (PDAC).

RESULTS

We implemented preamplification of KRAS alleles (wild-type and mutant) to reveal the presence of mutant KRAS with CRISPR-Cas13a. The discrimination of KRASG12D from KRASWT was poor for the generic KRAS preamplification templates and depended on the crRNA design, the secondary structure of the target templates, and the nature of the mismatches between the guide and the templates. To improve the specificity, we used an allele-specific PCR preamplification method called CASPER (Cas13a Allele-Specific PCR Enzyme Recognition). CASPER enabled specific and sensitive detection of KRASG12D with low DNA input. CASPER detected KRAS mutations in DNA extracted from patients' pancreatic ultrasound-guided fine-needle aspiration fluid.

CONCLUSION

CASPER is easy to implement and is a versatile and reliable method that is virtually adaptable to any point mutation.

Minorities Face Delays to Pancreatic Cancer Treatment Regardless of Diagnosis Setting

INTRODUCTION

Our analysis was designed to characterize the demographics and disparities between the diagnosis of pancreas cancer during emergency presentation (EP) and the outpatient setting (OP) and to see the impact of our institutions pancreatic multidisciplinary clinic (PMDC) on these disparities.

METHODS

Institutional review board-approved retrospective review of our institutional cancer registry and PMDC databases identified patients diagnosed/treated for pancreatic ductal adenocarcinoma between 2014 and 2022. Chi-square tests were used for categorical variables, and one-way ANOVA with a Bonferroni correction was used for continuous variables. Statistical significance was set at p < 0.05.

RESULTS

A total of 286 patients met inclusion criteria. Eighty-nine patients (31.1%) were underrepresented minorities (URM). Fifty-seven (64.0%) URMs presented during an EP versus 100 (50.8%) non-URMs (p = 0.037). Forty-one (46.1%) URMs were reviewed at PMDC versus 71 (36.0%) non-URMs (p = 0.10). No differences in clinical and pathologic stage between the cohorts (p = 0.28) were present. URMs took 22 days longer on average to receive treatment (66.5 days vs. 44.8 days, p = 0.003) in the EP cohort and 18 days longer in OP cohort (58.0 days vs. 40.5 days, p < 0.001) compared with non-URMs. Pancreatic Multidisciplinary Clinic enrollment in EP cohort eliminated the difference in time to treatment between cohorts (48.3 days vs. 37.0 days; p = 0.151).

RESULTS

Underrepresented minorities were more likely to be diagnosed via EP and showed delayed times to treatment compared with non-URM counterparts. Our PMDC alleviated some of these observed disparities. Future studies are required to elucidate the specific factors that resulted in these findings and to identify solutions.

The impact of the COVID-19 pandemic on patients with pancreatic cancer

BACKGROUND

It remains unclear today whether the poor prognosis of pancreatic ductal adenocarcinoma (PDAC) was further worsened by the COVID-19 pandemic and whether this may affect providers and patients, today. Hence, this study aimed to investigate the effect of COVID-19 on care delivery and outcomes of patients with PDAC in the United States.

METHODS

The National Cancer Database was queried for PDAC, between 2017 and 2020. Changes in the number of diagnoses and treatment patterns were compared annually for the entire cohort. Changes in surgical outcomes and median time from diagnosis to treatment were compared and analyzed. Chi-square, Mann-Whitney U, and Kruskal-Wallis tests were performed.

RESULTS

Of 127,613 patients with PDAC, PDAC diagnoses from 2017 (30,573) to 2019 (33,465) increased but decreased in 2020 (31,218). The number of patients receiving surgery or radiotherapy was stable between 2017 to 2019 (21.75% ± 0.05% and 13.9% ± 0.3%, respectively) but decreased in 2020 (20.7% and 12.4% respectively). Although patients received chemotherapy with increasing frequently from 2016 (60.7%) to 2019 (63.5%), this trend stopped in 2020 (63%). Of 27,490 patients undergoing surgery, the mean time from diagnosis to surgery increased from 2017 (34 days) to 2019 (56 days), with an increase in delay in 2020 (81 days). Moreover, patients who were tested for COVID-19, had a longer median time from diagnosis to surgery even if tested negative (COVID+, 140 days; COVID-, 112 days; P < .001).

CONCLUSION

Although the oncologic quality of PDAC surgery remained the same during the pandemic, not only did the pandemic lead to an underdiagnosis of PDAC and care delays, but even the suspicion of COVID-19 in patients with a negative test adversely affected their care.

Diagnosis of Pancreatic Cancer after Cholecystectomy in the Elderly

BACKGROUND

Previous studies evaluating whether recent cholecystectomy is associated with a pancreas cancer diagnosis are limited. We aimed to examine if cholecystectomy was performed more frequently in the year prior to cancer diagnosis than would be expected in a similar non-cancer population.

METHODS

SEER-Medicare linked files were used to identify patients with pancreatic adenocarcinoma. Cancer diagnoses were considered to be "timely" if within 2 months of cholecystectomy or "delayed" if 2-12 months after cholecystectomy. Clinical factors and survival outcomes were compared using chi-square and Kaplan-Meier analyses.

RESULTS

Rate of cholecystectomy in the year prior to diagnosis of cancer was 1.9% for the cancer group, compared to .4% in the non-cancer group (OR = 4.7, 95% CI 4.4-5.1). Differences in the cancer vs non-cancer cohorts at the time of cholecystectomy included a higher age (74 vs 70, P < .0001), more males (49.9% vs 41.7%, P < .0001), and more frequent open technique (21.0% vs 9.4%, P < .0001). Acute pancreatitis was nearly twice as common in the cancer cohort (19.1%) vs the non-cancer cohort (10.7%), P < .0001. There were no differences between patients who had a timely diagnosis after cholecystectomy compared to a delayed diagnosis with regard to age, gender, comorbidity index, race, or rural/urban designation. The rates of localized disease and subsequent resection were also similar between the delayed and timely groups. Overall unadjusted survival was no different between timely and delayed diagnoses, P = .96.

DISCUSSION

Elderly patients diagnosed with pancreatic adenocarcinoma are more likely to have had a recent cholecystectomy compared to those without.

Single-cell transcriptome reveals the heterogeneity of malignant ductal cells and the prognostic value of REG4 and SPINK1 in primary pancreatic ductal adenocarcinoma

Background

Pancreatic ductal adenocarcinoma (PDAC) is one of the leading causes of cancer-related deaths, with very limited therapeutic options available. This study aims to comprehensively depict the heterogeneity and identify prognostic targets for PDAC with single-cell RNA sequencing (scRNA-seq) analysis.

Methods

ScRNA-seq analysis was performed on 16 primary PDAC and three adjacent lesions. A series of analytical methods were applied for analysis in cell clustering, gene profiling, lineage trajectory analysis and cell-to-cell interactions. In vitro experiments including colony formation, wound healing and sphere formation assay were performed to assess the role of makers.

Results

A total of 32,480 cells were clustered into six major populations, among which the ductal cell cluster expressing high copy number variants (CNVs) was defined as malignant cells. Malignant cells were further subtyped into five subgroups which exhibited specific features in immunologic and metabolic activities. Pseudotime trajectory analysis indicated that components of various oncogenic pathways were differentially expressed along tumor progression. Furthermore, intensive substantial crosstalk between ductal cells and stromal cells was identified. Finally, genes (REG4 and SPINK1) screened out of differentially expressed genes (DEGs) were upregulated in PDAC cell lines. Silencing either of them significantly impaired proliferation, invasion, migration and stemness of PDAC cells.

Conclusions

Our findings offer a valuable resource for deciphering the heterogeneity of malignant ductal cells in PDAC. REG4 and SPINK1 are expected to be promising targets for PDAC therapy.

Time Kills: Impact of Socioeconomic Deprivation on Timely Access to Guideline-Concordant Treatment in Foregut Cancer

BACKGROUND

Receipt of guideline-concordant treatment (GCT) is associated with improved prognosis in foregut cancers. Studies show that patients living in areas of high neighborhood deprivation have worse healthcare outcomes; however, its effect on GCT in foregut cancers has not been evaluated. We studied the impact of the area deprivation index (ADI) as a barrier to GCT.

STUDY DESIGN

A single-institution retrospective review of 498 foregut cancer patients (gastric, pancreatic, and hepatobiliary adenocarcinoma) from 2018 to 2022 was performed. GCT was defined based on National Comprehensive Cancer Network guidelines. ADI, a validated measure of neighborhood disadvantage was divided into terciles (low, medium, and high) with high ADI indicating the most disadvantage.

RESULTS

Of 498 patients, 328 (66%) received GCT: 66%, 72%, and 59% in pancreatic, gastric, and hepatobiliary cancers, respectively. Median (interquartile range) time from symptoms to workup was 6 (3 to 13) weeks, from diagnosis to oncology appointment was 4 (1 to 10) weeks, and from oncology appointment to treatment was 4 (2 to 10) weeks. Forty-six percent were diagnosed in the emergency department. On multivariable analyses, age 75 years or older (odds ratio [OR] 0.39 [95% CI 0.18 to 0.87]), Black race (OR 0.52 [95% CI 0.31 to 0.86]), high ADI (OR 0.25 (95% CI 0.14 to 0.48]), 6 weeks or more from symptoms to workup (OR 0.44 [95% CI 0.27 to 0.73]), 4 weeks or more from diagnosis to oncology appointment (OR 0.76 [95% CI 0.46 to 0.93]), and 4 weeks or more from oncology appointment to treatment (OR 0.63 [95% CI 0.36 to 0.98]) were independently associated with nonreceipt of GCT.

CONCLUSIONS

Residence in an area of high deprivation predicts nonreceipt of GCT. This is due to multiple individual- and system-level barriers. Identifying these barriers and developing effective interventions, including community outreach and collaboration, leveraging telehealth, and increasing oncologic expertise in underserved areas, may improve access to GCT.

Overcoming Microbiome-Acquired Gemcitabine Resistance in Pancreatic Ductal Adenocarcinoma

Gastrointestinal cancers (GICs) are one of the most recurrent diseases in the world. Among all GICs, pancreatic cancer (PC) is one of the deadliest and continues to disrupt people's lives worldwide. The most frequent pancreatic cancer type is pancreatic ductal adenocarcinoma (PDAC), representing 90 to 95% of all pancreatic malignancies. PC is one of the cancers with the worst prognoses due to its non-specific symptoms that lead to a late diagnosis, but also due to the high resistance it develops to anticancer drugs. Gemcitabine is a standard treatment option for PDAC, however, resistance to this anticancer drug develops very fast. The microbiome was recently classified as a cancer hallmark and has emerged in several studies detailing how it promotes drug resistance. However, this area of study still has seen very little development, and more answers will help in developing personalized medicine. PC is one of the cancers with the highest mortality rates; therefore, it is crucial to explore how the microbiome may mold the response to reference drugs used in PDAC, such as gemcitabine. In this article, we provide a review of what has already been investigated regarding the impact that the microbiome has on the development of PDAC in terms of its effect on the gemcitabine pathway, which may influence the response to gemcitabine. Therapeutic advances in this type of GIC could bring innovative solutions and more effective therapeutic strategies for other types of GIC, such as colorectal cancer (CRC), due to its close relation with the microbiome.

Pancreatic cancer symptom trajectories from Danish registry data and free text in electronic health records

Pancreatic cancer is one of the deadliest cancer types with poor treatment options. Better detection of early symptoms and relevant disease correlations could improve pancreatic cancer prognosis. In this retrospective study, we used symptom and disease codes (ICD-10) from the Danish National Patient Registry (NPR) encompassing 6.9 million patients from 1994 to 2018,, of whom 23,592 were diagnosed with pancreatic cancer. The Danish cancer registry included 18,523 of these patients. To complement and compare the registry diagnosis codes with deeper clinical data, we used a text mining approach to extract symptoms from free text clinical notes in electronic health records (3078 pancreatic cancer patients and 30,780 controls). We used both data sources to generate and compare symptom disease trajectories to uncover temporal patterns of symptoms prior to pancreatic cancer diagnosis for the same patients. We show that the text mining of the clinical notes was able to complement the registry-based symptoms by capturing more symptoms prior to pancreatic cancer diagnosis. For example, 'Blood pressure reading without diagnosis', 'Abnormalities of heartbeat', and 'Intestinal obstruction' were not found for the registry-based analysis. Chaining symptoms together in trajectories identified two groups of patients with lower median survival (<90 days) following the trajectories 'Cough→Jaundice→Intestinal obstruction' and 'Pain→Jaundice→Abnormal results of function studies'. These results provide a comprehensive comparison of the two types of pancreatic cancer symptom trajectories, which in combination can leverage the full potential of the health data and ultimately provide a fuller picture for detection of early risk factors for pancreatic cancer.

Recent Progress in Enhanced Cancer Diagnosis, Prognosis, and Monitoring Using a Combined Analysis of the Number of Circulating Tumor Cells (CTCs) and Other Clinical Parameters

Analysis of circulating tumor cells (CTCs) holds promise to diagnose cancer or monitor its development. Among the methods, counting CTC numbers in blood samples could be the simplest way to implement it. Nevertheless, its clinical utility has not yet been fully accepted. The reasons could be due to the rarity and heterogeneity of CTCs in blood samples that could lead to misleading results from assays only based on single CTC counts. To address this issue, a feasible direction is to combine the CTC counts with other clinical data for analysis. Recent studies have demonstrated the use of this new strategy for early detection and prognosis evaluation of cancers, or even for the distinguishment of cancers with different stages. Overall, this approach could pave a new path to improve the technical problems in the clinical applications of CTC counting techniques. In this review, the information relevant to CTCs, including their characteristics, clinical use of CTC counting, and technologies for CTC enrichment, were first introduced. This was followed by discussing the challenges and new perspectives of CTC counting techniques for clinical applications. Finally, the advantages and the recent progress in combining CTC counts with other clinical parameters for clinical applications have been discussed.

Can we rely on contrast-enhanced CT to identify pancreatic ductal adenocarcinoma? A population-based study in sensitivity and factors associated with false negatives

OBJECTIVES

To determine the sensitivity of contrast-enhanced computed tomography (CECT) in detecting pancreatic ductal adenocarcinoma (PDAC) and identify factors associated with false negatives (FNs).

METHODS

Patients diagnosed with PDAC in 2014-2015 were retrospectively identified by a cancer registry. CECTs performed during the diagnostic interval were retrospectively classified as true positive (TP), indeterminate, or FN. Sensitivity TP/(TP+FN) was calculated for all CECTs and the following subgroups: protocol (uniphasic vs. biphasic); tumor size (≤ 2 cm vs. > 2 cm); and resectability (potentially resectable vs. unresectable). Multivariate logistic regression was performed to assess which of the following factors were associated with FN: clinical suspicion of PDAC; size >2 cm; presence of metastases; protocol; isoattenuating tumor; and potentially resectable disease on imaging.

RESULTS

In total, 176 CECTs (127 uniphasic; 49 biphasic) in 154 patients (90 men, mean age 72 ± 11 years) were included. Sensitivity was 125/149 (83.9%) overall and 87/106 (82.1%) and 38/43 (88.4%) for uniphasic and biphasic protocols, respectively. Sensitivity was decreased for tumors ≤ 2 cm (45.4% vs. 90.6%), no liver metastases (78.0% vs. 95.9%), and potentially resectable disease (65.3% vs. 93.0%). Factors significantly associated with FN were clinical suspicion (OR, 0.24, 95% CI: 0.07-0.75), size>2 cm (OR, 0.10, 95% CI: 0.02-0.44), absence of liver metastases (OR, 4.94, 95% CI: 1.29-22.99), and potentially resectable disease (OR, 4.13, 95% CI: 1.07-16.65).

CONCLUSIONS

In our population, the overall sensitivity of CECT to detect PDAC is 83.9%; however, this is substantially lower in several scenarios, including patients with potentially resectable disease. This finding has important implications for patient outcomes and efforts to maximize CECT sensitivity should be sought.

CLINICAL RELEVANCE STATEMENT

The sensitivity of CECT to detect PDAC is significantly decreased in the setting of sub-2 cm tumors and potentially resectable disease. A dedicated biphasic pancreatic CECT protocol has higher sensitivity and should be applied in patients with suspected pancreatic disease.

KEY POINTS

• The sensitivities of contrast-enhanced CT for the detection of PDAC were 87/106 (82.1%) and 38/43 (88.4%) for uniphasic and biphasic protocols, respectively. • The sensitivity of contrast-enhanced CT was decreased for small tumors ≤ 2 cm (45.4% vs. 90.6%), if there were no liver metastases (78.0% vs. 95.9%), and with potentially resectable disease (65.3% vs. 93.0%). • Absence of liver metastases (OR, 4.94, 95% CI: 1.29-22.99) and potentially resectable disease (OR, 4.13, 95% CI: 1.07-16.65) were associated with a false--negative (FN) CT result; suspicion of malignancy on the imaging requisition (OR, 0.24, 95% CI: 0.07-0.75) and size > 2 cm (OR, 0.10, 95% CI: 0.02-0.44) were negatively associated with FN.

Systemic treatment for advanced pancreatic cancer

Pancreatic cancer is a deadly disease with an extremely poor 5-year survival rate due to treatment resistance and late-stage detection. Despite numerous years of research and pharmaceutical development, these figures have not changed. Treatment options for advanced pancreatic cancer are still limited. This illness is typically detected at a late stage, making curative surgical resection impossible. Chemotherapy is the most commonly utilized technique for treating advanced pancreatic cancer but has poor efficacy. Targeted therapy and immunotherapy have made significant progress in many other cancer types and have been proven to have extremely promising possibilities; these therapies also hold promise for pancreatic cancer. There is an urgent need for research into targeted treatment, immunotherapy, and cancer vaccines. In this review, we emphasize the foundational findings that have fueled the therapeutic strategy for advanced pancreatic cancer. We also address current advancements in targeted therapy, immunotherapy, and cancer vaccines, all of which continue to improve the clinical outcome of advanced pancreatic cancer. We believe that clinical translation of these novel treatments will improve the low survival rate of this deadly disease.

Primary care practitioners' priorities for improving the timeliness of cancer diagnosis in primary care: a European cluster-based analysis

BACKGROUND

Diagnosing cancer at an early stage increases the likelihood of survival, and more advanced cancers are more difficult to treat successfully. Primary care practitioners (PCPs) play a key role in timely diagnosis of cancer. PCPs' knowledge of their own patient populations and health systems could help improve the planning of more effective approaches to earlier cancer recognition and referral. How PCPs act when faced with patients who may have cancer is likely to depend on how their health systems are organised, and this may be one explanation for the wide variation on cancer survival rates across Europe.

OBJECTIVES

To identify and characterise clusters of countries whose PCPs perceive the same factors as being important in improving the timeliness of cancer diagnosis.

METHODS

A cluster analysis of qualitative data from an online survey was carried out. PCPs answered an open-ended survey question on how the speed of diagnosis of cancer in primary care could be improved. Following coding and thematic analysis, we identified the number of times per country that an item in a theme was mentioned. k-means clustering identified clusters of countries whose PCPs perceived the same themes as most important. Post-hoc testing explored differences between these clusters.

SETTING

Twenty-five primary care centres in 20 European countries. Each centre was asked to recruit at least 50 participants.

PARTICIPANTS

Primary care practitioners of each country.

RESULTS

In all, 1,351 PCPs gave free-text answers. We identified eighteen themes organising the content of the responses. Based on the frequency of the themes, k-means clustering identified three groups of countries. There were significant differences between clusters regarding the importance of: access to tests (p = 0.010); access to specialists (p = 0.014), screening (p < 0.001); and finances, quotas & limits (p < 0.001).

CONCLUSIONS

Our study identified three distinct clusters of European countries within which PCPs had similar views on the factors that would improve the timeliness of cancer diagnosis. Further work is needed to understand what it is about the clusters that have produced these patterns, allowing healthcare systems to share best practice and to reduce disparities.

Maintaining early diagnosis of pancreatic adenocarcinoma in Japan: Local resilience against COVID-19

BACKGROUND AND AIMS

This study evaluated the impact of the coronavirus disease 2019 (COVID-19) pandemic on pancreatic adenocarcinoma (PA) practice in our region and discussed the effects of our institution's regional collaborative system, the "Early Stage Pancreatic Cancer Diagnosis Project," which was originally unrelated to this study's purpose.

METHODS

We retrospectively investigated 150 patients with PA at Yokohama Rosai Hospital by defining three time periods: before (C0), during the first year (C1), and during the second year (C2) of the COVID-19 pandemic.

RESULTS

Among the three periods (C0, C1, and C2), there were significantly less patients with stage I PA (14.0%, 0%, and 7.4%, p = 0.032) in C1, and significantly more patients with stage III PA (10.0%, 28.3%, and 9.3%, p = 0.014) in C1. The pandemic significantly prolonged the median durations from disease onset to patients' first visits (28, 49, and 14 days, p = 0.012). In contrast, there was no significant difference in the median durations from referral to first visit to our institution (4, 4, and 6 days, p = 0.391).

CONCLUSIONS

The pandemic advanced the stage of PA in our region. Although the pancreatic referral network remained functional during the pandemic, there were delays from disease onset to patients' first visit to healthcare providers, including clinics. While the pandemic caused temporary damage to PA practice, the routine regional collaboration provided by our institution's project allowed for early resilience. A notable limitation is that the impact of the pandemic on PA prognosis was not evaluated.

FOXM1: A small fox that makes more tracks for cancer progression and metastasis

Transcription factors (TFs) are indispensable for the modulation of various signaling pathways associated with normal cell homeostasis and disease conditions. Among cancer-related TFs, FOXM1 is a critical molecule that regulates multiple aspects of cancer cells, including growth, metastasis, recurrence, and stem cell features. FOXM1 also impact the outcomes of targeted therapies, chemotherapies, and immune checkpoint inhibitors (ICIs) in various cancer types. Recent advances in cancer research strengthen the cancer-specific role of FOXM1, providing a rationale to target FOXM1 for developing targeted therapies. This review compiles the recent studies describing the pivotal role of FOXM1 in promoting metastasis of various cancer types. It also implicates the contribution of FOXM1 in the modulation of chemotherapeutic resistance, antitumor immune response/immunotherapies, and the potential of small molecule inhibitors of FOXM1.

An analysis of time to treatment in patients with pancreatic adenocarcinoma

BACKGROUND

Currently, no guidelines exist regarding the appropriate time from diagnosis to treatment among pancreatic adenocarcinoma patients. Herein, we aim to define the median time to treatment in pancreatic adenocarcinoma, factors associated with treatment delay, and prognostic significance.

METHODS

We conducted a retrospective study of pancreatic adenocarcinoma patients, stage I-IV, at a tertiary referral center (2017-2020). We subdivided time to treatment (days) into 4 components: (1) Ti: symptom onset to initial provider evaluation, (2) Tii: initial provider evaluation to diagnosis, (3) Tiii: diagnosis to specialist consultation, (4) Tiv: specialist visit to treatment.

RESULTS

In total, 217 patients met the inclusion criteria. The median Ti, Tii, Tiii, and Tiv were 20, 12, 4, and 14 days, respectively. The total time to treatment was 75 days. Patients with weight loss had longer Ti (β = 108.6). More frequent hospitalizations (β = 19.5) and misdiagnosis (β = 33.4) were associated with longer Tii. Patients with a history of malignancy (β = 15) or active treatment of a second disease (β = 19.4) had longer Tiii. Poor performance status (β = 6.2) or private insurance (β = 50.2) were associated with a longer Tiv. Black patients had longer Ti+ii+iii+iv (β = 100). Time to treatment was not associated with overall survival (P > .05).

CONCLUSION

It takes a median time of less than a month for a patient with pancreatic adenocarcinoma to start treatment, even after they visit a primary provider. The greatest opportunity to shorten the overall time to treatment is by having patients seek medical attention earlier (Ti).

Histone Modifications Represent a Key Epigenetic Feature of Epithelial-to-Mesenchyme Transition in Pancreatic Cancer

Pancreatic cancer is one of the most lethal malignant diseases due to its high invasiveness, early metastatic properties, rapid disease progression, and typically late diagnosis. Notably, the capacity for pancreatic cancer cells to undergo epithelial-mesenchymal transition (EMT) is key to their tumorigenic and metastatic potential, and is a feature that can explain the therapeutic resistance of such cancers to treatment. Epigenetic modifications are a central molecular feature of EMT, for which histone modifications are most prevalent. The modification of histones is a dynamic process typically carried out by pairs of reverse catalytic enzymes, and the functions of these enzymes are increasingly relevant to our improved understanding of cancer. In this review, we discuss the mechanisms through which histone-modifying enzymes regulate EMT in pancreatic cancer.

A retrospective preliminary study of intrapancreatic late enhancement as a noteworthy imaging finding in the early stages of pancreatic adenocarcinoma

OBJECTIVE

To characterize intrapancreatic late enhancement (ILE) observed in the early stages of pancreatic adenocarcinoma (PAC).

METHODS

Among 203 patients pathologically diagnosed with PAC between October 2011 and February 2021, 32 patients with pre-diagnostic abdominal contrast-enhanced CT performed from 6 months to 5 years before the diagnosis were enrolled in this study. Indirect findings (IFs) on pre-diagnostic CT, including ILE, were evaluated and examined for various clinical data and time intervals to diagnosis (TIDs). The detected ILE was quantitatively evaluated, and the effect of ILE awareness on lesion detection by two radiologists and their interobserver agreement were assessed.

RESULTS

Among the 32 patients, 23 showed IFs. ILE was observed in 14 patients (63%), with a median TID of 17 months (interquartile ratio [IQR]: 9.3-42.3). ILE alone was observed in eight patients (35%), ILE with focal pancreatic parenchymal atrophy (FPPA) was observed in five patients (22%), and ILE with main pancreatic duct abnormalities (MPDA) was observed in one patient (4%). Pancreatic head lesions were significantly more frequent in patients with ILE alone than in patients with FPPA or MPDA (p = 0.026). The median long-axis diameters of the region with ILE and ILE-to-pancreas contrast were 10 (IQR: 5-11) mm and 24 (IQR: 17-33) HU, respectively. Awareness of ILE led observers to detect two or three more pancreatic head lesions, and interobserver agreement increased from poor agreement (k = 0.17) to moderate agreement (k = 0.55).

CONCLUSION

ILE is a significant IF for early PAC detection.

KEY POINTS

• Intrapancreatic late enhancement (ILE) is a significant indirect finding in the early detection of pancreatic adenocarcinoma. • ILE without other indirect findings is expected to help detect pancreatic head lesions. • Image evaluation focusing on ILE can increase lesion detection and improve the interobserver agreement.

Evaluation of an Innovative Care Pathway in the Diagnostic and Therapeutic Management of Hepatobiliary and Pancreatic Pathologies: "One-Day Diagnosis"

“One-Day Diagnosis” (1DD) for hepatobiliary and pancreatic (HBP) diseases is an innovative care pathway that combines, on the same day, surgical consultation, medical imaging, anesthesia, diagnosis announcement, and therapeutic support consultations. The objective was to evaluate the length of the 1DD care pathway compared to a conventional one. The prospective “1DD care pathway” arm included 330 consecutive patients (January 2017−April 2019) vs. 152 (November 2014−November 2015) in the retrospective “conventional” one. In the 1DD group, diagnosis was made on the same day in 83% of consultations vs. 68.4% (p = 0.0005). Although there was no difference in overall time to diagnosis, diagnostic and therapeutic management was faster in the 1DD group (1 day vs. 15 days, p < 0.0004). In addition, 77% of patients who benefited from 1DD were very satisfied with their treatment overall. The mean cost of the 1DD consultation was EUR 176.8 +/− 149 (range: 50−546). The median cost of the overall program was similar (EUR 584 vs. EUR 563, p = 0.67). As an organizational innovation, the 1DD for HBP pathologies is a promising care pathway that optimizes diagnostic and therapeutic management, without creating medical overconsumption or additional costs. Given patient satisfaction, this model should be generalized to optimize cancer care by adapting it to the constraints of different healthcare structures.

Transabdominal ultrasound of pancreatic ductal adenocarcinoma: A multi-centered population-based study in sensitivity, associated diagnostic intervals, and survival

OBJECTIVES

To determine the sensitivity of ultrasound (US) in detecting pancreatic ductal adenocarcinoma in our region, to identify factors associated with US test result, and assess the impact on the diagnostic interval and survival.

METHODS

Patients diagnosed between January 1, 2014 and December 31, 2015 in Nova Scotia, Canada were identified by a cancer registry. US performed prior to diagnosis were retrospectively graded as true positive (TP), indeterminate or false negative (FN). Amongst US results, differences in age, weight and tumor size were assessed [one-way analysis of variance (ANOVA)]. Associations between result and sex, tumor location (proximal/distal), clinical suspicion of malignancy, and visualization of the pancreas, tumor, secondary signs and liver metastases were assessed (Chi-square). Mean follow-up imaging, diagnostic, and survival intervals were assessed (one-way ANOVA).

RESULTS

One hundred thirteen US of 107 patients (54 women; mean 70 ± 13 years) were graded as follows: 48/113 (42.5%) TPs; 42/113 (37.2%) indeterminates; and 23/113 (20.4%) FNs. Sensitivity was 48/71(67.6%). There was no difference in age, weight or tumor size amongst US result (P > 0.5). FNs had proportionally more men (P = 0.011) and lacked clinical suspicion of malignancy (P = 0.0006); TPs had proportionally more proximal tumors (P = 0.017). US result was associated with visualization of the pancreas, tumor, secondary signs and liver metastases (P < 0.005). FNs had longer mean follow-up imaging (P < 0.0001) and diagnostic (P = 0.0007) intervals, and worse mean survival (P = 0.034).

CONCLUSIONS

In our region, the sensitivity of US in detecting pancreatic ductal adenocarcinoma is 67.6%. A false negative US is associated with delayed diagnostic work-up and worse mean survival.

Time interval from last visit to imaging diagnosis influences outcome in pancreatic adenocarcinoma: A regional population-based study on linked medico-administrative and clinical data

Background:

Excessive waiting time intervals for the diagnosis and treatment of patients with pancreatic cancer can influence their prognosis but they remain unclear. The objective was to describe time intervals from the medical visit to diagnostic imaging and to treatment and their prognostic impact in pancreatic cancer in one French region.

Methods:

This retrospective observational multicentre study included all patients with pancreatic cancer seen for the first time in 2017 in multidisciplinary team meetings (MTMs), where clinical data were collected. A probabilistic matching with the medico-administrative data from the French national healthcare database (Système National des Données de Santé) was performed to define the care pathway from clinical presentation to the beginning of treatment. Median key time intervals were estimated for both resected and unresected tumours. Factors associated with 1-year survival were studied using Cox model.

Results:

A total of 324 patients (88% of total patients with MTM presentation) were matched and included: male 54%, mean age 72 years ±9.2, Eastern Cooperative Oncology Group (ECOG) PS > 1 19.5%, metastatic disease at diagnosis 47.4%, tumour resection 16%. At 1 year, 57% had died (65% in the unresected group and 17% in the resected group). The median time interval from the medical visit to diagnostic imaging was 15 days [Q1–Q3: 8–44]. After imaging, median time intervals to definite diagnosis and to first treatment were 11 and 20 days, respectively. Significant prognostic factors associated with the risk of death at 1 year were ECOG PS > 1 (hazard ratio (HR) 2.1 [1.4–3.0]), metastasis (HR 2.7 [1.9–3.9]), no tumour resection (HR 2.7 [1.3–5.6]) and time interval between the medical visit and diagnostic imaging ⩾25 days (HR 1.7 [1.2–2.3]).

Conclusion:

Delay in access to diagnostic imaging impacted survival in patients with pancreatic cancer, regardless of whether tumour resection had been performed.

Time to Neoadjuvant Chemotherapy Initiation Is not Associated With Survival in Pancreatic Cancer

INTRODUCTION

Not all patients with pancreatic adenocarcinoma (PDAC) tolerate multiagent neoadjuvant chemotherapy (NAC). We utilized institutional data and the National Cancer Database (NCDB) to investigate if time from diagnosis to NAC initiation is associated with survival.

METHODS

Patients who received NAC and underwent pancreatectomy at our institution (2010-2021) or within the NCDB (2010-2016) were identified. Time from diagnosis to NAC was grouped: <21, 21-35, and >35 d. Recurrence-free (RFS) and overall survival (OS) was compared.

RESULTS

At our institution, 122 patients received NAC before pancreatectomy (<21 d: n = 36; 21-35 d: n = 61; >35 d: n = 25). Demographics, performance status, and anatomic resectability were similar. There was no difference in RFS (13.3 versus 12.4 versus 11.9 mo) or OS (26.7 versus 25.8 versus 26.1 mo) based on NAC timing. Patients who received FOLFIRINOX had an improvement in RFS (14.4 versus 12.2 versus 6.8 mo, P = 0.05) and OS (39.2 versus 21.4 versus 17.3 mo, P = 0.01) compared to gemcitabine with nab-paclitaxel or other regimens. Within the NCDB, 6713 patients were included (<21 d: n = 2087; 21-35 d: n = 2656; >35 d: n = 1970). There was no difference in OS (21.6 versus 20.9 versus 22.2 mo). Multiagent NAC was associated with improved OS compared to single-agent (22.6 versus 18.8 mo, P < 0.001).

CONCLUSIONS

Delay in NAC initiation for PDAC is not associated with survival. Patient optimization could be considered with the goal of improving tolerance of multiagent chemotherapy.

Healthcare use in the year preceding a diagnosis of pancreatic cancer: a register-based cohort study in Denmark

OBJECTIVE

To describe the use of healthcare prior to a diagnosis of pancreatic cancer in Denmark.

DESIGN

A population-based cohort study using prospectively recorded data from Danish National Health Registries.

SETTING

Danish general practice and hospitals.

SUBJECTS

A total of 5926 patients diagnosed with pancreatic cancer in 2012-2018 and 59,260 matched references without pancreatic cancer from the Danish general population.

MAIN OUTCOME MEASURES

The monthly frequency of healthcare use (contacts and tests in general practice and contacts and diagnostic investigations in hospitals) during the 12 months preceding the pancreatic cancer diagnosis and a corresponding index date assigned to the references.

RESULTS

Compared to the references, the patients had increased contacts and diagnostic tests, especially blood glucose testing, in general practice from 7 to 12 months before diagnosis. Hospital contacts and diagnostic imaging increased from 5 months before the diagnosis.

CONCLUSIONS

The pattern of increasing healthcare contacts before a diagnosis of pancreatic cancer may represent a window of opportunity to diagnose pancreatic cancer earlier. The increased use of blood glucose test in general practice may represent an important sign of an underlying disease. Key pointsPancreatic cancer is a rapidly progressing and highly lethal disease. Focus on early diagnosis is essential to improve the prognosis.Patients with pancreatic cancer had increased number of healthcare contacts from 7 months before the diagnosis.Patients with pancreatic cancer had increased number of blood glucose tests taken throughout almost the entire year before the diagnosis.The results may indicate that a window of opportunity exists to diagnose pancreatic cancer earlier.

The SYMPTOM-upper gastrointestinal study: A mixed methods study exploring symptom appraisal and help-seeking in Australian upper gastrointestinal cancer patients

Objective

There is limited evidence on the development of pancreatic and oesophagogastric cancer, how patients decide to seek help and the factors impacting help‐seeking. Our study, the first in Australia, aimed to explore symptom appraisal and diagnostic pathways in these patients. A secondary aim was to examine the potential to recruit cancer patients through a cancer quality registry.

Methods

Patients diagnosed with pancreatic or oesophagogastric cancer were recruited through Monash University's Upper‐Gastrointestinal Cancer Registry. Data collected through general practitioners (GP) and patient questionnaires included symptoms and their onset, whereas patient interviews focused on the patient's decision‐making in seeking help from healthcare pracitioners. Data collection and analysis was informed by the Aarhus statement. Coding was inductive, and themes were mapped onto the Model of Pathways to Treatment.

Results

Between November 2018 and March 2020, 27 patient questionnaires and 13 phone interviews were completed. Prior to diagnosis, patients lacked awareness of pancreatic and oesophagogastric cancer symptoms, leading to the normalisation, dismissal and misattribution of the symptoms. Patients initially self‐managed symptoms, but worsening of symptoms and jaundice triggered help‐seeking. Competing priorities, beliefs about illnesses and difficulties accessing healthcare delayed help‐seeking.

Conclusion

Increased awareness of insidious pancreatic and oesophagogastric cancer symptoms in patients and general practitioners may prompt more urgent investigations and lead to earlier diagnosis.

Role of artificial intelligence in early detection and screening for pancreatic adenocarcinoma

Pancreatic adenocarcinoma remains to be one of the deadliest malignancies in the world despite treatment advancement over the past few decades. Its low survival rates and poor prognosis can be attributed to ambiguity in recommendations for screening and late symptom onset, contributing to its late presentation. In the recent years, artificial intelligence (AI) as emerged as a field to aid in the process of clinical decision making. Considerable efforts have been made in the realm of AI to screen for and predict future development of pancreatic ductal adenocarcinoma. This review discusses the use of AI in early detection and screening for pancreatic adenocarcinoma, and factors which may limit its use in a clinical setting.

Pancreatic Cancer Metastasis to the Spine: A Systematic Review of Management Strategies and Outcomes with Case Illustration

OBJECTIVE

We aim to provide a thorough review of the literature regarding patient characteristics, treatment options, and outcomes of pancreatic cancer metastasis to the spine. We also provide an illustrative case from our institution of a patients with pancreatic adenocarcinoma presenting initially as cervical radiculopathy with an isolated cervical spine lesion.

METHODS

Using the PRISMA guidelines, the literature in PubMed, Google Scholar, and Web of Science databases was searched. We excluded systematic reviews and meta-analyses that did not provide novel cases, as well as reports of metastatic disease from other nonpancreatic primary cancers.

RESULTS

Thirty-two patients across 21 studies met the inclusion criteria. The patients were predominantly male (58%), with a mean age of 59 years. Of patients, 64% presented with back pain, 39% with motor deficits, and 15% with bladder or bowel dysfunction. For treatment, chemotherapy was used in 55% of cases and radiotherapy in 42%. Surgical treatment was performed in 42% of cases, with complete tumor resection achieved in 24% of cases. The mean patient survival after treatment was 28 weeks (range, 1-83 weeks), with patients undergoing treatment involving surgery having increased survival (44 weeks) compared with noninvasive treatment alone (18 weeks).

CONCLUSIONS

Spinal metastasis of pancreatic cancer is rare and typically portends a poor prognosis. It is vital to recognize the presence of spinal involvement early in the disease course and initiate treatment.

Translational advances in pancreatic ductal adenocarcinoma therapy

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive cancer that is most frequently detected at advanced stages, limiting treatment options to systemic chemotherapy with modest clinical responses. Here, we review recent advances in targeted therapy and immunotherapy for treating subtypes of PDAC with diverse molecular alterations. We focus on the current preclinical and clinical evidence supporting the potential of these approaches and the promise of combinatorial regimens to improve the lives of patients with PDAC.

A decision support tool for the detection of pancreatic cancer in general practice: A modified Delphi consensus

BACKGROUND/OBJECTIVES

Diagnosis of pancreatic cancer is often delayed, contributing to patient and family distress and leading to worse survival. We aimed to develop a decision support tool to support primary care providers to identify patients that should undergo investigations for pancreatic cancer, and to recommend initial diagnostic pathways.

METHODS

A modified Delphi process, including a series of three surveys, was undertaken to ascertain clinical expert opinion on which combinations of signs, symptoms and risk factors should be included in a tool for the early identification of pancreatic cancer. A group of clinical specialists finalised the development of the tool during a focus group meeting.

RESULTS

The tool presents individual or combinations of signs, symptoms, and risk factors in three tiers which direct the urgency of investigation. Tier 1 includes 5 clinical presentation and risk factors clusters that indicate the need for urgent investigation of the pancreas. A further five clusters are included as Tier 2 aiming to elimate other causes and reduce the time to investigating the pancreas. Tier 3 includes a list of non-specific signs, symptoms and risk factors that indicate the need to consider pancreatic cancer as a potential diagnosis, but without specific recommendations for investigation.

CONCLUSIONS

Prospective validation studies are now required prior to implementation in the primary care setting. Implementation into primary care practice and as an educational resource may facilitate rapid diagnosis and improve outcomes such as distress and survival.

The Value of 18F-FDG PET/CT in Diagnosing Pancreatic Lesions: Comparison With CA19-9, Enhanced CT or Enhanced MR

Objective: To investigate the value of ¹⁸F-FDG PET/CT in diagnosing pancreatic lesions, and compare it with CA19-9, contrast-enhanced CT (CECT), and contrast-enhanced MRI (CEMR). Methods: Cases of patients with suspected pancreatic lesions examined between January 1, 2011 and June 30, 2017 were retrospectively analyzed. CA19-9, CECT and CEMR within 2 weeks of PET/CT were evaluated. We compared the diagnostic efficacy of PET/CT with CA19-9, CECT and CEMR as well as combined tests. Results: A total of 467 cases were examined in this study, including 293 males and 174 females, with an average age of 57.79 ± 12.68 y (16-95 y). Cases in the malignant group (n = 248) had significantly higher SUVmax (7.34 ± 4.17 vs. 1.70 ± 2.68, P < 0.001) and CA19-9 (663.21 ± 531.98 vs. 87.80 ± 218.47, P < 0.001) than those in the benign group (n = 219). The sensitivity, specificity and accuracy of PET/CT were 91.9, 96.3, and 94.0%, respectively. Those for CECT were 83.6, 77.8, 81.2%, respectively; and 91.2, 75.0, 81.7% were for CEMR. PET/CT corrected 14.7% (28/191) CECT diagnoses and 12.2% (10/82) CEMR diagnoses. Although the diagnostic efficiency of CA19-9 was acceptable (80.0, 69.0, 74.9% respectively), the joint application of PET/CT and CA19-9 could significantly enhance the diagnostic efficiency compared with PET/CT alone (sen 97.4 vs. 90.5%, P = 0.0003; spe 100.0 vs. 95.2%, P = 0.0047). Conclusions: PET/CT has sensitivity similar to CECT, CEMR and significantly higher specificity and accuracy, helping reduce false diagnoses of morphological images. Combining PET/CT with CA19-9 could enhance diagnostic efficiency.

Recent Trends in the Incidence and Survival of Stage 1A Pancreatic Cancer: A Surveillance, Epidemiology, and End Results Analysis

BACKGROUND

Rapid access to pancreatic imaging and regular pancreatic surveillance may help identify stage I pancreatic cancer. We investigated recent trends in the stage of newly diagnosed pancreatic ductal adenocarcinoma (PDACs), age at diagnosis, and survival.

METHODS

Trends in age-adjusted incidence of stage IA PDAC between 2004 and 2016 were determined from the National Cancer Institute's Surveillance, Epidemiology and End Results database. All tests were two-sided.

RESULTS

The incidence of stage IA PDAC cases diagnosed increased statistically significantly from 2004 to 2016 (annual percent change = 14.5, 95% confidence interval [CI] = 11.4 to 17.7; P < .001). During the study period, average age at diagnosis for stage IA and IB casesAQ3 declined by 3.5 years (95% CI = 1.2 to 5.9; P = .004) and 5.5 years (95% CI = 3.4 to 7.6; P < .001), whereas average age increased for higher-stage cases (by 0.6 to 1.4 years). Among stage IA cases, the proportion of blacks was smaller (10.2% vs 12.5%), and the proportion of other non-Caucasians was higher compared with higher-stage cases (11.9% vs 8.4%; P < .001). Stage IA cases were more likely to carry insurance (vs Medicaid or none) than higher-stage cases (cases aged younger than 65 years; odds ratio = 2.45, 95% CI = 1.96 to 3.06; P < .001). The 5-year overall survival for stage IA PDAC improved from 44.7% (95% CI = 31.4 to 63.7) in 2004 to 83.7% (95% CI = 78.6% to 89.2%) in 2012; 10-year survival improved from 36.7% (95% CI = 24.1 to 55.8) in 2004 to 49.0% (95% CI = 37.2% to 64.6%) in 2007.

CONCLUSIONS

In recent years, the proportion of patients diagnosed with stage IA PDAC has increased, their average age at diagnosis has decreased, and their overall survival has improved. These trends may be the result of improved early diagnosis and early detection.

Review of clinical and emerging biomarkers for early diagnosis and treatment management of pancreatic cancer: towards personalised medicine

Background:

Pancreatic cancer is the 12th most commonly diagnosed cancer and the 3rd leading cause of cancer mortality and accounts for approximately 2·7% of all newly diagnosed cancer cases and 6·4% of all cancer mortalities in Canada. It has a very poor survival rate mainly due to the difficulty of detecting the disease at an early stage. Consequently, in the advancement of disease management towards the concept of precision medicine that takes individual patient variabilities into account, several investigators have focused on the identification of effective clinical biomarkers with high specificity and sensitivity, capable of early diagnosis of symptomatic patients and early detection of the disease in asymptomatic individuals at high risk for developing pancreatic cancer.

Materials and methods:

We searched several databases from August to December 2020 for relevant studies published in English between 2000 and 2020 and reporting on biomarkers for the management of pancreatic cancer. In this narrative review paper, we describe 13 clinical and emerging biomarkers for pancreatic cancers used in screening for early detection and diagnosis, to identify patients’ risk for metastatic disease and subsequent relapse, to monitor patient response to specific treatment and to provide clinicians the possibility of prospectively identifying groups of patients who will benefit from a particular treatment.

Conclusions:

Current and emerging biomarkers for pancreatic cancer with high specificity and sensitivity has the potential to account for individual patient variabilities, for early detection of disease before the onset of metastasis to improve treatment outcome and patients’ survival, help screen high-risk populations, predict prognosis, provide accurate information of patient response to specific treatment and improve patients monitoring during treatment. Thus, the future holds promise for the use of effective clinical biomarkers or a panel of biomarkers for personalised patient-specific targeted medicine for pancreatic cancer.

Disparities in access to health care system as determinant of survival for patients with pancreatic cancer in the State of São Paulo, Brazil

Little is known about the features and outcomes of Brazilian patients with pancreatic cancer. We sought to describe the socio-economic characteristics, patterns of health care access, and survival of patients diagnosed with malignant pancreatic tumors from 2000 to 2014 in São Paulo, Brazil. We included patients with malignant exocrine and non-classified pancreatic tumors according to the International Classifications of Disease (ICD)-O-2 and -O-3, diagnosed from 2000 to 2014, who were registered in the FOSP database. Prognostic factors for overall survival (OS) in the subgroup of patients with ductal or non-specified (adeno)carcinoma were evaluated using Cox proportional hazard model. The study population consists of 6855 patients. Median time from the first visit to diagnosis and treatment were 13 (Interquartile range [IQR] 4-30) and 24 (IQR 8-55) days, respectively. Both intervals were longer for patients treated in the public setting. Median OS was 4.9 months (95% confidence interval [95% CI] 4.7-5.2). Increasing age, male gender, lower educational level, treatment in the public setting, absence of treatment, advanced stage, and treatment from 2000 to 2004 were associated with inferior OS. From 2000-2004 to 2010-2014, no improvement in OS was seen for patients treated in the public setting. Survival of patients with malignant pancreatic tumors remains dismal. Socioeconomical variables, especially health care funding, are major determinants of survival. Further work is necessary to decrease inequalities in access to medical care for patients with pancreatic cancer in Brazil.

Cancer diagnostic tools to aid decision-making in primary care: mixed-methods systematic reviews and cost-effectiveness analysis

BACKGROUND

Tools based on diagnostic prediction models are available to help general practitioners diagnose cancer. It is unclear whether or not tools expedite diagnosis or affect patient quality of life and/or survival.

OBJECTIVES

The objectives were to evaluate the evidence on the validation, clinical effectiveness, cost-effectiveness, and availability and use of cancer diagnostic tools in primary care.

METHODS

Two systematic reviews were conducted to examine the clinical effectiveness (review 1) and the development, validation and accuracy (review 2) of diagnostic prediction models for aiding general practitioners in cancer diagnosis. Bibliographic searches were conducted on MEDLINE, MEDLINE In-Process, EMBASE, Cochrane Library and Web of Science) in May 2017, with updated searches conducted in November 2018. A decision-analytic model explored the tools' clinical effectiveness and cost-effectiveness in colorectal cancer. The model compared patient outcomes and costs between strategies that included the use of the tools and those that did not, using the NHS perspective. We surveyed 4600 general practitioners in randomly selected UK practices to determine the proportions of general practices and general practitioners with access to, and using, cancer decision support tools. Association between access to these tools and practice-level cancer diagnostic indicators was explored.

RESULTS

Systematic review 1 - five studies, of different design and quality, reporting on three diagnostic tools, were included. We found no evidence that using the tools was associated with better outcomes. Systematic review 2 - 43 studies were included, reporting on prediction models, in various stages of development, for 14 cancer sites (including multiple cancers). Most studies relate to QCancer® (ClinRisk Ltd, Leeds, UK) and risk assessment tools.

DECISION MODEL

In the absence of studies reporting their clinical outcomes, QCancer and risk assessment tools were evaluated against faecal immunochemical testing. A linked data approach was used, which translates diagnostic accuracy into time to diagnosis and treatment, and stage at diagnosis. Given the current lack of evidence, the model showed that the cost-effectiveness of diagnostic tools in colorectal cancer relies on demonstrating patient survival benefits. Sensitivity of faecal immunochemical testing and specificity of QCancer and risk assessment tools in a low-risk population were the key uncertain parameters.

SURVEY

Practitioner- and practice-level response rates were 10.3% (476/4600) and 23.3% (227/975), respectively. Cancer decision support tools were available in 83 out of 227 practices (36.6%, 95% confidence interval 30.3% to 43.1%), and were likely to be used in 38 out of 227 practices (16.7%, 95% confidence interval 12.1% to 22.2%). The mean 2-week-wait referral rate did not differ between practices that do and practices that do not have access to QCancer or risk assessment tools (mean difference of 1.8 referrals per 100,000 referrals, 95% confidence interval -6.7 to 10.3 referrals per 100,000 referrals).

LIMITATIONS

There is little good-quality evidence on the clinical effectiveness and cost-effectiveness of diagnostic tools. Many diagnostic prediction models are limited by a lack of external validation. There are limited data on current UK practice and clinical outcomes of diagnostic strategies, and there is no evidence on the quality-of-life outcomes of diagnostic results. The survey was limited by low response rates.

CONCLUSION

The evidence base on the tools is limited. Research on how general practitioners interact with the tools may help to identify barriers to implementation and uptake, and the potential for clinical effectiveness.

FUTURE WORK

Continued model validation is recommended, especially for risk assessment tools. Assessment of the tools' impact on time to diagnosis and treatment, stage at diagnosis, and health outcomes is also recommended, as is further work to understand how tools are used in general practitioner consultations.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017068373 and CRD42017068375.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 66. See the NIHR Journals Library website for further project information.

Influence of KRAS mutations, persistent organic pollutants, and trace elements on survival from pancreatic ductal adenocarcinoma

INTRODUCTION

Reasons why pancreatic ductal adenocarcinoma (PDAC) continues to have poor survival are only partly known. No previous studies have analyzed the combined influence of KRAS mutations, persistent organic pollutants (POPs), and trace elements upon survival in PDAC or in any other human cancer.

OBJECTIVE

To analyze the individual and combined influence of KRAS mutations, POPs, and trace elements upon survival from PDAC.

METHODS

Incident cases of PDAC (n = 185) were prospectively identified in five hospitals in Eastern Spain in 1992-1995 and interviewed face-to-face during hospital admission. KRAS mutational status was determined from tumour tissue through polymerase chain reaction and artificial restriction fragment length polymorphism. Blood and toenail samples were obtained before treatment. Serum concentrations of POPs were analyzed by high-resolution gas chromatography with electron-capture detection. Concentrations of 12 trace elements were determined in toenail samples by inductively coupled plasma mass spectrometry. Multivariable Cox proportional hazards regression was used to assess prognostic associations.

RESULTS

Patients with a KRAS mutated tumor had a 70% higher risk of early death than patients with a KRAS wild-type PDAC (hazard ratio [HR] = 1.7, p = 0.026), adjusting for age, sex, and tumor stage. KRAS mutational status was only modestly and not statistically significantly associated with survival when further adjusting by treatment or by treatment intention. The beneficial effects of treatment remained unaltered when KRAS mutational status was taken into account, and treatment did not appear to be less effective in the subgroup of patients with a KRAS mutated tumor. POPs did not materially influence survival: the adjusted HR of the highest POP tertiles was near unity for all POPs. When considering the joint effect on survival of POPs and KRAS, patients with KRAS mutated tumors had modest and nonsignificant HRs (most HRs around 1.3 to 1.4). Higher concentrations of lead, cadmium, arsenic, vanadium, and aluminium were associated with better survival. When KRAS status, POPs, and trace elements were simultaneously considered along with treatment, only the latter was statistically significantly related to survival.

CONCLUSIONS

In this study based on molecular, clinical, and environmental epidemiology, KRAS mutational status, POPs, and trace elements were not adversely related to PDAC survival when treatment was simultaneously considered; only treatment was independently related to survival. The lack of adverse prognostic effects of POPs and metals measured at the time of diagnosis provide scientific and clinical reassurance on the effects of such exposures upon survival of patients with PDAC. The weak association with KRAS mutations contributes to the scant knowledge on the clinical implications of a genetic alteration highly frequent in PDAC.

Sex-based differences in time to surgical care among pancreatic cancer patients: A national study of Medicare beneficiaries

INTRODUCTION

The objective of this study was to characterize time from cancer symptoms to diagnosis and time from diagnosis to surgical treatment among patients undergoing pancreatectomy for cancer.

METHODS

Medicare beneficiaries who underwent pancreatectomy for cancer between 2013 and 2017 were identified using the 100% Medicare Inpatient Standard Analytic Files. Mixed effects negative binomial regression models were utilized to determine which factors were associated with the number of weeks to diagnosis and pancreatic resection.

RESULTS

Among 7647 Medicare beneficiaries, two-thirds (n = 5127, 67%) had symptoms associated with a pancreatic cancer diagnosis before surgery. Median time from the first symptom to diagnosis was 6 weeks (IQR: 1-25) and the median time from diagnosis to surgery was 4 weeks (IQR: 2-15). In risk-adjusted models, female patients had 13% longer waiting times from identification of a related symptom to pancreatic cancer diagnosis (OR = 1.13, 95% CI: 1.05-1.21) and 12% longer waiting times from diagnosis to surgery (OR = 1.12, 95% CI: 1.07-1.18). Older age was associated with 10% longer waiting times from symptom identification to diagnosis (p < .0001).

CONCLUSIONS

Female and older patients had longer wait times between symptom presentation and pancreatic cancer diagnosis. Sex-based disparities in cancer care need to be recognized and addressed by policymakers and health care institutions.

Current Status of Circulating Tumor DNA Liquid Biopsy in Pancreatic Cancer

Pancreatic cancer is a challenging disease with a low 5-year survival rate. There are areas for improvement in the tools used for screening, diagnosis, prognosis, treatment selection, and assessing treatment response. Liquid biopsy, particularly cell free DNA liquid biopsy, has shown promise as an adjunct to our standard care for pancreatic cancer patients, but has not yet been universally adopted into regular use by clinicians. In this publication, we aim to review cfDNA liquid biopsy in pancreatic cancer with an emphasis on current techniques, clinical utility, and areas of active investigation. We feel that researchers and clinicians alike should be familiar with this exciting modality as it gains increasing importance in the care of cancer patients.

Factors associated with missed and misinterpreted cases of pancreatic ductal adenocarcinoma

OBJECTIVES

To retrospectively examine US, CT, and MR imaging examinations of missed or misinterpreted pancreatic ductal adenocarcinoma (PDAC), and identify factors which may have confounded detection or interpretation.

METHODS

We reviewed 107 examinations in 66/257 patients (26%, mean age 73.7 years) diagnosed with PDAC in 2014 and 2015, with missed or misinterpreted imaging findings as determined by a prior study. For each patient, images and reports were independently reviewed by two radiologists, and in consensus, the following factors which may have confounded assessment were recorded: inherent tumor factors, concurrent pancreatic pathology, technical limitations, and cognitive biases. Secondary signs of PDAC associated with each examination were recorded and compared with the original report to determine which findings were missed.

RESULTS

There were 66/107 (62%) and 49/107 (46%) cases with missed and misinterpreted imaging findings, respectively. A significant number of missed tumors were < 2 cm (45/107, 42%), isoattenuating on CT (32/72, 44%) or non-contour deforming (44/107, 41%). Most (29/49, 59%) misinterpreted examinations were reported as uncomplicated pancreatitis. Almost all examinations (94/107, 88%) demonstrated secondary signs; pancreatic duct dilation was the most common (65/107, 61%) and vascular invasion was the most commonly missed 35/39 (90%). Of the CT and MRIs, 28 of 88 (32%) had suboptimal contrast dosing. Inattentional blindness was the most common cognitive bias, identified in 55/107 (51%) of the exams.

CONCLUSION

Recognizing pitfalls of PDAC detection and interpretation, including intrinsic tumor features, secondary signs, technical factors, and cognitive biases, can assist radiologists in making an early and accurate diagnosis.

KEY POINTS

• There were 66/107 (62%) and 49/107 (46%) cases with missed and misinterpreted imaging findings, respectively, with tumoral, technical, and cognitive factors leading to the misdiagnosis of pancreatic ductal adenocarcinoma. • The majority (29/49, 59%) of misinterpreted cases of pancreatic ductal adenocarcinoma were mistaken for pancreatitis, where an underlying mass or secondary signs were not appreciated due to inflammatory changes. • The most common missed secondary sign of pancreatic ductal adenocarcinoma was vascular encasement, missed in 35/39 (90%) of cases, indicating the importance of evaluating the peri-pancreatic vasculature.

Impact of time interval between multidisciplinary team meeting and intended pancreatoduodenectomy on oncological outcomes

BACKGROUND

Dutch guidelines indicate that treatment of pancreatic head and periampullary malignancies should be started within 3 weeks of the multidisciplinary team (MDT) meeting. This study aimed to assess the impact of time to surgery on oncological outcomes.

METHODS

This was a retrospective population-based cohort study of patients with pancreatic head and periampullary malignancies included in the Netherlands Cancer Registry. Patients scheduled for pancreatoduodenectomy and who were discussed in an MDT meeting from May 2012 to December 2016 were eligible. Time to surgery was defined as days between the final preoperative MDT meeting and surgery, categorized in tertiles (short interval, 18 days or less; intermediate, 19-32 days; long, 33 days or more). Oncological outcomes included overall survival, resection rate and R0 resection rate.

RESULTS

A total of 2027 patients were included, of whom 677, 665 and 685 had a short, intermediate and long time interval to surgery respectively. Median time to surgery was 25 (i.q.r. 14-36) days. Longer time to surgery was not associated with overall survival (hazard ratio 0·99, 95 per cent c.i. 0·87 to 1·13; P = 0·929), resection rate (relative risk (RR) 0·96, 95 per cent c.i. 0·91 to 1·01; P = 0·091) or R0 resection rate (RR 1·01, 0·94 to 1·09; P = 0·733). Patients with pancreatic ductal adenocarcinoma and a long time interval had a lower resection rate (RR 0·92, 0·85 to 0·99; P = 0·029).

DISCUSSION

A longer time interval between the last MDT meeting and pancreatoduodenectomy did not decrease overall survival.

The implications of missed or misinterpreted cases of pancreatic ductal adenocarcinoma on imaging: a multi-centered population-based study

OBJECTIVES

To assess the proportion of missed/misinterpreted imaging examinations of pancreatic ductal adenocarcinoma (PDAC), and their association with the diagnostic interval and survival.

METHODS

Two hundred fifty-seven patients (mean age, 71.8 years) diagnosed with PDAC in 2014-2015 were identified from the Nova Scotia Cancer Registry. Demographics, stage, tumor location, and dates of initial presentation, diagnosis, and, if applicable, surgery and death were recorded. US, CT, and MRI examinations during the diagnostic interval were independently graded by two radiologists using the RADPEER system; discordance was resolved in consensus. Mean diagnostic interval and survival were compared amongst RADPEER groups (one-way ANOVA). Kaplan-Meier analysis was performed for age (< 65, 65-79, ≥ 80), sex, tumor location (proximal/distal), stage (I-IV), surgery (yes/no), chemotherapy (yes/no), and RADPEER score (1-3). Association between these covariates and survival was assessed (multivariate Cox proportion hazards model).

RESULTS

RADPEER 1-3 scores were assigned to 191, 27, and 39 patients, respectively. Mean diagnostic intervals were 53, 86, and 192 days, respectively (p = 0.018). There were only 3/257 (1.2%) survivors. Mean survival was not different between groups (p = 0.43). Kaplan-Meier analysis showed worse survival in RADPEER 1-2 (p = 0.007), older age (p < 0.001), distal PDAC (p = 0.016), stage (p < 0.0001), and no surgery (p < 0.001); survival was not different with sex (p = 0.083). Cox analysis showed better survival in RADPEER 3 (p = 0.005), women (p = 0.002), surgical patients (p < 0.001), and chemotherapy (p < 0.001), and worse survival in stage IV (p = 0.006).

CONCLUSION

Imaging-related delays occurred in one-fourth of patients and were associated with longer diagnostic intervals but not worse survival, potentially due to overall poor survival in the cohort.

KEY POINTS

• One-fourth of patients (66/257, 25.7%) with pancreatic ductal adenocarcinoma (PDAC) underwent imaging examinations that demonstrated manifestations of the disease, but findings were either missed or misinterpreted; RADPEER 2 and 3 scores were assigned to 10.5% and 15.2% of patients, respectively. • Patients with imaging examinations assigned RADPEER 3 scores were associated with significantly longer diagnostic intervals (192 ± 323 days) than RADPEER 1 (53 ± 86 days) and RADPEER 2 (86 ± 120 days) (p < 0.001). • Imaging-related diagnostic delays were not associated with worse survival; however, this may have been confounded by the overall poor survival in our cohort (only 3/257 (1.2%) survivors).

The effect of 1-day multidisciplinary clinic on breast cancer treatment

PURPOSE

A delay in breast cancer treatment is associated with inferior survival outcomes; however, no clear guidelines exist defining the appropriate time frame from diagnosis to definitive treatment of breast cancer. A multidisciplinary approach for breast cancer treatment can minimize the time from diagnosis to first treatment. We hypothesized single-day multidisciplinary clinic (MDC) may accelerate the time to first treatment on complex breast cancer cases at our institution.

METHODS

We identified patients who were treated at Johns Hopkins for stage II or III breast cancer, who were at least 18 years of age, and were seen in a new single-day MDC with coordination between two or three specialties or by specialists from varying disciplines on different days (IDC). Patients who initiated treatment between May 2015 (initiation of MDC clinic) and December 2017 were included in our study.

RESULTS

A total of 296 patient records were reviewed independently. The mean (SD) patient age was 55 (13) years. The median time to first neoadjuvant chemotherapy (NACT) was significantly reduced for patients seen in the MDC (12.7 days), compared to those seen at the IDC (24.4 days, logrank p < 0.001). The median time to definitive surgery was similar between groups (31 and 32 days for the MDC and IDC cohorts, respectively).

CONCLUSIONS

A single-day MDC visit is associated with a reduced time from diagnosis to NACT. Further studies are needed to determine if a shorter interval can improve the management and the outcome of complex breast cancer cases.

Time intervals to diagnosis and chemotherapy do not influence survival outcome in patients with advanced pancreatic adenocarcinoma

BACKGROUND

The effect of treatment delay on survival in pancreatic ductal adenocarcinoma (PDAC) remains unclear.

AIMS

This study aimed to assess the prognostic impact of time to diagnosis and chemotherapy in advanced PDAC and factors influencing the time intervals.

METHODS

advanced PDAC patients receiving chemotherapy in five centers in the decade 2007-2016 were included. Key time points during care pathway from clinical presentation to beginning of chemotherapy were retrospectively collected. Multivariate Cox proportional hazard model was performed.

RESULTS

A total of 409 patients were included (mean age 66.1 ± 10.3 years; 250 metastatic (61%); 139 received FOLFIRINOX chemotherapy (34%). The median overall survival (OS) was 7.2 months. The median times from first symptoms and from first specialist visit to the beginning of chemotherapy were respectively 100 days and 47 days. None of time intervals was significantly associated with OS. Significant prognostic factors were FOLFIRINOX chemotherapy (HR 0.6 [0.5-0.8]; P < 0.001), metastasis (HR 1.6 [1.3-2.0]; P = 0.001), WHO PS ≥ 2 (HR 1.6 [1.2-2.1]; P < 0.001) and acute pancreatitis as first symptom (HR 2.9 [1.7-4.9]; P < 0.001). Jaundice shortened time to diagnosis (P < 0.001). Acute pancreatitis (P < 0.001) and diabetes (P = 0.01) increased time to treatment.

CONCLUSION

Wait times from clinical presentation to beginning of chemotherapy do not influence survival in advanced PDAC.

The lncRNA ENSG00000254041.1 promotes cell invasiveness and associates with poor prognosis of pancreatic ductal adenocarcinoma

Pancreatic cancer (PC) mainly occurs after 60 years of age, and its prognosis remains poor despite modest improvements in recent decades. Long non-coding RNAs (lncRNAs) are well known as a class of transcripts involved in cancer occurrence and progression. The process of epithelial to a mesenchymal (EMT) phenotype in tumor cell increases their migratory and invasive properties, resulting in facilitating metastasis. Here, we reanalyzed RNA-seq data from the TCGA PC database and identified that ENSG00000254041.1 increasingly expressed in samples with elevated EMT signature score. Then, the evaluated expression and prognostic significance of ENSG00000254041.1 were verified in our cohort. Meanwhile, multivariate analysis suggested that ENSG00000254041.1 was independent factors for predicting the prognosis of PC, apart from advanced stage (III/IV). Moreover, functional assay revealed that knock down of ENSG00000254041.1 significantly decreased proliferation, invasion and chemoresistance of PC cells (SW1990 and BxPC-3), while overexpression of ENSG00000254041.1 in PC cells (Panc-1) resulted in the opposite effects. Western blot showed that knockdown of ENSG00000254041.1 expression in PC cells caused a significant downregulation of vimentin, Snail and SOX4, and upregulation of E-cadherin; also, ENSG00000254041.1 overexpression in PC cells resulted in opposite effects. In conclusion, these findings indicated that ENSG00000254041.1 promotes PC progression, and might provide a potential biomarker for predicting the prognosis of PC.

Diagnostic delay does not influence survival of pancreatic cancer patients

BACKGROUND

Most pancreatic ductal adenocarcinoma patients present with advanced disease. Whether it is possible to increase survival by earlier diagnosis is unclear.

OBJECTIVE

The purpose of this study was to investigate the association between presenting complaints and risk factors for pancreatic cancer with diagnostic delay, stage and survival.

METHODS

This was a single-centre retrospective cohort study. Consecutive patients were interviewed and data on demographics, medical history, risk factors and complaints leading to pancreatic ductal adenocarcinoma diagnosis and disease stage were recorded. Diagnostic delay was considered as time between first complaint and diagnosis. Patients received appropriate treatments and their outcome was recorded in a dedicated database. The Chi-square test for comparison of categorical variables and the Mann-Whitney test for continuous variables were employed with Bonferroni corrections. Correlation between continuous variables was evaluated by means of the Spearman correlation coefficient. Survival analysis was performed with the Kaplan-Meier method and a log-rank test.

RESULTS

The median diagnostic delay for 477 pancreatic ductal adenocarcinoma patients was two months (interquartile range 1-5), being significantly shorter for patients presenting with jaundice compared with those with pain, weight loss, diabetes (p < 0.001). The global rate of metastatic disease at diagnosis was 40%, being only 22% in those presenting with jaundice. The median diagnostic delay, however, was not significantly different among disease stages but was significantly longer in patients with a body mass index>25 kg/m2. The median survival time was seven months. Factors associated with worse survival at the multivariable analysis were older age (hazard ratio 1.02 per year), metastatic disease (hazard ratio 2.12) and pain as presenting complaint (hazard ratio 1.32), while diagnostic delay was not.

CONCLUSION

While some complaints are associated with a shorter diagnostic delay and less advanced disease stage, we could not demonstrate that delay is associated with survival, possibly suggesting that prevention rather than early recognition is important to tackle pancreatic cancer lethality.

Prolonged time to treatment initiation in advanced pancreatic cancer patients has no major effect on treatment outcome: a retrospective cohort study controlled for lead time bias and waiting time paradox

PURPOSE

A prolonged time to treatment initiation (TTI) correlates with an adverse prognosis in different cancer types including resectable pancreatic cancer (PC). Only limited evidence on the correlation between TTI and prognosis in advanced PC exists.

METHODS

Consecutive PC patients (n = 368) who were diagnosed or treated at our high-volume comprehensive cancer center were included in a prospectively maintained database. We retrospectively analyzed time from first imaging showing advanced PC to initiation of palliative first-line chemotherapy. Lead time bias and waiting time paradox were addressed by landmark analysis and correlation of tumor burden with TTI.

RESULTS

Two hundred and ninety-seven patients met the pre-specified in- and exclusion criteria of our study. Median TTI was 29 days (range: 1-124 days). Most common reasons for prolonged TTI (> 21 days) were referral from an external treatment center (39%) and a second biopsy (31%). A TTI above the median-, 75th or 90th percentile (43 or 60 days, respectively) had no impact on overall survival. Furthermore, no correlation between levels of carbohydrate antigen 19-9 (CA 19-9) at time of treatment initiation and TTI was observed.

CONCLUSION

While a timely work-up of advanced PC patients remains important, delays in treatment initiation due to repeated biopsies, inclusion in a clinical study or transfer to a specialized cancer center appear to be justified in light of the absence of a strong adverse effect of prolonged TTI on prognosis in advanced PC patients.

Benefits Of Timely Care In Pancreatic Cancer: A Systematic Review To Navigate Through The Contradictory Evidence

The evidence base of policies that improve the timeliness of cancer care is under ongoing debate. Pancreatic cancer is frequently diagnosed in a stage when curative therapy is not feasible; hence, it is an important target for timelier healthcare interventions. The objectives of our research were to identify all clinical studies on pancreatic cancer care delays via a systematic literature review, to assess the study methodologies for possible biases, to conclude on the available evidence, and to formulate research recommendations on evidence gaps. Nineteen studies were identified and eight reported multivariate analyses. Although many sources of bias shifted the results towards negative or paradoxical findings, a statistically significant association of shorter delays with better clinical outcomes was demonstrated in the majority of studies reporting multivariate analyses. Noninferiority analyses were not published. Further efforts to provide timely care for pancreatic cancer patients are encouraged, and studies on the associations of delay with patient experience and healthcare resource utilization are warranted.

Disparities in Pancreatic Cancer Treatment and Outcomes

Purpose: Pancreatic cancer remains a major health concern; in the next 2 years, it will become the second leading cause of cancer deaths in the United States. Health disparities in the treatment of pancreatic cancer exist across many disciplines, including race and ethnicity, socioeconomic status (SES), and insurance. This narrative review discusses what is known about these disparities, with the goal of highlighting targets for equity promoting interventions.

Methods: We performed a narrative review of health disparities in pancreatic cancer spanning greater than ten areas, including epidemiology, treatment, and outcome, using the PubMed NIH database from 2000 to 2019 in the Unites States.

Results: African Americans (AAs) tend to present at diagnosis with later stage disease. AAs and Hispanics have lower rates of surgical resection, are more likely to be treated at low volume hospitals, and often experience higher rates of morbidity and mortality compared to white patients, although control for confounders is often limited. Insurance and SES also factor into the delivery of treatment for pancreatic cancer.

Conclusion: Disparities by race and SES exist in the diagnosis and treatment of pancreatic cancer that are largely driven by race and SES. Improved understanding of underlying causes could inform interventions.

How European primary care practitioners think the timeliness of cancer diagnosis can be improved: a thematic analysis

BACKGROUND

National European cancer survival rates vary widely. Prolonged diagnostic intervals are thought to be a key factor in explaining these variations. Primary care practitioners (PCPs) frequently play a crucial role during initial cancer diagnosis; their knowledge could be used to improve the planning of more effective approaches to earlier cancer diagnosis.

OBJECTIVES

This study sought the views of PCPs from across Europe on how they thought the timeliness of cancer diagnosis could be improved.

DESIGN

In an online survey, a final open-ended question asked PCPs how they thought the speed of diagnosis of cancer in primary care could be improved. Thematic analysis was used to analyse the data.

SETTING

A primary care study, with participating centres in 20 European countries.

PARTICIPANTS

A total of 1352 PCPs answered the final survey question, with a median of 48 per country.

RESULTS

The main themes identified were: patient-related factors, including health education; care provider-related factors, including continuing medical education; improving communication and interprofessional partnership, particularly between primary and secondary care; factors relating to health system organisation and policies, including improving access to healthcare; easier primary care access to diagnostic tests; and use of information technology. Re-allocation of funding to support timely diagnosis was seen as an issue affecting all of these.

CONCLUSIONS

To achieve more timely cancer diagnosis, health systems need to facilitate earlier patient presentation through education and better access to care, have well-educated clinicians with good access to investigations and better information technology, and adequate primary care cancer diagnostic pathway funding.