1
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Roth GS, Fayet Y, Benmameche-Medjahed S, Ducimetière F, Charreton A, Cropet C, Chabaud S, Marion-Audibert AM, Berthelet O, Walter T, Adham M, Baconnier M, Tavan D, Williet N, Artru P, Huet-Penz F, Ray-Coquard I, Farsi F, Labrosse H, de la Fouchardière C. Structural and Socio-Spatial Determinants Influencing Care and Survival of Patients with a Pancreatic Adenocarcinoma: Results of the PANDAURA Cohort. Cancers (Basel) 2022; 14:cancers14215413. [PMID: 36358831 PMCID: PMC9658615 DOI: 10.3390/cancers14215413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/29/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
Background and aims: Pancreatic cancer is highly lethal and often diagnosed at an advanced stage. This cohort study analyzes the impact of care pathways, delays, and socio-spatial determinants on pancreatic cancer patients’ diagnosis, treatment, and prognosis. Method: Patients with pancreatic adenocarcinoma newly diagnosed at all stages between January and June 2016 in the AuRA French region were included. The influence on survival of delays of care, healthcare centers’ expertise, and socio-spatial determinants was evaluated. Results: Here, 538 patients were included in 76 centers including 116 patients (21.8%) with resectable, 64 (12.0%) borderline-resectable, 147 (27.6%) locally-advanced tumors, and 205 (38.5%) with metastatic disease. A delay between first symptoms and CT scans did not statistically influence overall survival (OS). In resected patients, OS was significantly higher in centers with more than 20 surgeries (HR<5 surgeries/year = 2.236 and HR5-20 surgeries/year = 1.215 versus centers with > 20 surgeries/year p = 0.0081). Regarding socio-spatial determinants, patients living in municipalities with greater access to a general practitioner (HR = 1.673, p = 0.0153) or with a population density below 795.1 people/km2 (HR = 1.881, p = 0.0057) were significantly more often resectable. Conclusion: This cohort study supports the pivotal role of general practitioner in cancer care and the importance of the centralization of pancreatic surgery to optimize pancreatic cancer patients’ care and outcomes. However, delays of care did not impact patient survival.
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Affiliation(s)
- Gaël S. Roth
- University Grenoble Alpes/Hepato-Gastroenterology and Digestive Oncology Department, CHU Grenoble Alpes/Institute for Advanced Biosciences, CNRS UMR 5309-INSERM U1209, 38043 Grenoble, France
- Correspondence: (G.S.R.); (C.d.l.F.)
| | - Yohan Fayet
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Equipe EMS-Social and Human Sciences Department, Centre Léon Bérard, 69008 Lyon, France
| | - Sakina Benmameche-Medjahed
- Medical Oncology Department, Centre Léon Bérard/Research Center of Lyon (CRCL), UMR INSERM 1052, 28 rue Laennec, 69008 Lyon, France
| | - Françoise Ducimetière
- Medical Oncology Department, Centre Léon Bérard/Research Center of Lyon (CRCL), UMR INSERM 1052, 28 rue Laennec, 69008 Lyon, France
| | - Amandine Charreton
- Medical Oncology Department, Centre Léon Bérard/Research Center of Lyon (CRCL), UMR INSERM 1052, 28 rue Laennec, 69008 Lyon, France
| | - Claire Cropet
- Biostatistics Deparment, Centre Léon Bérard/Research Center of Lyon (CRCL), UMR INSERM 1052, 28 rue Laennec, 69008 Lyon, France
| | - Sylvie Chabaud
- Biostatistics Deparment, Centre Léon Bérard/Research Center of Lyon (CRCL), UMR INSERM 1052, 28 rue Laennec, 69008 Lyon, France
| | - Anne-Marie Marion-Audibert
- Gastroenterology and Hepatology, Clinique du Val d’Ouest, 39 Chemin de la Vernique, 69130 Ecully, France
| | - Olivier Berthelet
- Hepato-Gastroenterology Department, Centre Hospitalier Métropole Savoie, 73011 Chambery, France
| | - Thomas Walter
- Medical Oncology Department, Hopital Edouard Herriot, 69003 Lyon, France
| | - Mustapha Adham
- Surgery Department, Hopital Edouard Herriot, 69003 Lyon, France
| | - Mathieu Baconnier
- Hépatogastroenterology Department, Centre Hospitalier Annecy Genevois, 74370 Epagny Metz-Tessy, France
| | - David Tavan
- Hépatogastroentérology Department, Infirmerie Protestante, 69300 Caluire-et-Cuire, France
| | - Nicolas Williet
- Hepatogastroenterology and Digestive oncology Department, University Hospital of Saint-Etienne, 42270 Saint-Priest-en-Jarez, France
| | - Pascal Artru
- Gastroenterology Department, Hopital privé Jean Mermoz, 69008 Lyon, France
| | - Floriane Huet-Penz
- Hepato-Gastroenterologie, Centre Hospitalier Alpes Léman, 74130 Contamine sur Arve, France
| | - Isabelle Ray-Coquard
- Medical Oncology Department, Centre Léon Bérard/Research Center of Lyon (CRCL), UMR INSERM 1052, 28 rue Laennec, 69008 Lyon, France
| | - Fadila Farsi
- ONCOAURA, Dispositif Spécifique Régional de Cancérologie, 60 Avenue Rockefeller, 69008 Lyon, France
| | - Hélène Labrosse
- ONCOAURA, Dispositif Spécifique Régional de Cancérologie, 60 Avenue Rockefeller, 69008 Lyon, France
| | - Christelle de la Fouchardière
- Medical Oncology Department, Centre Léon Bérard/Research Center of Lyon (CRCL), UMR INSERM 1052, 28 rue Laennec, 69008 Lyon, France
- Correspondence: (G.S.R.); (C.d.l.F.)
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2
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Effects of socioeconomic status on cancer patient survival: counterfactual event-based mediation analysis. Cancer Causes Control 2020; 32:83-93. [PMID: 33211220 DOI: 10.1007/s10552-020-01361-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 10/22/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE This study investigated the direct and indirect effects of socioeconomic status (SES) on the survival time of cancer patients by using cancer stage to create a pathway from SES to health outcomes and facilitate a mechanistic inference. METHODS Both a traditional mediation analysis and a counterfactual event-based mediation analysis were applied to SEER (The Surveillance, Epidemiology, and End Results) data from the National Cancer Institute of the United States. A Cox proportional hazards model for survival analysis was performed in the mediation analysis. RESULTS The counterfactual event-based mediation analysis showed that the effect of SES on survival time was partially mediated by stage at diagnosis in lung (12%), liver (14.33%), and colorectal (9%) cancers. Investigation of the fundamental mechanism involved thus established the direct effect of SES on survival time and the indirect effect of SES on survival time through stage at diagnosis. Moreover, the mediation analysis also revealed that the disparity in timely diagnosis (i.e., stage at diagnosis) caused by SES was slightly significant. CONCLUSIONS SES can either affect cancer survival directly or indirectly through stage at diagnosis. Opportunities to reduce cancer disparity exist in the design of early detection policies or mechanisms for patients with varying resources.
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3
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Spatial distribution and clusters of pancreatic cancer mortality in Shandong Province, China. Sci Rep 2019; 9:12917. [PMID: 31501496 PMCID: PMC6733872 DOI: 10.1038/s41598-019-49357-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/23/2019] [Indexed: 12/13/2022] Open
Abstract
This study aimed to explore the geographic distribution and risk clusters of pancreatic cancer mortality from 2011 to 2013 in Shandong, China, and to detect the differences between urban and rural areas. Our data were obtained from the Shandong Death Registration System (SDRS) and were adjusted according to the underreporting level. The distribution of mortality was displayed with GIS-based maps at the county level. The results showed an increasing trend in pancreatic cancer mortality from the western region to the eastern region of Shandong. Additionally, four significant risk clusters were detected, and the most likely cluster was focused in the northeastern and northern regions. Urban-rural differences in the mortality distribution and risk clusters were also detected. In conclusion, our study identified pancreatic cancer mortality clusters in Shandong in urban and rural areas; these results can contribute to the development of effective and targeted strategies to control pancreatic cancer in different areas.
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4
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Mora-Oliver I, Garcés-Albir M, Dorcaratto D, Muñoz-Forner E, Izquierdo Moreno A, Carbonell-Aliaga MP, Sabater L. Pancreatoduodenectomy with artery-first approach. MINERVA CHIR 2019; 74:226-236. [PMID: 30600965 DOI: 10.23736/s0026-4733.18.07944-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
"Artery-first approach" encompasses different aspects for the surgical treatment of pancreatic cancer. It is a surgical technique or set of techniques which share in common the dissection of the main arterial vasculature involved in pancreatic cancer, before any irreversible surgical step is performed. On the other hand it represents the need for a meticulous dissection of the arterial planes and clearing of the retropancreatic tissue between the superior mesenteric artery, the common hepatic artery and portal vein in an attempt to achieve R0 resections. The recent expansion of this approach is based mainly on three factors: venous involvement should not be considered a contraindication for resection, most of the pancreatic resections performed with a standard procedure may be in fact non-oncological (R1) resections and the postero-medial or vascular margin is the most frequently invaded by the tumor. This review aimed to summarize and update the artery-first approach in pancreaticoduodenectomy.
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Affiliation(s)
- Isabel Mora-Oliver
- Liver, Biliary and Pancreatic Unit, Department of General Surgery, Hospital Clínico, University of Valencia, Spain.,Biomedical Research Institute INCLIVA, Valencia, Spain
| | - Marina Garcés-Albir
- Liver, Biliary and Pancreatic Unit, Department of General Surgery, Hospital Clínico, University of Valencia, Spain.,Biomedical Research Institute INCLIVA, Valencia, Spain
| | - Dimitri Dorcaratto
- Liver, Biliary and Pancreatic Unit, Department of General Surgery, Hospital Clínico, University of Valencia, Spain.,Biomedical Research Institute INCLIVA, Valencia, Spain
| | - Elena Muñoz-Forner
- Liver, Biliary and Pancreatic Unit, Department of General Surgery, Hospital Clínico, University of Valencia, Spain.,Biomedical Research Institute INCLIVA, Valencia, Spain
| | - Ana Izquierdo Moreno
- Liver, Biliary and Pancreatic Unit, Department of General Surgery, Hospital Clínico, University of Valencia, Spain.,Biomedical Research Institute INCLIVA, Valencia, Spain
| | - Mari P Carbonell-Aliaga
- Liver, Biliary and Pancreatic Unit, Department of General Surgery, Hospital Clínico, University of Valencia, Spain.,Biomedical Research Institute INCLIVA, Valencia, Spain
| | - Luis Sabater
- Liver, Biliary and Pancreatic Unit, Department of General Surgery, Hospital Clínico, University of Valencia, Spain - .,Biomedical Research Institute INCLIVA, Valencia, Spain
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5
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Morita K, Oshiro H, Mito K, Mieno MN, Tamba-Sakaguchi M, Niki T, Miki A, Koizumi M, Sakuma Y, Komatsubara T, Sata N, Fukushima N. Prognostic significance of the degree of lymphatic vessel invasion in locally advanced, surgically resectable pancreatic head cancer: A single center experience. Medicine (Baltimore) 2018; 97:e13466. [PMID: 30544433 PMCID: PMC6310507 DOI: 10.1097/md.0000000000013466] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Little is known concerning the prognostic significance of the degree of lymphatic vessel invasion in pancreatic head cancer. To address this gap in knowledge, we retrospectively examined 60 patients with locally advanced, surgically resectable pancreatic head cancer who underwent pancreaticoduodenectomy and lymph node (LN) dissection.All cases were histopathologically diagnosed as ductal adenocarcinoma, stage II (25 pT3N0 cases, 35 pT3N1 cases). The following variables were investigated: age; sex; neoadjuvant therapy; adjuvant therapy; tumor size; tumor grade; invasion into the serosa, retropancreatic tissue, duodenum, bile duct, portal venous system and perineural area; cut margins; LN metastasis; and the number of invaded lymphatic vessels (LVI-score).Univariate analysis demonstrated that LN metastasis and an LVI-score ≥5 were significantly associated with poor disease-free survival. Multivariate Cox regression analysis confirmed that LN metastasis and an LVI-score ≥7 were significantly associated with poor disease-free survival. Additionally, LVI-scores ≥9 and ≥10 were comparable to or surpassed the significance of LN metastasis based on the hazard ratio. Univariate analysis demonstrated that tumor size >30 mm, duodenal invasion, LN metastasis and an LVI-score ≥2 were significantly associated with poor overall survival. Multivariate Cox regression analysis confirmed that LN metastasis and LVI-scores ≥9 and ≥10 were significantly associated with poor overall survival, and an LVI-score ≥10 was comparable to or surpassed the significance of LN metastasis based on the hazard ratio.Our study strongly suggests that a high degree of lymphatic vessel invasion is associated with a poor prognosis in patients with locally advanced, surgically resectable pancreatic head cancer.
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Affiliation(s)
- Kohei Morita
- Department of Diagnostic Pathology, Jichi Medical University Hospital
| | - Hisashi Oshiro
- Department of Diagnostic Pathology, Jichi Medical University Hospital
| | - Kumiko Mito
- Department of Diagnostic Pathology, Jichi Medical University Hospital
| | - Makiko Naka Mieno
- Department of Medical Informatics, Center for Information, Jichi Medical University
| | | | - Toshiro Niki
- Department of Diagnostic Pathology, Jichi Medical University Hospital
| | - Atsushi Miki
- Department of Surgery, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Masaru Koizumi
- Department of Surgery, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Yasunaru Sakuma
- Department of Surgery, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Toshihide Komatsubara
- Department of Surgery, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Naohiro Sata
- Department of Surgery, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
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6
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Kirkegård J, Ladekarl M, Fristrup CW, Hansen CP, Sall M, Mortensen FV. Urban versus rural residency and pancreatic cancer survival: A Danish nationwide population-based cohort study. PLoS One 2018; 13:e0202486. [PMID: 30114213 PMCID: PMC6095589 DOI: 10.1371/journal.pone.0202486] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 08/04/2018] [Indexed: 02/08/2023] Open
Abstract
It is unknown whether urban versus rural residency affects pancreatic cancer survival in a universal tax-financed healthcare system. We conducted a nationwide, population-based cohort study of all patients diagnosed with pancreatic cancer in Denmark from 2004–2015. We used nationwide registries to collect information on characteristics, comorbidity, cancer-directed treatment, and vital status. We followed the patients from pancreatic cancer diagnosis until death, emigration, or 1 October 2017, whichever occurred first. We truncated at five years of follow up. We stratified patients into calendar periods according to year of diagnosis (2004–2007, 2008–2011, and 2012–2015). We used Cox proportional hazards model to compute hazard ratios (HRs) with associated 95% confidence intervals (CIs) of death, comparing patients in urban and rural areas. HRs were adjusted for age, sex, comorbidity, tumor stage, and localization. In a sub-analysis, we also adjusted for cancer-directed treatment. We included 10,594 patients diagnosed with pancreatic cancer. Median age was 71 years (inter-quartile range: 63–78 years), and half were men. The majority (61.7%) lived in an urban area at the time of diagnosis. When adjusting for potential confounders, we observed a better survival rate among pancreatic cancer patients residing in urban areas compared with rural areas (adjusted HR: 0.92; 95% CI: 0.87–0.98). When taking treatment into account, the association was unclear (adjusted HR: 0.96; 95% CI: 0.88–1.04). Pancreatic cancer patients residing in urban areas had a slightly better survival rate compared with patients in rural areas.
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Affiliation(s)
- Jakob Kirkegård
- Department of Surgery, HPB section, Aarhus University Hospital, Aarhus, Denmark
- * E-mail:
| | - Morten Ladekarl
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Claus Wilki Fristrup
- Odense Pancreas Center (OPAC), Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Carsten Palnæs Hansen
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, Copenhagen, Denmark
| | - Mogens Sall
- Department of Surgery, Aalborg University Hospital, Aaborg, Denmark
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7
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Pointer DT, Al-Qurayshi Z, Hamner JB, Slakey DP, Kandil E. Factors leading to pancreatic resection in patients with pancreatic cancer: a national perspective. Gland Surg 2018; 7:207-215. [PMID: 29770314 DOI: 10.21037/gs.2017.12.04] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Resection is the only option for potential cure in pancreatic cancer. Patients admitted for resection may have the procedure deferred during their hospitalization. We aim to identify factors that lead pancreatic cancer patients to undergo resection. Methods An analysis utilizing the Nationwide Inpatient Sample (NIS) database, 2003-2009. Study population included adults (≥18 years) with pancreatic cancer who underwent either pancreatic resection or other interventions. Surgeon volume classified based on the median into low and high-volume surgeon. Results Eleven thousand three hundred and sixty-five patients were included; 68.0% underwent pancreatic resection, while 32.0% had other interventions. The majority of patients resected were <60 years old, female, with higher annual household income (P<0.05 for all). Patients with Medicaid coverage and comorbidity scores ≥2 were least likely to undergo pancreatic resection. Resection was more likely for high-volume surgeons, high-volume hospitals and teaching hospitals (P<0.05 for all). Those managed by high-volume surgeons were at a lower risk of postoperative complications, lower mortality, shorter hospital stay, and lower healthcare costs (P<0.05 for all). Conclusions Patients' insurance type and economic status are significantly associated with their ability to achieve pancreatic resection. Surgeon experience and hospital volumes were also significantly associated with pancreatic resection, clinical and economic outcomes.
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Affiliation(s)
- David T Pointer
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Zaid Al-Qurayshi
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - John B Hamner
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Douglas P Slakey
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Emad Kandil
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
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8
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Klein J, von dem Knesebeck O. [Social disparities in outpatient and inpatient care: An overview of current findings in Germany]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2017; 59:238-44. [PMID: 26631009 DOI: 10.1007/s00103-015-2283-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
There is controversy about social disparities in healthcare services in Germany, but a differentiated analysis regarding various dimensions of healthcare is lacking. This narrative review intends to summarize conceptually the current state of research and draw subsequent conclusions. Separated into access, utilization and quality, the findings of social inequality in outpatient and inpatient care in Germany are summarized. Besides the common individual indicators of socioeconomic status (SES), regional deprivation and health insurance status are also included. Despite methodical diversity, the results show that healthcare inequalities due to SES exist, but not universally. Furthermore, there is a differentiated pattern respecting separate dimensions of healthcare. Concerning access (e.g. waiting times, co-payments) lower status groups and patients covered by statutory health insurance are deprived. Higher utilization becomes apparent among higher status groups and privately insured patients in terms of specialist consultations and prevention services. The findings regarding quality of process and outcome differ depending on quality indicator and disease. In different dimensions of medical healthcare, social disparities still exist, though the impact on health remains unclear for some types of healthcare inequalities. Moreover, it is often difficult to conclude from unequal outcome quality the inequalities of healthcare. Depending on access, utilization and quality, separate interventions for reducing these disparities are to be introduced.
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Affiliation(s)
- Jens Klein
- Institut für Medizinische Soziologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20146, Hamburg, Deutschland.
| | - Olaf von dem Knesebeck
- Institut für Medizinische Soziologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20146, Hamburg, Deutschland
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9
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The Impact of Socioeconomic Status, Surgical Resection and Type of Hospital on Survival in Patients with Pancreatic Cancer. A Population-Based Study in The Netherlands. PLoS One 2016; 11:e0166449. [PMID: 27832174 PMCID: PMC5104385 DOI: 10.1371/journal.pone.0166449] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 10/28/2016] [Indexed: 12/21/2022] Open
Abstract
The influence of socioeconomic inequalities in pancreatic cancer patients and especially its effect in patients who had a resection is not known. Hospital type in which resection is performed might also influence outcome. Patients diagnosed with pancreatic cancer from 1989 to 2011 (n = 34,757) were selected from the population-based Netherlands Cancer Registry. Postal code was used to determine SES. Multivariable survival analyses using Cox regression were conducted to discriminate independent risk factors for death. Patients living in a high SES neighborhood more often underwent resection and more often were operated in a university hospital. After adjustment for clinicopathological factors, risk of dying was increased independently for patients with intermediate and low SES compared to patients with high SES. After resection, no survival difference was found among patients in the three SES groups. However, survival was better for patients treated in university hospitals compared to patients treated in non-university hospitals. Low SES was an independent risk factor for poor survival in patients with pancreatic cancer. SES was not an adverse risk factor after resection. Resection in non-university hospitals was associated with a worse prognosis.
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10
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Axtner J, Steele M, Kröz M, Spahn G, Matthes H, Schad F. Health services research of integrative oncology in palliative care of patients with advanced pancreatic cancer. BMC Cancer 2016; 16:579. [PMID: 27485618 PMCID: PMC4971628 DOI: 10.1186/s12885-016-2594-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 07/21/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Pancreatic cancer has a dire prognosis and is associated with a high mortality. Palliative patients have special needs and often seek help in integrative oncological concepts (IO) that combine conventional and complementary therapies. Nevertheless there are few recommendations regarding IO in current cancer guidelines. The aims of this study were to report on implementation of IO in everyday palliative care and to analyze patient survival in advanced pancreatic cancer. METHODS This multicenter observational study investigates the implementation of IO and length of survival of patients suffering from advanced pancreatic cancer (stage IV). We analyzed patient's survival by employing multivariable proportional hazard models using different parametric distribution functions and compared patients receiving chemotherapy only, a combination of chemotherapy and Viscum album (VA) treatment, and VA treatment only. RESULTS Records of 240 patients were analyzed. Complementary therapy showed high acceptance (93 %). Most frequent therapy was VA treatment (74 %) that was often administered concomitantly to chemotherapy (64 %). Both therapies had positive effects on patient survival as they had significant negative effects on the hazard in our log-normal model. A second analysis showed that patients with combined chemotherapy and VA therapy performed significantly better than patients receiving only chemotherapy (12.1 to 7.3 month). Patients receiving only VA therapy showed longer survival than those receiving neither chemotherapy nor VA therapy (5.4 to 2.5 months). Our data demonstrates that IO can be implemented in the everyday care of patients without disregarding conventional treatment. Patients combining VA with chemotherapy showed longest survival. CONCLUSIONS Our data demonstrate the importance and potential of health services research showing that IO treatment can be successfully implemented in the every-day care of patients suffering from advanced pancreatic cancer. Patients combining VA with chemotherapy showed longest survival. To address patients' needs adequately, future cancer guidelines might increasingly include comments on complementary treatment options in addition to conventional therapies. Further studies should investigate the effect of complementary treatments on survival and quality of life in more detail.
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Affiliation(s)
- Jan Axtner
- Forschungsinstitut Havelhöhe gGmbH, Kladower Damm 221, 14089, Berlin, Germany
| | - Megan Steele
- Forschungsinstitut Havelhöhe gGmbH, Kladower Damm 221, 14089, Berlin, Germany.,ihop Research Group, Queensland University of Technology, School of Public Health and Social Work, Victoria Park Road, 4059, Brisbane, Australia
| | - Matthias Kröz
- Forschungsinstitut Havelhöhe gGmbH, Kladower Damm 221, 14089, Berlin, Germany.,Krankenhaus Havelhöhe, Kladower Damm 221, 14089, Berlin, Germany
| | - Günther Spahn
- Institut für Integrative Krebstherapie, Hans-Böckler-Str. 7, 55128, Mainz, Germany
| | - Harald Matthes
- Forschungsinstitut Havelhöhe gGmbH, Kladower Damm 221, 14089, Berlin, Germany.,Krankenhaus Havelhöhe, Kladower Damm 221, 14089, Berlin, Germany
| | - Friedemann Schad
- Forschungsinstitut Havelhöhe gGmbH, Kladower Damm 221, 14089, Berlin, Germany. .,Krankenhaus Havelhöhe, Kladower Damm 221, 14089, Berlin, Germany.
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11
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Kagedan DJ, Abraham L, Goyert N, Li Q, Paszat LF, Kiss A, Earle CC, Mittmann N, Coburn NG. Beyond the dollar: Influence of sociodemographic marginalization on surgical resection, adjuvant therapy, and survival in patients with pancreatic cancer. Cancer 2016; 122:3175-3182. [DOI: 10.1002/cncr.30148] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 05/02/2016] [Accepted: 05/18/2016] [Indexed: 01/06/2023]
Affiliation(s)
- Daniel J. Kagedan
- Division of General Surgery, Department of Surgery; University of Toronto; Toronto Ontario Canada
| | - Liza Abraham
- Faculty of Medicine; University of Toronto; Toronto Ontario Canada
| | - Nik Goyert
- Sunnybrook Health Sciences Centre; Toronto Ontario Canada
| | - Qing Li
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Lawrence F. Paszat
- Faculty of Medicine; University of Toronto; Toronto Ontario Canada
- Sunnybrook Health Sciences Centre; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Alexander Kiss
- Sunnybrook Health Sciences Centre; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
| | - Craig C. Earle
- Faculty of Medicine; University of Toronto; Toronto Ontario Canada
- Sunnybrook Health Sciences Centre; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
| | - Nicole Mittmann
- Health Outcomes and PharmacoEconomic (HOPE) Research Centre; Sunnybrook Research Institute; Toronto Ontario Canada
| | - Natalie G. Coburn
- Division of General Surgery, Department of Surgery; University of Toronto; Toronto Ontario Canada
- Sunnybrook Health Sciences Centre; Toronto Ontario Canada
- Institute for Clinical Evaluative Sciences; Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation; University of Toronto; Toronto Ontario Canada
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12
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Burmeister EA, Waterhouse M, Jordan SJ, O'Connell DL, Merrett ND, Goldstein D, Wyld D, Beesley V, Gooden H, Janda M, Neale RE. Determinants of survival and attempted resection in patients with non-metastatic pancreatic cancer: An Australian population-based study. Pancreatology 2016; 16:873-81. [PMID: 27374480 DOI: 10.1016/j.pan.2016.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/21/2016] [Accepted: 06/21/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are indications that pancreatic cancer survival may differ according to sociodemographic factors, such as residential location. This may be due to differential access to curative resection. Understanding factors associated with the decision to offer a resection might enable strategies to increase the proportion of patients undergoing potentially curative surgery. METHODS Data were extracted from medical records and cancer registries for patients diagnosed with pancreatic cancer between July 2009 and June 2011, living in one of two Australian states. Among patients clinically staged with non-metastatic disease we examined factors associated with survival using Cox proportional hazards models. To investigate survival differences we examined determinants of: 1) attempted surgical resection overall; 2) whether patients with locally advanced disease were classified as having resectable disease; and 3) attempted resection among those considered resectable. RESULTS 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. CONCLUSIONS 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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Affiliation(s)
- E A Burmeister
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia; The University of Queensland, Brisbane, Queensland, Australia.
| | - M Waterhouse
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - S J Jordan
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - D L O'Connell
- Cancer Council NSW, Sydney, Australia; University of Newcastle, NSW, Australia; University of Sydney, NSW, Australia
| | - N D Merrett
- Western Sydney University, NSW, Australia; Bankstown Hospital, NSW, Australia
| | - D Goldstein
- University of New South Wales, NSW, Australia; Prince of Wales Hospital, NSW, Australia
| | - D Wyld
- The University of Queensland, Brisbane, Queensland, Australia; Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - V Beesley
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - H Gooden
- University of Sydney, NSW, Australia
| | - M Janda
- Queensland University of Technology, Brisbane, Australia
| | - R E Neale
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
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13
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Caso R, Miller G. Role of tumor associated macrophages in regulating pancreatic cancer progression. World J Immunol 2016; 6:9-18. [DOI: 10.5411/wji.v6.i1.9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/24/2015] [Accepted: 01/04/2016] [Indexed: 02/05/2023] Open
Abstract
Pancreatic cancer has an overall 5-year survival rate of less than 5%. Unfortunately, patient survival has not substantially improved in the last couple of decades despite advances in treatment modalities that have been successful in other cancer types. The poor response of pancreatic cancer to therapy is a major obstacle faced by clinicians. Increasing attention is being paid to how tumor cells and non-tumor cells influence each other in the pancreatic tumor microenvironment. Tumor-associated macrophages (TAMs) are a highlight in this field because of their vast presence in the tumor microenvironment. TAMs promote angiogenesis, metastasis, and suppress the anti-tumor immune response. Here we review the current understanding of the role of TAMs in regulating the progression of pancreatic cancer.
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14
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Abraham A, Al-Refaie WB, Parsons HM, Dudeja V, Vickers SM, Habermann EB. Disparities in pancreas cancer care. Ann Surg Oncol 2013; 20:2078-87. [PMID: 23579872 DOI: 10.1245/s10434-012-2843-z] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Indexed: 12/31/2022]
Abstract
BACKGROUND Prior literature shows demographic differences in patients surgically treated for pancreatic cancer (PC). We hypothesized that socioeconomic disparities also exist across all aspects of PC care, in both surgically and non-surgically treated patients. METHODS We identified a cohort of patients with American Joint Committee on Cancer (AJCC) stage I-IV PC in the 1994-2008 California Cancer Registry. We used multivariate logistic regression to examine the impact of race, sex, and insurance status on (1) resectability (absence of advanced disease), (2) receipt of surgery, and (3) receipt of adjuvant/primary chemotherapy (+/- radiotherapy). RESULTS Among 20,312 patients, 7,585 (37 %) had resectable disease; 40 % who met this definition received surgery (N = 3,153). On multivariate analysis, males were less likely to present with resectable tumors [odds ratio (OR) 0.91, 95 % confidence interval (CI) 0.85-0.96], but sex did not otherwise predict treatment. Black patients were as likely as White patients to show resectable disease, yet were less likely to receive surgery (OR 0.66, 95 % CI 0.54-0.80), and adjuvant (OR 0.75, 95 % CI 0.58-0.98) or primary chemotherapy +/- radiation. Compared with Medicaid recipients, non-Medicare/Medicaid enrollees were more likely to receive surgery (OR 1.7, 95 % CI 1.4-2.2), and the uninsured were less likely to receive adjuvant therapy (OR 0.54, 95 % CI 0.30-0.98). CONCLUSIONS Though Black patients appear to present with comparable rates of resectability, they receive care that deviates from current guidelines. Insurance status is associated with inferior profiles of resectability and treatments. Future policies and research should identify effective strategies to ensure receipt of standard care.
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Affiliation(s)
- Anasooya Abraham
- The Minnesota Surgical Outcomes Workgroup, University of Minnesota Surgical Outcomes Research Center, University of Minnesota, Minneapolis, MN, USA
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15
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Abstract
BACKGROUND Optimal treatment choice for patients with esophageal cancer (EC) is complex and largely determined by tumor characteristics, comorbidity, and age. GOALS This study describes the role of patient characteristics, among which is socioeconomic status (SES), in EC treatment. STUDY Patients diagnosed with primary EC between 1990 and 2008 in the southern part of the Netherlands were identified using the Eindhoven Cancer Registry. Multivariable logistic and proportional hazard regression analyses were used to identify determinants of treatment and survival. RESULTS We included 1914 patients, and 37% of them underwent intentionally curative treatment. Low-SES patients were diagnosed at older age (16% vs. 9%, age more than or equal to 80) and with more advanced tumor stages (13% vs. 10%, stage T4) than high-SES patients. Age less than 60 compared with 70 to 79 years [adjusted odds ratio, 4.51; 95% confidence interval (CI), 2.98-6.84] and high SES compared with low SES (adjusted odds ratio 1.59; 95% CI, 1.07-2.37) were independent predictors for curative treatment. Probability of death for high-SES patients undergoing palliative treatment was decreased compared with low-SES patients (hazard ratio, 0.84; 95% CI, 0.71-0.99). CONCLUSIONS SES is an important factor in treatment choice of EC. As health care is equally accessible to the whole population in the Netherlands, this suggests that both patient-related and physician-related factors are involved in this phenomenon.
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16
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Ochi A, Graffeo CS, Zambirinis CP, Rehman A, Hackman M, Fallon N, Barilla RM, Henning JR, Jamal M, Rao R, Greco S, Deutsch M, Medina-Zea MV, Saeed UB, Ego-Osuala MO, Hajdu C, Miller G. Toll-like receptor 7 regulates pancreatic carcinogenesis in mice and humans. J Clin Invest 2012; 122:4118-29. [PMID: 23023703 PMCID: PMC3484447 DOI: 10.1172/jci63606] [Citation(s) in RCA: 156] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 08/02/2012] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma is an aggressive cancer that interacts with stromal cells to produce a highly inflammatory tumor microenvironment that promotes tumor growth and invasiveness. The precise interplay between tumor and stroma remains poorly understood. TLRs mediate interactions between environmental stimuli and innate immunity and trigger proinflammatory signaling cascades. Our finding that TLR7 expression is upregulated in both epithelial and stromal compartments in human and murine pancreatic cancer led us to postulate that carcinogenesis is dependent on TLR7 signaling. In a mouse model of pancreatic cancer, TLR7 ligation vigorously accelerated tumor progression and induced loss of expression of PTEN, p16, and cyclin D1 and upregulation of p21, p27, p53, c-Myc, SHPTP1, TGF-β, PPARγ, and cyclin B1. Furthermore, TLR7 ligation induced STAT3 activation and interfaced with Notch as well as canonical NF-κB and MAP kinase pathways, but downregulated expression of Notch target genes. Moreover, blockade of TLR7 protected against carcinogenesis. Since pancreatic tumorigenesis requires stromal expansion, we proposed that TLR7 ligation modulates pancreatic cancer by driving stromal inflammation. Accordingly, we found that mice lacking TLR7 exclusively within their inflammatory cells were protected from neoplasia. These data suggest that targeting TLR7 holds promise for treatment of human pancreatic cancer.
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MESH Headings
- Animals
- Carcinoma, Pancreatic Ductal/genetics
- Carcinoma, Pancreatic Ductal/immunology
- Carcinoma, Pancreatic Ductal/metabolism
- Carcinoma, Pancreatic Ductal/pathology
- Cell Transformation, Neoplastic/genetics
- Cell Transformation, Neoplastic/immunology
- Cell Transformation, Neoplastic/metabolism
- Cell Transformation, Neoplastic/pathology
- Gene Expression Regulation, Neoplastic/genetics
- Gene Expression Regulation, Neoplastic/immunology
- Humans
- Immunity, Innate/genetics
- Inflammation/genetics
- Inflammation/immunology
- Inflammation/metabolism
- Inflammation/pathology
- MAP Kinase Signaling System/genetics
- MAP Kinase Signaling System/immunology
- Membrane Glycoproteins/genetics
- Membrane Glycoproteins/immunology
- Membrane Glycoproteins/metabolism
- Mice
- Mice, Mutant Strains
- Neoplasm Proteins/genetics
- Neoplasm Proteins/immunology
- Neoplasm Proteins/metabolism
- Pancreatic Neoplasms/genetics
- Pancreatic Neoplasms/immunology
- Pancreatic Neoplasms/metabolism
- Pancreatic Neoplasms/pathology
- Toll-Like Receptor 7/genetics
- Toll-Like Receptor 7/immunology
- Toll-Like Receptor 7/metabolism
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Affiliation(s)
- Atsuo Ochi
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
| | - Christopher S. Graffeo
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
| | - Constantinos P. Zambirinis
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
| | - Adeel Rehman
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
| | - Michael Hackman
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
| | - Nina Fallon
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
| | - Rocky M. Barilla
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
| | - Justin R. Henning
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
| | - Mohsin Jamal
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
| | - Raghavendra Rao
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
| | - Stephanie Greco
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
| | - Michael Deutsch
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
| | - Marco V. Medina-Zea
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
| | - Usama Bin Saeed
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
| | - Melvin O. Ego-Osuala
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
| | - Cristina Hajdu
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
| | - George Miller
- Department of Surgery,
Department of Cell Biology, and
Department of Pathology, S. Arthur Localio Laboratory, New York University School of Medicine, New York, New York, USA
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