HPB cancers in older patients | inclusion of older/senior patients in clinical trials

Surgical management for elderly patients with pancreatic cancer

Pancreatic cancer, one of the diseases of the elderly, has dismal prognosis, demanding major surgery with high risk and life quality problems, especially in the elderly. Therefore, treatment selection, whether or not to undergo surgery, preoperative risk assessment, and perioperative management of the elderly are becoming critical issues. Although the elderly are expected to have higher morbidity and mortality and lower long-term survival outcomes, surgery is becoming safer over time. Appropriate surgical indication selection, patient-centered decision-making, adequate prehabilitation and postoperative geriatric care are expected to improve surgical outcomes in the elderly. Surgeons must have the concept of geriatric care, and efforts based on institutional systems and academic societies are required. If well selected and prepared, the same surgical principle as non-elderly patients can be applied to elderly patients. In this paper, the surgical treatment of elderly patients with pancreatic cancer is reviewed.

Use of the Rockwood Clinical Frailty Scale in patients with advanced hepatopancreaticobiliary malignancies

BACKGROUND

Co-existing frailty in older patients with hepatopancreaticobiliary (HPB) malignancies is common. This study assessed the relationship between the Rockwood Clinical Frailty scale (CFS) and systemic anti-cancer therapy dose intensity (SACT-DI) and overall survival (OS) in patients with advanced HPB malignancies.

RESEARCH DESIGN AND METHODS

CFS was assessed prospectively for consecutive patients with newly diagnosed advanced HPB malignancy (The Christie; Sep-2019 to June-2020). Mann-Whitney U test assessed association between CFS, ECOG Performance Status (ECOG PS), and SACT-DI and Spearman's rank assessed the association between ECOG PS, age, and frailty. Survival analysis was performed using Kaplan-Meier and Cox regression.

RESULTS

Two hundred patients met inclusion criteria. SACT-DI was higher in Group-1 (not frail) (CFS 1-3)(median = 61%) than Group-2 (vulnerable/mildly frail) (CFS 4-5)(median = 25.1%), p < 0.001.       Median OS was shorter in frail and pre-frail patients (HR 2.3(95%CI 1.8-2.9),p < 0.001. On multivariable analysis, both CFS (HR 1.5-(95%CI 1.2-1.9), p = 0.002) and ECOG PS (HR 1.9 (95%CI 1.6-2.3), p < 0.001) were independent prognostic factors for OS.

CONCLUSION

Frailty assessments, in addition to ECOG PS, may identify patients that will benefit from systemic therapy and are both independent prognostic factors for OS.

Access Denied: Inequities in Clinical Trial Enrollment for Pancreatic Cancer

BACKGROUND

The influence of social determinants of health (SDH) on participation in clinical trials for pancreatic cancer is not well understood. In this study, we describe trends and identify disparities in pancreatic cancer clinical trial enrollment.

PATIENTS AND METHODS

This is a retrospective study of stage I-IV pancreatic cancer patients in the 2004-2016 National Cancer Database. Cohort was stratified into those enrolled in clinical trials during first course of treatment versus not enrolled. Bivariate analysis and logistic regression were used to understand the relationship between SDH and clinical trial participation.

RESULTS

A total of 1127 patients (0.4%) enrolled in clinical trials versus 301,340 (99.6%) did not enroll. Enrollment increased over the study period (p < 0.001), but not for Black patients or patients on Medicaid. The majority enrolled had metastatic disease (65.8%). On multivariate analysis, in addition to year of diagnosis (p < 0.001), stage (p < 0.001), and Charlson score (p < 0.001), increasing age [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.96-0.97], non-white race (OR 0.54, CI 0.44-0.66), living in the South (OR 0.42, CI 0.35-0.51), and Medicaid, lack of insurance, or unknown insurance (0.41, CI 0.31-0.53) were predictors of lack of participation. Conversely, treatment at an academic center (OR 6.36, CI 5.4-7.4) and higher neighborhood education predicted enrollment (OR 2.0, CI 1.55-2.67 for < 7% with no high school degree versus > 21%).

DISCUSSION

Age, race, insurance, and geography are barriers to clinical trial enrollment for pancreatic cancer patients. While overall enrollment increased, Black patients and patients on Medicaid remain underrepresented. After adjusting for cancer-specific factors, SDH are still associated with clinical trial enrollment, suggesting need for targeted interventions.

Identification of a peptide that crosses the blood-cerebrospinal fluid barrier by phage display technology

Treatments of brain diseases are heavily limited by the existence of the blood-brain barrier (BBB), which precludes efficient drug delivery to the brain. Compared with the BBB, drugs may have a better likelihood of reaching the brain via the cerebrospinal fluid (CSF) because of the lack of a barrier between the CSF and the brain. In this study, phage display technology was effectively applied to screen novel peptides as targeting motifs to transport drugs across the blood-cerebrospinal fluid barrier (BCSFB). We applied a phage seven-mer cyclic peptide library (Ph.D.-C7C™) intravenously to rats and later recovered phages from the CSF. After several rounds of screening, the candidate phages that could cross the BCSFB were enriched. Several bacteriophage clones from the final round were randomly selected and sequenced. A peptide sequence denoted as PMK, which was demonstrated to be able to cross the BCSFB via in vivo optical imaging analysis, could be used in the future for the construction of targeted drug delivery systems.