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Guillot Morales M, Visa L, Brozos Vázquez E, Feliu Batlle J, Khosravi Shahi P, Laquente Sáez B, de San Vicente Hernández BL, Macarulla T, Gironés Sarrió R. Update on the management of older patients with pancreatic adenocarcinoma: a perspective from medical oncology. Clin Transl Oncol 2024; 26:1570-1583. [PMID: 38329611 DOI: 10.1007/s12094-024-03386-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/04/2024] [Indexed: 02/09/2024]
Abstract
In the context of pancreatic cancer, surgical intervention is typically recommended for localized tumours, whereas chemotherapy is the preferred approach in the advanced and/or metastatic setting. However, pancreatic cancer is closely linked to ageing, with an average diagnosis at 72 years. Paradoxically, despite its increased occurrence among older individuals, this population is often underrepresented in clinical studies, complicating the decision-making process. Age alone should not determine the therapeutic strategy but, given the high comorbidity and mortality of this disease, a comprehensive geriatric assessment (CGA) is necessary to define the best treatment, prevent toxicity, and optimize older patient care. In this review, a group of experts from the Oncogeriatrics Section of the Spanish Society of Medical Oncology (Sociedad Española de Oncología Médica, SEOM), the Spanish Cooperative Group for the Treatment of Digestive Tumours (Grupo Español de Tratamiento de los Tumores Digestivos, TTD), and the Multidisciplinary Spanish Group of Digestive Cancer (Grupo Español Multidisciplinar en Cáncer Digestivo, GEMCAD) have assessed the available scientific evidence and propose a series of recommendations on the management and treatment of the older population with pancreatic cancer.
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Affiliation(s)
- Mónica Guillot Morales
- Spanish Society of Medical Oncology (SEOM) Oncogeriatrics Section, Department of Medical Oncology, Son Espases University Hospital, Carretera de Valldemossa, 79, Islas Baleares, 07120, Palma de Mallorca, Spain.
| | - Laura Visa
- Spanish Society of Medical Oncology (SEOM) Oncogeriatrics Section, Mar-Parc de Salut Mar Hospital, Barcelona, Spain
| | - Elena Brozos Vázquez
- Spanish Society of Medical Oncology (SEOM) Oncogeriatrics Section, A Coruña University Clinical Hospital, A Coruña, Spain
| | - Jaime Feliu Batlle
- Multidisciplinary Spanish Group of Digestive Cancer (GEMCAD), La Paz University Hospital, IDIPAZ, CIBERONC, Cathedra UAM-AMGEN, Madrid, Spain
| | - Parham Khosravi Shahi
- Spanish Society of Medical Oncology (SEOM) Oncogeriatrics Section, Gregorio Marañón University Hospital, Madrid, Spain
| | - Berta Laquente Sáez
- Spanish Society of Medical Oncology (SEOM) Oncogeriatrics Section, ICO L´Hospitalet-IDIBELL, Barcelona, Spain
| | | | - Teresa Macarulla
- Spanish Cooperative Group for the Treatment of Digestive Tumours (TTD), Hebron University Hospital, Vall d, Barcelona, Spain
| | - Regina Gironés Sarrió
- Spanish Society of Medical Oncology (SEOM), Polytechnic la Fe University Hospital, Valencia, Spain
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Puleo A, Malla M, Boone BA. Defining the Optimal Duration of Neoadjuvant Therapy for Pancreatic Ductal Adenocarcinoma: Time for a Personalized Approach? Pancreas 2022; 51:1083-1091. [PMID: 37078929 PMCID: PMC10144367 DOI: 10.1097/mpa.0000000000002147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 11/03/2022] [Indexed: 04/21/2023]
Abstract
ABSTRACT Despite recent advances, pancreatic ductal adenocarcinoma (PDAC) continues to be associated with dismal outcomes, with a cure evading most patients. While historic treatment for PDAC has been surgical resection followed by 6 months of adjuvant therapy, there has been a recent shift toward neoadjuvant treatment (NAT). Several considerations support this approach, including the characteristic early systemic spread of PDAC, and the morbidity often surrounding pancreatic resection, which can delay recovery and preclude patients from starting adjuvant treatment. The addition of NAT has been suggested to improve margin-negative resection rates, decrease lymph node positivity, and potentially translate to improved survival. Conversely, complications and disease progression can occur during preoperative treatment, potentially eliminating the chance of curative resection. As NAT utilization has increased, treatment durations have been found to vary widely between institutions with an optimal duration remaining undefined. In this review, we assess the existing literature on NAT for PDAC, reviewing treatment durations reported across retrospective case series and prospective clinical trials to establish currently used approaches and seek the optimal duration. We also analyze markers of treatment response and review the potential for personalized approaches that may help clarify this important treatment question and move NAT toward a more standardized approach.
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Affiliation(s)
- Amanda Puleo
- From the Division of Surgical Oncology, Department of Surgery
| | - Midhun Malla
- Section of Hematology/Oncology, Department of Medicine
| | - Brian A. Boone
- From the Division of Surgical Oncology, Department of Surgery
- Department of Microbiology, Immunology and Cell Biology, West Virginia University, Morgantown, WV
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Novel Considerations in Surgical Management of Individuals with Pancreatic Adenocarcinoma. Hematol Oncol Clin North Am 2022; 36:979-994. [DOI: 10.1016/j.hoc.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Rieser CJ, Narayanan S, Bahary N, Bartlett DL, Lee KK, Paniccia A, Smith K, Zureikat AH. Optimal management of patients with operable pancreatic head cancer: A Markov decision analysis. J Surg Oncol 2021; 124:801-809. [PMID: 34231222 DOI: 10.1002/jso.26589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/11/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Neoadjuvant therapy (NAT) is an emerging strategy for operable pancreatic ductal adenocarcinoma (PDAC). While NAT increases multimodal therapy completion, it risks functional decline and treatment dropout. We used decision analysis to determine optimal management of localized PDAC and consider risks faced by elderly patients. METHODS A Markov cohort decision analysis model evaluated treatment options for a 60-year-old patient with resectable PDAC: (1) upfront pancreaticoduodenectomy or (2) NAT. One-way and probabilistic sensitivity analyses were performed. A subanalysis considered the scenario of a 75-year-old patient. RESULTS For the base case, NAT offered an incremental survival gain of 4.6 months compared with SF (overall survival: 26.3 vs. 21.7 months). In one-way sensitivity analyses, findings were sensitive to recurrence-free survival for NAT patients undergoing adjuvant, probability of completing NAT, and probability of being resectable at exploration after NAT. On probabilistic analysis, NAT was favored in a majority of trials (97%) with a median survival benefit of 5.1 months. In altering the base case for the 75-year-old scenario, NAT had a survival benefit of 3.8 months. CONCLUSIONS This analysis demonstrates a significant benefit to NAT in patients with localized PDAC. This benefit persists even in the elderly cohort.
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Affiliation(s)
- Caroline J Rieser
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sowmya Narayanan
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nathan Bahary
- Department of Medical Oncology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David L Bartlett
- AHN Cancer Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Kenneth K Lee
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alessandro Paniccia
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kenneth Smith
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Ward EP, Evans DB, Tsai S. Ten-year experience in optimizing neoadjuvant therapy for localized pancreatic cancer-Medical college of Wisconsin perspective. J Surg Oncol 2021; 123:1405-1413. [PMID: 33831252 DOI: 10.1002/jso.26395] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/09/2021] [Indexed: 01/06/2023]
Abstract
Treatment of localized pancreatic cancer has also evolved to prioritize preoperative (neoadjuvant) multimodality therapy over a surgery-first approach. Given the complexities of pancreatic cancer staging and the challenge of delivering multiple treatment modalities (chemotherapy, radiation therapy, and surgery), an experienced and highly integrated multidisciplinary team is necessary to achieve the best outcomes. In this review, we will discuss our institutional experience with neoadjuvant therapy, guiding principles for treatment, and outline the landscape for future investigations.
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Affiliation(s)
- Erin P Ward
- Department of Surgery, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Douglas B Evans
- Department of Surgery, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Susan Tsai
- Department of Surgery, LaBahn Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Achieving 'Marginal Gains' to Optimise Outcomes in Resectable Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13071669. [PMID: 33916294 PMCID: PMC8037133 DOI: 10.3390/cancers13071669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 12/21/2022] Open
Abstract
Simple Summary Improving outcomes in pancreatic cancer is achievable through the accumulation of marginal gains. There exists evidence of variation and undertreatment in many areas of the care pathway. By fully realising the existing opportunities, there is the potential for immediate improvements in outcomes and quality of life. Abstract Improving outcomes among patients with resectable pancreatic cancer is one of the greatest challenges of modern medicine. Major improvements in survival will result from the development of novel therapies. However, optimising existing pathways, so that patients realise benefits of already proven treatments, presents a clear opportunity to improve outcomes in the short term. This narrative review will focus on treatments and interventions where there is a clear evidence base to improve outcomes in pancreatic cancer, and where there is also evidence of variation and under-treatment. Avoidance of preoperative biliary drainage, treatment of pancreatic exocrine insufficiency, prehabiliation and enhanced recovery after surgery, reducing perioperative complications, optimising opportunities for elderly patients to receive therapy, optimising adjuvant chemotherapy and regular surveillance after surgery are some of the strategies discussed. Each treatment or pathway change represents an opportunity for marginal gain. Accumulation of marginal gains can result in considerable benefit to patients. Given that these interventions already have evidence base, they can be realised quickly and economically.
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Rieser CJ, Zenati M, Narayanan S, Bahary N, Lee KK, Paniccia A, Bartlett DL, Zureikat AH. Optimal Management of Resectable Pancreatic Head Cancer in the Elderly Patient: Does Neoadjuvant Therapy Offer a Survival Benefit? Ann Surg Oncol 2021; 28:6264-6272. [PMID: 33748894 DOI: 10.1245/s10434-021-09822-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 02/22/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Neoadjuvant therapy (NAT) is a growing strategy for patients with resectable pancreatic ductal adenocarcinoma (PDAC). Elderly patients are at increased risk of treatment withdrawal due to functional decline, and the benefit of NAT in this cohort remains to be studied. OBJECTIVE The objective of this study was to compare outcomes of elderly patients with resectable head PDAC who underwent NAT or a surgery-first (SF) approach. METHODS All patients 75 years of age and older with radiographically resectable (National Comprehensive Cancer Network criteria) PDAC who underwent pancreaticoduodenectomy at a single institution from 2008 to 2017 were analyzed. Baseline characteristics and perioperative outcomes were compared between the SF and NAT cohorts. Recurrence-free survival and overall survival (OS) were analyzed by treatment strategy. RESULTS Overall, 158 patients were identified: SF cohort = 90 (57%) and NAT cohort = 68 (43%). Patients in the SF cohort were older (80 vs. 78 years; p = 0.01) but there were no differences in preoperative comorbidities or frailty indices. SF patients had a trend toward higher rates of major complications (38% vs. 24%; p = 0.06) with higher Comprehensive Complication Index totals (20.9 vs. 20; p = 0.03). There were similar rates of adjuvant therapy. NAT was associated with significantly longer OS (24.6 vs. 17.6 months; p = 0.01) in both the intent-to-treat and resected cohorts. On multivariable analysis (MVA), NAT remained an independent predictor of OS (hazard ratio 0.60; p = 0.02). CONCLUSION NAT is safe and effective for elderly patients with PDAC. This study suggests NAT is associated with fewer complications after surgery, equal rates of adjuvant therapy receipt, and increased OS over a surgery-first approach.
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Affiliation(s)
- Caroline J Rieser
- Division of GI Surgical Oncology, Department of Surgery, Pancreatic Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mazen Zenati
- Department of Surgery and Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sowmya Narayanan
- Division of GI Surgical Oncology, Department of Surgery, Pancreatic Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nathan Bahary
- Department of Medical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kenneth K Lee
- Division of GI Surgical Oncology, Department of Surgery, Pancreatic Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alessandro Paniccia
- Division of GI Surgical Oncology, Department of Surgery, Pancreatic Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - David L Bartlett
- AHN Cancer Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of GI Surgical Oncology, Department of Surgery, Pancreatic Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA.
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Sonohara F, Yamada S, Kurimoto K, Inokawa Y, Takami H, Hayashi M, Shimizu D, Hattori N, Kanda M, Tanaka C, Nakayama G, Koike M, Fujii T, Kodera Y. Age-Related Differences in the Prognosis of Pancreatic Cancer According to Perioperative Systemic Therapy. Pancreas 2021; 50:37-46. [PMID: 33370021 DOI: 10.1097/mpa.0000000000001712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES In this study, we retrospectively assessed the feasibility and prognostic efficacy of perioperative chemo(radio)therapy for pancreatic cancer (PC) patients according to age. METHODS A total of 556 consecutive patients who underwent curative-intent pancreatectomy for PC between 2000 and 2018 were enrolled. RESULTS Of the 556 patients who underwent resection, 95 (17%) were elderly (age, ≥75 years). Postoperative complications did not significantly differ between the 2 age groups, and postoperative prognoses were also similar (recurrence-free survival [RFS], P = 0.68; overall survival [OS], P = 0.28). In this cohort, 103 patients (19%) underwent preoperative chemo(radio)therapy, and 417 (77%) underwent postoperative chemotherapy. Perioperative therapy was found to be significantly beneficial for younger patients (preoperative therapy: RFS, P = 0.006; OS, P < 0.001; postoperative therapy: RFS, P < 0.001; OS, P < 0.001). Conversely, no significant survival benefit of perioperative therapy was found for the elderly (preoperative therapy: RFS, P = 0.28; OS, P = 0.44; postoperative therapy: RFS, P = 0.77; OS, P = 0.08). CONCLUSIONS This study demonstrated that, although perioperative therapy is feasible for selected elderly patients with PC, this approach might not be as beneficial as it is for younger PC patients.
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Affiliation(s)
- Fuminori Sonohara
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Suguru Yamada
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Keisuke Kurimoto
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Yoshikuni Inokawa
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Hideki Takami
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Masamichi Hayashi
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Dai Shimizu
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Norifumi Hattori
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Mitsuro Kanda
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Chie Tanaka
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Goro Nakayama
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Masahiko Koike
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Yasuhiro Kodera
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
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Laura A, Anna C, Cinquepalmi M, Giovanni M, Sole MM, Nava AK, Niccolò P, Giuseppe N, Stefano V, Paolo A, Francesco D, Giovanni R. Is Complete Pathologic Response in Pancreatic Cancer Overestimated? A Systematic Review of Prospective Studies. J Gastrointest Surg 2020; 24:2336-2348. [PMID: 32583324 DOI: 10.1007/s11605-020-04697-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 06/11/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND In literature, percentages of pathologic complete response (pCR) in patients presenting with resectable (RES), borderline resectable (BLR) or locally advanced (LA) pancreatic cancer (PaC) after neoadjuvant treatment (NADT) are variable, ranging 0-33%. Those data come mostly from retrospective reviews of single centres. The objective of this systematic review is to assess the incidence of pCR. METHODS Following the criteria of the PRISMA statement, a literature search was conducted looking for prospective papers focusing on neoadjuvant treatment in PaC. Retrospective papers, other than ductal carcinoma histologies and trials including metastatic patients, were excluded from the present review. Data extraction was carried out by 3 independent investigators. Meta-analysis was performed with ProMeta3 Software (Internovi, 2015). PROSPERO registry: CRD42018095641. RESULTS The literature search of Embase, Cochrane and Medline with the terms "neoadjuvant OR preoperative", "pancreatic OR pancreas" and "cancer OR adenocarcinoma OR tumor" led to the identification of 3128 papers. We restricted the search to humans, last 10 years and English language articles resulting in 1158 eligible articles to review. Extended paper revision led to the inclusion of 27 papers. Complete pathologic response ranged 0-11.11%, at the meta-analysis 4% (95% CI 3-5%), in prospective studies 0-9.09% and in prospective databases 1.63-11.11%. CONCLUSIONS Pathologic complete response in pancreatic cancer is actually infrequent: high-quality studies provide a more reliable picture of neoadjuvant effects, high rates of pCR are reported in selected retrospective studies but it is overestimated.
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Affiliation(s)
- Antolino Laura
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Crovetto Anna
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Matteo Cinquepalmi
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy.
| | - Moschetta Giovanni
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Mattei Maria Sole
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Andrea Kazemi Nava
- Hepatopancreaticobiliary Group, Saint Vincent's University Hospital, Dublin, Ireland
| | - Petrucciani Niccolò
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Nigri Giuseppe
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Valabrega Stefano
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Aurello Paolo
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - D'Angelo Francesco
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
| | - Ramacciato Giovanni
- General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottorassa 1035, 00168, Rome, Italy
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Pandé R, Roberts KJ. Determining Optimal Routes to Surgery for Borderline Resectable Venous Pancreatic Cancer-Where Is the Least Harm and Most Benefit? Front Oncol 2019; 9:1060. [PMID: 31681596 PMCID: PMC6811510 DOI: 10.3389/fonc.2019.01060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 09/30/2019] [Indexed: 11/13/2022] Open
Abstract
Surgery among patients with borderline resectable pancreatic cancer (BRPC) and venous disease has emerged as a viable strategy to achieve curative treatment. By definition, these patients are at increased risk of a positive resection margin, however, controversy exists with regards to necessity of radical surgery and optimum pathways with no consensus on definitive treatment. A surgery first approach is possible though outcomes vary but patients can have an efficient pathway to surgery, particularly if biliary drainage is avoided which limits overall complications. Neoadjuvant therapy (NAT) is emerging as a widely used strategy to improve oncological outcomes, including resection margin status. However, some patients progress on NAT whilst others suffer major complications whilst elderly patients are unlikely to be offered effective NAT limiting the widespread applicability of this therapy. In this article an overview of the entire pathway is presented along with assimilation of current best evidence to determine optimal routes to surgery for BRPC with venous involvement.
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Affiliation(s)
- Rupaly Pandé
- Department of HPB Surgery and Liver Transplant, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Keith J Roberts
- Department of HPB Surgery and Liver Transplant, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Department of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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Jariwalla NR, Khan AH, Dua K, Christians KK, Clarke CN, Aldakkak M, George B, Tutton S, Rilling W, Erickson B, Evans DB, Tsai S. Management of Acute Cholecystitis during Neoadjuvant Therapy in Patients with Pancreatic Adenocarcinoma. Ann Surg Oncol 2019; 26:4515-4521. [DOI: 10.1245/s10434-019-07906-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Indexed: 01/27/2023]
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Abstract
The majority of patients with localized pancreatic cancer who undergo surgery with or without adjuvant therapy will develop metastatic disease, suggesting that surgery alone is not sufficient for cure and micrometastases are present at the time of diagnosis even when not clinically apparent. As such, the field is rapidly moving to consensus on treatment sequencing, which emphasizes the early delivery of systemic therapy and the application of surgery to the population of patients most likely to receive clinical benefit from such large operations-namely, those with stable or responding disease following systemic therapy and often chemoradiation. There remains incomplete consensus about the definition of what is operable (both tumor anatomy and patient age/comorbidities) and whether the operation should be performed in a high-volume center by more experienced surgeons. In this article, we try to provide a comprehensive description of when surgery should be performed and what constitutes an operable tumor. Such information is critically important for the optimal delivery of stage-specific therapy and to allow physicians to provide accurate expectations to all patients for treatment outcome. The complex issues of where and by whom such large operations should be performed is beyond the scope of this review.
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Affiliation(s)
- Douglas B Evans
- From the Pancreatic Cancer Program and Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
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Outcomes after neoadjuvant treatment with gemcitabine and erlotinib followed by gemcitabine-erlotinib and radiotherapy for resectable pancreatic cancer (GEMCAD 10-03 trial). Cancer Chemother Pharmacol 2018; 82:935-943. [PMID: 30225601 DOI: 10.1007/s00280-018-3682-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/27/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neoadjuvant therapy (NAT) for pancreatic adenocarcinoma (PDAC) patients has shown promising results in non-randomized trials. This is a multi-institutional phase II trial of NAT in resectable PDAC patients. METHODS Patients with confirmed resectable PDAC after agreement by two expert radiologists were eligible. Patients received three cycles of GEM (1000 mg/m2/week) plus daily erlotinib (ERL) (100 mg/day). After re-staging, patients without progressive disease underwent 5 weeks of therapy with GEM (300 mg/m2/week), ERL 100 mg/day and concomitant radiotherapy (45 Gy). Efficacy was assessed using tumor regression grade (TRG) and resection margin status. Using a single-arm Simon's design, considering the therapy not useful if R0 < 40% and useful if the R0 > 70% (alpha 5%, beta 10%), 24 patients needed to be recruited. This trial was registered at ClinicalTrials.gov, number NCT01389440. RESULTS Twenty-five patients were enrolled. Adverse effects of NAT were mainly mild gastrointestinal disorders. Resectability rate was 76%, with a R0 rate of 63.1% among the resected patients. Median overall survival (OS) and disease-free survival (DFS) were 23.8 (95% CI 11.4-36.2) and 12.8 months (95% CI 8.6-17.1), respectively. R0 resection patients had better median OS, compared with patients with R1 resection or not resected (65.5 months vs. 15.5 months, p = 0.01). N0 rate among the resected patients was 63.1%, and showed a longer median OS (65.5 vs. 15.2 months, p = 0.009). CONCLUSION The results of this study confirm promising oncologic results with NAT for patients with resectable PDAC. Therefore, the present trial supports the development of phase II randomized trials comparing NAT vs. upfront surgery in resectable pancreatic cancer.
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Garcia G, Odaimi M. Systemic Combination Chemotherapy in Elderly Pancreatic Cancer: a Review. J Gastrointest Cancer 2018; 48:121-128. [PMID: 28303435 DOI: 10.1007/s12029-017-9930-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE In recent years, significant progress in survival has been achieved using systemic combination chemotherapy in patients with pancreatic cancer. However, the elderly are largely underrepresented in clinical trials, and gains made from these may not necessarily apply to this important subgroup of patients. We review the currently available data regarding contemporary combination chemotherapy regimens, including FOLFIRINOX, gemcitabine plus nab-paclitaxel, nanoliposomal irinotecan plus 5-fluorouracil and leucovorin, and gemcitabine plus capecitabine, in elderly pancreatic cancer patients. METHODS We performed a search of Pubmed using the terms "pancreatic cancer", "elderly", "FOLFIRINOX", "gemcitabine", "nab-paclitaxel", "capecitabine", and "nanoliposomal irinotecan" and included articles investigating the use of combination chemotherapy in the elderly with pancreatic adenocarcinoma. Relevant abstracts from American Society of Clinical Oncology and European Society of Medical Oncology meetings were included. RESULTS Current clinical evidence and experience suggests that relatively fit elderly pancreatic cancer patients may derive significant benefit from contemporary combination chemotherapy regimens. Strategies to improve tolerability without decreasing efficacy include dose reduction, schedule modification, and growth factor support. Phase III clinical trials are ongoing to determine the optimal use of combination chemotherapy regimens in elderly patients with pancreatic cancer. CONCLUSION Identifying elderly patients who will benefit from combination chemotherapy for pancreatic cancer remains a significant clinical challenge. An assessment of medical comorbidities and functional status plays a key role in determining fitness for intensive chemotherapeutic regimens in this important subset of patients.
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Affiliation(s)
- Gwenalyn Garcia
- Division of Hematology/Oncology, Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY, 10305, USA.
| | - Marcel Odaimi
- Division of Hematology/Oncology, Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY, 10305, USA
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15
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Abstract
OPINION STATEMENT Pancreatic cancer surgery is a continuously evolving field. Despite tremendous advances in perioperative outcomes, pancreatic resection is still associated with substantial morbidity, and mortality is not nil. Institutional caseload is a well-established determinant of patient outcomes, and centralization to experienced centers is essential to the safety and oncological appropriateness of the resection. Minimally invasive approaches are increasingly applied for pancreatic resection, even in cancer patients. Nevertheless, the level of evidence in this field remains low. Minimally invasive distal pancreatectomy appears potentially beneficial towards some perioperative outcomes, although its oncological results remain incompletely studied. Data regarding perioperative and oncologic outcomes for minimally invasive pancreaticoduodenectomy (Whipple's resection) is even less mature, but suggest that similar results as the open approach can be achieved in selected, high-volume centers. Conversely, its indiscriminate adoption by inexperienced surgeons and institutions has potential deleterious effects given its steep learning curve. Newer neoadjuvant treatment protocols display enhanced ability to downstage advanced tumors, increasing candidates for potentially curative surgery. Conversely, putative benefits of neoadjuvant treatment in patients with technically resectable tumors have not been reliably demonstrated and its optimal indications remain highly controversial.
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Affiliation(s)
- Laura Maggino
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA.,Unit of General and Pancreatic Surgery, Department of Surgery and Oncology-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Charles M Vollmer
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA.
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16
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Lin R, Han CQ, Wang WJ, Liu J, Qian W, Ding Z, Hou XH. Analysis on survival and prognostic factors in patients with resectable pancreatic adenocarcinoma. ACTA ACUST UNITED AC 2017; 37:612-620. [PMID: 28786050 DOI: 10.1007/s11596-017-1780-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 04/25/2017] [Indexed: 12/17/2022]
Abstract
Survival after pancreatic cancer surgery is extremely unfavorable even after curative resection. Prognostic factors have been explored but remain largely undefined. The present study was to identify the role of clinical and laboratory variables in the prognostic significance of resectable pancreatic adenocarcinoma. A total of 96 patients who underwent curative resection for pancreatic cancer were included. Survival was evaluated based on complete follow-up visits and was associated with potential prognostic factors using the Kaplan-Meier method and Cox proportional hazard model survival analyses. The results showed that prognostic variables significantly reduced survival, including old age, poorly differentiated tumors, elevated tumor markers and positive lymph node metastasis (LNM). Age of older than 60 years (HR=1.83, P=0.04), LNM (HR=2.22, P=0.01), lymph node ratio (0<LNR≤0.2, HR=1.38, P=0.042; LNR>0.2, HR=1.92, P=0.017), initial CA199 (HR=4.80, P=0.004), and CEA level (HR=2.59, P=0.019) were identified as independent prognostic factors by multivariate analysis. It was concluded that LNR may be potent predictor of survival and suggests that surgeons and the pathologists should thoroughly assess lymph nodes prior to surgery.
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Affiliation(s)
- Rong Lin
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Chao-Qun Han
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Wei-Jun Wang
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jun Liu
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Wei Qian
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Zhen Ding
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Xiao-Hua Hou
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
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17
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Abstract
Pancreatic cancer is more common in older adults, who are underrepresented in clinical trials and frequently under treated. Chronological age alone should not deter clinicians from offering treatment to geriatric patients, as they are a heterogeneous population. Geriatric assessment, frailty assessment tools, and toxicity risk scores help clinicians select appropriate patients for therapy. For resectable disease, surgery can be safe but should be done at a high-volume center. Adjuvant therapy is important; though there remains controversy on the role of radiation, chemotherapy is well studied and efficacious. In locally advanced unresectable disease, chemoradiation or chemotherapy alone is an option. Neoadjuvant therapy improves the chances of resectability in borderline resectable disease. Chemotherapy extends survival in metastatic disease, but treatment goals and risk-benefit ratios have to be clarified. Adequate symptom management and supportive care are important. There are now many new treatment strategies and novel therapies for this disease.
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18
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Miller-Ocuin JL, Zenati MS, Ocuin LM, Varley PR, Novak SM, Winters S, Zureikat AH, Zeh HJ, Hogg ME. Failure to Treat: Audit of an Institutional Cancer Registry Database at a Large Comprehensive Cancer Center Reveals Factors Affecting the Treatment of Pancreatic Cancer. Ann Surg Oncol 2017; 24:2387-2396. [DOI: 10.1245/s10434-017-5880-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Indexed: 12/14/2022]
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19
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Neoadjuvant treatment in pancreatic cancer: Evidence-based medicine? A systematic review and meta-analysis. Med Oncol 2017; 34:85. [PMID: 28391577 DOI: 10.1007/s12032-017-0951-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 04/04/2017] [Indexed: 12/21/2022]
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20
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Tsai S, Erickson BA, Dua K, Ritch PS, Tolat P, Evans DB. Evolution of the Management of Resectable Pancreatic Cancer. J Oncol Pract 2016; 12:772-8. [DOI: 10.1200/jop.2016.015818] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
In pancreatic cancer, as with many other solid tumors, a commonly held surgical adage—a chance to cut is a chance to cure—has been promulgated throughout the years. Following such reasoning, surgical extirpation of a localized tumor would prevent tumor dissemination and metastatic tumor progression. However, decades of surgical experience have demonstrated that surgical resection alone provides a limited median survival benefit. Despite the optimization of surgical technique and perioperative management over the past three decades, little progress has been made to improve the limited survival of patients with localized pancreatic cancer who receive surgery. In this article, we discuss the rationale for a novel management strategy for patients with resectable pancreatic cancer, which may improve patient selection and the delivery of multimodality therapy.
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Affiliation(s)
- Susan Tsai
- Medical College of Wisconsin, Milwaukee, WI
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21
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Xia BT, Habib DA, Dhar VK, Levinsky NC, Kim Y, Hanseman DJ, Sutton JM, Wilson GC, Smith M, Choe KA, Sussman JJ, Ahmad SA, Abbott DE. Early Recurrence and Omission of Adjuvant Therapy after Pancreaticoduodenectomy Argue against a Surgery-First Approach. Ann Surg Oncol 2016; 23:4156-4164. [PMID: 27459987 DOI: 10.1245/s10434-016-5457-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Sequencing therapy for patients with periampullary malignancy is controversial. Clinical trial data report high rates of adjuvant therapy completion, though contemporary, real-world rates remain incomplete. We sought to identify patients who failed to receive adjuvant therapy and those at risk for early recurrence (ER) who might benefit most from neoadjuvant therapy (NT). METHODS We retrospectively reviewed medical records of 201 patients who underwent pancreaticoduodenectomy for periampullary malignancies between 1999 and 2015; patients receiving NT were excluded. Univariate and multivariate analyses were performed to identify predictors of failure to receive adjuvant therapy and ER (within 6 months) as the primary end points. RESULTS The median age at the time of surgery was 65.5 years (interquartile range 57-74 years). The majority of tumors were pancreatic ductal adenocarcinoma (76.6 %), and 71.6 % of patients received adjuvant therapy after resection. Univariate predictors of failure to undergo adjuvant therapy were advanced age, age-adjusted Charlson comorbidity index, operative transfusion, reoperation, length of stay, and 30- to 90-day readmissions (all p < 0.05). Advanced age, specifically among patients >70 years, persisted as a significant preoperative predictor on multivariate analysis (p < 0.01). Patients who failed to receive adjuvant therapy and/or developed ER had significantly worse overall survival rates compared to all other patients (27.8 vs. 9.7 months; p < 0.01). CONCLUSIONS Approximately one-third of surgery-first patients undergoing pancreaticoduodenectomy at our institution did not receive adjuvant therapy and/or demonstrated ER. This substantial subset of patients may particularly benefit from NT, ensuring completion of multimodal therapy and/or avoiding futile surgical intervention.
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Affiliation(s)
- Brent T Xia
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - David A Habib
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Vikrom K Dhar
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Nick C Levinsky
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Young Kim
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Dennis J Hanseman
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Jeffrey M Sutton
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Gregory C Wilson
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Milton Smith
- Department of Medicine, Division of Gastroenterology, University of Cincinnati, Cincinnati, OH, USA
| | - Kyuran Ann Choe
- Department of Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Jeffrey J Sussman
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Syed A Ahmad
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, WI, USA.
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22
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Asare EA, Evans DB, Erickson BA, Aburajab M, Tolat P, Tsai S. Neoadjuvant treatment sequencing adds value to the care of patients with operable pancreatic cancer. J Surg Oncol 2016; 114:291-5. [PMID: 27264017 DOI: 10.1002/jso.24316] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 05/23/2016] [Indexed: 12/14/2022]
Abstract
Treatment sequencing for resectable pancreatic cancer remains controversial and there is lack of level one evidence comparing neoadjuvant versus adjuvant strategies. However, a comparison of the cost-effectiveness analysis of the treatment strategies may help to better define the healthcare value of each approach. This review will highlight the rationale for multimodality therapy in the treatment of pancreatic cancer, discuss the advantages and disadvantages of adjuvant therapy, and conceptualize the cost-effectiveness of a neoadjuvant approach with regard to healthcare value. J. Surg. Oncol. 2016;114:291-295. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Elliot A Asare
- Pancreatic Cancer Program, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Douglas B Evans
- Pancreatic Cancer Program, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Beth A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Murad Aburajab
- Division of Gastroenterology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Parag Tolat
- Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Susan Tsai
- Pancreatic Cancer Program, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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23
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Tang K, Lu W, Qin W, Wu Y. Neoadjuvant therapy for patients with borderline resectable pancreatic cancer: A systematic review and meta-analysis of response and resection percentages. Pancreatology 2015; 16:28-37. [PMID: 26687001 DOI: 10.1016/j.pan.2015.11.007] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 11/08/2015] [Accepted: 11/10/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND We systematically reviewed and performed a meta-analysis of the available data regarding neoadjuvant chemo- and/or radiotherapy with special emphasis on tumor response/progression rates, toxicities, and clinical benefit, i.e. resection probabilities and survival estimates. METHODS AND FINDINGS Trials were identified by searching PUBMED, MEDLINE, and the Cochrane Central Register of Controlled Trials from 1966 to Feb 2015. A total of 18 studies (n = 959) were analyzed. the estimated fraction of patients with complete response was 2.8% (CI 0.8-4.7%) and with partial response 28.7% (CI 18.9%-38.5%). Stable disease was averaged to 45.9% (CI 32.9%-58.9%) in all patients and tumor progression under therapy occurred by estimation in 16.9% (CI 10.2%-23.6%) of the patients. The weighted frequency of those who underwent resection was 65.3% (CI 54.2%-76.5%), and the proportion of R0 resection amounted to 57.4% (CI 48.2%-66.5%). The weighted mean of median survival amounted to 17.9 months (range: 14.7-21.2 months) for the overall cohort of patients, 25.9 months (range: 21.1-30.7 months) for those who were resected, and 11.9 months (range: 10.4-13.5 months) for unresected patients. CONCLUSIONS The resection and R0 resection rates in the group of borderline resectable tumor patients after neoadjuvant therapy are similar to the resectable tumor patients, much higher than those in unresectable tumor patients. The survival estimates of borderline resectable tumor patients after neoadjuvant therapy were similar to resectable tumor patients. Patients with borderline resectable pancreatic cancer should be included in neoadjuvant protocols and subsequently be reevaluated for resection. How to find chemo-responsiveness before neoadjuvant chemotherapy so as to give individualized treatment is still an important issue.
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Affiliation(s)
- Kezhong Tang
- Department of Surgery, 2nd Affiliated Hospital of Zhejiang University Medical College, Hangzhou 310009, PR China
| | - Wenjie Lu
- Department of Surgery, 2nd Affiliated Hospital of Zhejiang University Medical College, Hangzhou 310009, PR China
| | - Wenjie Qin
- Department of Surgery, 2nd Affiliated Hospital of Zhejiang University Medical College, Hangzhou 310009, PR China
| | - Yulian Wu
- Department of Surgery, 2nd Affiliated Hospital of Zhejiang University Medical College, Hangzhou 310009, PR China.
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