Survival from cancer of the pancreas in England and Wales up to 2001

Can we screen for pancreatic cancer? Identifying a sub-population of patients at high risk of subsequent diagnosis using machine learning techniques applied to primary care data

BACKGROUND

Pancreatic cancer (PC) represents a substantial public health burden. Pancreatic cancer patients have very low survival due to the difficulty of identifying cancers early when the tumour is localised to the site of origin and treatable. Recent progress has been made in identifying biomarkers for PC in the blood and urine, but these cannot be used for population-based screening as this would be prohibitively expensive and potentially harmful.

METHODS

We conducted a case-control study using prospectively-collected electronic health records from primary care individually-linked to cancer registrations. Our cases were comprised of 1,139 patients, aged 15-99 years, diagnosed with pancreatic cancer between January 1, 2005 and June 30, 2009. Each case was age-, sex- and diagnosis time-matched to four non-pancreatic (cancer patient) controls. Disease and prescription codes for the 24 months prior to diagnosis were used to identify 57 individual symptoms. Using a machine learning approach, we trained a logistic regression model on 75% of the data to predict patients who later developed PC and tested the model's performance on the remaining 25%.

RESULTS

We were able to identify 41.3% of patients < = 60 years at 'high risk' of developing pancreatic cancer up to 20 months prior to diagnosis with 72.5% sensitivity, 59% specificity and, 66% AUC. 43.2% of patients >60 years were similarly identified at 17 months, with 65% sensitivity, 57% specificity and, 61% AUC. We estimate that combining our algorithm with currently available biomarker tests could result in 30 older and 400 younger patients per cancer being identified as 'potential patients', and the earlier diagnosis of around 60% of tumours.

CONCLUSION

After further work this approach could be applied in the primary care setting and has the potential to be used alongside a non-invasive biomarker test to increase earlier diagnosis. This would result in a greater number of patients surviving this devastating disease.

Pancreatic ductal adenocarcinoma survival in South Australia: time trends and impact of tumour location

BACKGROUND

It is unclear how global developments in management of pancreatic ductal adenocarcinoma (PDAC) have affected survival of Australian patients. This study aimed to determine trends in survival of PDAC over the last three decades in South Australia and to compare survival based on cancer location (head and uncinate process versus body and tail).

METHODS

A retrospective observational cohort study to include all cases of PDAC reported to the South Australian (state) Cancer Registry from 1990 to 2017.

RESULTS

A total of 1051 patients diagnosed with PDAC between 1990 and 2017 were included. An overall increase in number of reported PDAC cases over time with more than a doubling in the crude rate from 1.73 to 3.50 per 100 000 persons between the decades 1990-1999 and 2010-2017 (P < 0.001) was noted. Overall median survival for PDAC was 7.4 months (95% confidence interval 6.8-8.0 months) and this has improved in recent decades. Overall median survival for PDAC affecting head and uncinate process of pancreas was significantly higher compared to body and tail (7.6 months versus 4.1 months; P < 0.001).

CONCLUSIONS

This study from South Australia demonstrates an increased reporting of PDAC over the last three decades. Although overall survival for patients with PDAC remains low, there has been a modest improvement in recent decades. The overall survival is significantly lower for patients with PDAC involving the body and tail compared to the head and uncinate process of pancreas. Risk factors for poor survival include the male gender and advancing age (>70 years).

Occupational class differences in pancreatic cancer survival: A population-based cancer registry-based study in Japan

Background

Little is known about occupational class differences in pancreatic cancer survival.

Methods

Using a population‐based cancer registry in Japan, 3 578 patients with incident pancreatic cancer (1970‐2011) were followed up for 5 years (median follow‐up time 0.42 years). We classified patients into four occupational classes based on their longest‐held jobs: white‐collar (professional and managers), service, blue‐collar, and those not actively employed. Using white‐collar class as the reference group, hazard ratios (HRs) and 95% confidence intervals (CIs) for overall death were estimated by Cox proportional hazard model. Covariates included age, sex, and year of diagnosis. Prognostic variables (pathology, stage, and treatment) and smoking behaviors were additionally adjusted as possible mediating factors.

Results

Overall survival was poor in this population (median, 0.50 and 0.33 years in white‐collar and service classes, respectively). Compared with white‐collar patients, survival was significantly poorer across all occupational classes, most pronounced in the service worker group: mortality HRs ranged from 1.11 (95% CI 1.00‐1.24) in blue‐collar workers to 1.24 (95% CI 1.12‐1.37) in service workers. Even after controlling for potential mediating factors, service workers showed worse survival.

Conclusion

We documented occupational class disparities in pancreatic cancer survival in Japan. Even in the setting of lethal prognostic cancer with universal health coverage, high‐occupational class groups may enjoy a health advantage.

Socioeconomic status impacts survival and access to resection in pancreatic adenocarcinoma: A high-resolution population-based cancer registry study

BACKGROUND

Survival of patients with pancreatic adenocarcinoma (PA) is very poor. Resection status is highly associated with prognosis but only 15%-20% are resectable. The aim of this study was to analyse the impact of socioeconomic deprivation on PA survival and to define which management steps are affected.

METHODS

Between 01/01/2000 and 31/12/2014, 1451 incident cases of PA recorded in the digestive cancer registry of the French department of Calvados were included. The population was divided between less deprived areas (quintile 1) and more deprived areas (quintile 2,3,4,5 aggregated).

RESULTS

Patients from less deprived areas were younger at diagnosis than those from more deprived areas (69.9 vs 72.3 years, p = 0.01). There was no difference in stage or comorbidities. Three- and 5-year survival rates were significantly higher for less deprived areas than more deprived areas: 10.5% vs 5.15% and 4.7% vs 1.7% respectively (p = 0.01). In univariate analysis, those living in less deprived areas had a better survival than those in more deprived areas (HR = 0.81 [0.69-0.95], p = 0.009) but not in multivariable analysis (HRa = 0.93 [0.79-1.11], p = 0.383) or analysis stratified on resection. In multivariable regression, less deprived areas had more access to surgery than more deprived areas (ORa = 1.73 [1.08-2.47], p = 0.013). No difference was observed on access to adjuvant chemotherapy (ORa = 0.95 [0.38-2.34], p = 0.681).

CONCLUSION

The key to reducing survival inequalities in PA is access to resection, so future studies should investigate the factors impacting this issue.

Proposal of a modified American Joint Committee on Cancer staging scheme for resectable pancreatic ductal adenocarcinoma with a lymph node ratio-based N classification: A retrospective cohort study

The recently launched 8th edition of the American Joint Committee on Cancer (AJCC) staging scheme for pancreatic ductal adenocarcinoma (PDAC) did not account for the impact of the total examined lymph node count on prognostic accuracy. In this population-based cohort study, we proposed a modified AJCC staging scheme by incorporating a lymph node ratio (LNR)-based N classification for patients with resectable PDAC.We analyzed 8615 patients with resectable PDAC from the Surveillance, Epidemiology, and End Results database between 2004 and 2013. The optimal cut-off points for LNR were identified by recursive partitioning, and an LNR-based N classification was designed accordingly.The LNR-based N classification could further stratify patients with the 8th AJCC N1 and N2 disease into subgroups with significantly different overall survival (P < .001 for both). By replacing the 8th AJCC N classification with the corresponding LNR-based N classification, we further proposed a modified AJCC staging scheme. The modified AJCC staging outperformed the 8th AJCC staging in terms of the discriminatory capacity measured by the concordance index and Akaike information criterion, and the prognostic homogeneity assessed by using the likelihood ratio chi-squared test and stratified survival analysis.Replacing the 8th AJCC N classification with the LNR-based N classification can improve the prognostic performance of the 8th AJCC staging scheme for PDAC.

Epidemiology of pancreatic cancer

Cancer of the pancreas remains one of the deadliest cancer types. Based on the GLOBOCAN 2012 estimates, pancreatic cancer causes more than 331000 deaths per year, ranking as the seventh leading cause of cancer death in both sexes together. Globally, about 338000 people had pancreatic cancer in 2012, making it the 11th most common cancer. The highest incidence and mortality rates of pancreatic cancer are found in developed countries. Trends for pancreatic cancer incidence and mortality varied considerably in the world. A known cause of pancreatic cancer is tobacco smoking. This risk factor is likely to explain some of the international variations and gender differences. The overall five-year survival rate is about 6% (ranges from 2% to 9%), but this vary very small between developed and developing countries. To date, the causes of pancreatic cancer are still insufficiently known, although certain risk factors have been identified, such as smoking, obesity, genetics, diabetes, diet, inactivity. There are no current screening recommendations for pancreatic cancer, so primary prevention is of utmost importance. A better understanding of the etiology and identifying the risk factors is essential for the primary prevention of this disease.

A systematic review of the prognostic value of lymph node ratio, number of positive nodes and total nodes examined in pancreatic ductal adenocarcinoma

BACKGROUND Pancreatic ductal adenocarcinoma is the most common pancreatic cancer. Five-year overall survival is currently 3.3-6.0%. The aim of this review was to evaluate the prognostic value of lymph node ratio, number of positive nodes and total nodes examined on overall survival rate following pancreatic resection. MATERIALS AND METHODS A literature search was conducted of MEDLINE, EMBASE, the Cochrane Library and Central Register of Controlled Trials and the Cochrane Database of Systematic Review databases, from January 1996 to January 2016. RESULTS Overall, 19 studies including 4,883 patients examined the relationship between lymph node ratio and overall survival. A high lymph node ratio was associated with decreased overall survival in 17 studies. A total of 12 studies examined the relationship between the number of positive nodes and overall survival, and 11 studies revealed that an increase in the number of positive nodes was associated with decreased overall survival. In 15 studies examining the relationship between the total nodes examined and overall survival, there was no association with overall survival in 12 studies. CONCLUSIONS Lymph node ratio and number of positive nodes are factors associated with overall survival in pancreatic ductal adenocarcinoma, but not total nodes examined.

A Systematic Review of the Burden of Pancreatic Cancer in Europe: Real-World Impact on Survival, Quality of Life and Costs

PURPOSE

The purpose of this study was to assess the overall burden of pancreatic cancer in Europe, with a focus on survival time in a real-world setting, and the overall healthy life lost to the disease.

METHODS

Real-world data were retrieved from peer-reviewed, observational studies identified by an electronic search. We performed two de novo analyses: a proportional shortfall analysis to quantify the proportion of healthy life lost to pancreatic cancer and an estimation of the aggregate life-years lost annually in Europe.

RESULTS

Ninety-one studies were included. The median, age-standardised incidence of pancreatic cancer per 100,000 was 7.6 in men and 4.9 in women. Overall median survival from diagnosis was 4.6 months; median survival was 2.8-5.7 months in patients with metastatic disease. The proportional shortfall analysis showed that pancreatic cancer results in a 98 % loss of healthy life, with a life expectancy at diagnosis of 4.6 months compared to 15.1 years for an age-matched healthy population. Annually, 610,000-915,000 quality-adjusted life-years (QALYs) are lost to pancreatic cancer in Europe. Patients had significantly lower scores on validated health-related quality of life instruments versus population norms.

CONCLUSIONS

To the best of our knowledge, this is the first study to systematically review real-world overall survival and patient outcomes of pancreatic cancer patients in Europe outside the context of clinical trials. Our findings confirm the poor prognosis and short survival reported by national studies. Pancreatic cancer is a substantial burden in Europe, with nearly a million aggregate life-years lost annually and almost complete loss of healthy life in affected individuals.

Selection criteria in resectable pancreatic cancer: A biological and morphological approach

Pancreatic ductal adenocarcinoma (PDA) remains one of the most aggressive tumors with a low rate of survival. Surgery is the only curative treatment for PDA, although only 20% of patients are resectable at diagnosis. During the last decade there was an improvement in survival in patients affected by PDA, possibly explained by the advances in cancer therapy and by improve patient selection by pancreatic surgeons. It is necessary to select patients not only on the basis of surgical resectability, but also on the basis of the biological nature of the tumor. Specific preoperative criteria can be identified in order to select patients who will benefit from surgical resection. Duration of symptoms and level of carbohydrate antigen 19.9 in resectable disease should be considered to avoid R1 resection and early relapse. Radiological assessment can help surgeons to distinguish resectable disease from borderline resectable disease and locally advanced pancreatic cancer. Better patient selection can increase survival rate and neoadjuvant treatment can help surgeons select patients who will benefit from surgery.

Development and characterization of nanoparticles for the delivery of gemcitabine hydrochloride

Gemcitabine (2,2-difluorodeoxycytidine) is a deoxycytidine analog, currently being used as a first-choice drug in pancreatic metastatic cancer. Gemcitabine is administered weekly as 30-minute infusion with starting dose ranging from 800 to 1250 mg/m(2). The aim of the present work was to develop starch nanoparticles (NPs) for the delivery of gemcitabine hydrochloride that could reduce its dose related side effects and may prolong its retention time (24 hrs) for the treatment of pancreatic cancer. Nanoparticles were prepared by emulsification diffusion method with slight modifications. Size and morphology of nanoparticles were investigated. Particles were spherical in shape with slightly rough surfaces. Particle size and polydispersity index were 231.4 nm and 1.0, respectively while zeta potential of blank NPs and drug loaded NPs were found to be -11.8 mV and -9.55 mV, respectively. Percent entrapment efficiency of different formulations was around ∼ 54% to 65%. In vitro release profile studies showed that around 70%-83% of drug was released from different formulations. Anticancerous cell line studies were also performed in human pancreatic cell lines (MIA-PA-CA-2).

Time trends in the treatment and prognosis of resectable pancreatic cancer in a large tertiary referral centre

OBJECTIVES

Mortality in pancreatic cancer has remained unchanged over the last 20-30 years. The aim of the present study was to analyse survival trends in a selected population of patients submitted to resection for pancreatic cancer at a single institution.

METHODS

Included were 544 patients who underwent pancreatectomy for pancreatic cancer between 1990 and 2009. Patients were categorized into two subgroups according to the decade in which resection was performed (1990-1999 and 2000-2009). Predictors of survival were analysed using univariate and multivariate analyses.

RESULTS

Totals of 114 (21%) and 430 (79%) resections were carried out during the periods 1990-1999 and 2000-2009, respectively (P < 0.0001). Hospital length of stay (16 days versus 10 days; P < 0.001) and postoperative mortality (3% versus 1%; P = 0.160) decreased over time. Median disease-specific survival significantly increased from 16 months in the first period to 29 months in the second period (P < 0.001). Following multivariate analysis, poorly differentiated tumour [hazard ratio (HR) 3.1, P < 0.001], lymph node metastases (HR = 1.9, P < 0.001), macroscopically positive margin (R2) resection (HR = 3.2, P < 0.0001), no adjuvant therapy (HR = 1.6, P < 0.001) and resection performed in the period 1990-1999 (HR = 2.18, P < 0.001) were significant independent predictors of a poor outcome.

CONCLUSIONS

Longterm survival after surgery for pancreatic cancer significantly improved over the period under study. Better patient selection and the routine use of adjuvant therapy may account for this improvement.

Incidence and survival for hepatic, pancreatic and biliary cancers in England between 1998 and 2007

INTRODUCTION

Hepatic, pancreatic and biliary (HPB) cancers are a group of diverse malignancies managed ideally in specialist centres. This study describes recent patterns in the incidence and survival of HPB cancers in England over a ten year period (1998-2007).

METHODS

Data on 99,379 English patients (50,656 males; 48,723 females) diagnosed with HPB cancers between 1998 and 2007 were extracted from the National Cancer Data Repository. Data were divided into six site-specific cancer groups; pancreas, ampulla of Vater, biliary tract, primary liver, gallbladder and duodenum. Age-standardised incidence rates (per 100,000 European standard population, (ASR(E))) were calculated for each of the six groups by year of diagnosis and by socioeconomic deprivation. Survival was estimated using the Kaplan-Meier method.

RESULTS

The largest group was pancreatic cancers (63%), followed by primary liver (14%) and biliary cancers (13%). ASR(E) were highest for pancreatic and primary liver cancers whereas cancers of the gallbladder, duodenum and ampulla of Vater had a very low incidence. Over time the incidence of all six groups remained relatively stable, although primary liver cancer increased slightly in males. Incidence rates were higher in males than in females in all groups except gallbladder cancer, and all six groups had a higher incidence in the more deprived quintiles. Overall survival was poor in each of the HPB cancer groups.

CONCLUSIONS

HPB tumours are uncommon and are associated with poor long term survival reflecting the late stage at presentation. Incidence patterns suggest variable rates linked to socioeconomic deprivation and highlight a male predominance in all sites except the gallbladder. Identification of high risk populations should be emphasised in initiatives to raise awareness and facilitate earlier diagnosis.

Pancreatic cancer; reporting and long-term survival in Sweden

BACKGROUND

The overall completeness of the Swedish Cancer Register is high, although underreporting for certain sites must be acknowledged. The aims of the present study were twofold. Firstly to assess the completeness of reporting of pancreatic cancer to the Swedish Cancer Register, and secondly to identify and characterise long-term survivors based on information from two separate population-based register resources.

MATERIAL AND METHODS

To assess the completeness of the Cancer Register, pancreatic cancer cases registered in the National Patient Register between 1987 and 1999 were compared to cases reported to the Cancer Register. For estimations of long-term survival, the study population was restricted to 4321 cases identified both in the Cancer Register and the Patient Register with a histopathologically confirmed diagnosis of pancreatic ductal adenocarcinoma. A complete follow-up of survival in this group was performed till December 31, 2004.

RESULTS

There was a considerable underreporting of pancreatic cancer to the Cancer Register. During the period under study, a total of 19 745 patients were identified with a diagnosis of pancreatic cancer. Of these, only 73% had been reported to the Cancer Register. The underreporting increased markedly with age at diagnosis and was more pronounced during the second period under study. Only 2.8% of patients with a histopathologically confirmed diagnosis of pancreatic ductal adenocarcinoma survived five years or longer. The likelihood of long-term survival was strongly associated with younger age and surgery. Pancreatic resection was reported in 20.4% of all patients. Median survival among those operated on was 12 months compared to 4.6 months in all patients.

CONCLUSIONS

Underreporting of pancreatic cancer to the Swedish Cancer Register was pronounced and increased with older age. Less than 3% of patients with a record of pancreatic cancer both in the Cancer Register and the Patient Register survived five years or longer.

A 4-week versus a 3-week schedule of gemcitabine monotherapy for advanced pancreatic cancer: a randomized phase II study to evaluate toxicity and dose intensity

BACKGROUND

This randomized phase II study compared the efficacy and toxicity between 4-week and 3-week schedules of gemcitabine monotherapy in advanced pancreatic cancer.

METHODS

Patients with advanced pancreatic cancer were randomly assigned to either a 4-week schedule (gemcitabine at 1000 mg/m² as a 30-min infusion weekly for 3 consecutive weeks every 4 weeks) or a 3-week schedule (gemcitabine at 1000 mg/m² as a 30-min infusion weekly for 2 consecutive weeks every 3 weeks). The primary endpoint was the compliance rate during the first 8 weeks between the two groups.

RESULTS

A total of 90 patients were enrolled. The compliance rate during the first 8 weeks was the same (53.3%). For the 4- and 3-week schedules, the tumor response rates were 14.2 and 17.1% (p = 0.92), median progression free survival was 112 and 114 days (p = 0.82), and median overall survival was 206 and 250 days (p = 0.84), respectively. Grade 3-4 neutropenia was the major adverse event in both schedules: 37.7 and 35.5% (p = 0.82). In contrast, thrombocytopenia (platelet count <70000/mm³) was significantly higher for the 4-week schedule: 26.6 and 4.4% (p = 0.008). The mean received dose intensity was equal: 588 and 550 mg/m²/week (p = 0.14).

CONCLUSIONS

The 3-week schedule of gemcitabine did not improve the compliance rate during 8 weeks compared with the 4-week schedule, but it attained a comparable efficacy with lower toxicity. Further investigation will be needed to introduce it into daily practice.

CLINICAL TRIAL REGISTRATION NUMBER

UMIN ID 974.

Chemoradiotherapy with or without induction chemotherapy for locally advanced pancreatic cancer: a UK multi-institutional experience

AIMS

The optimal management for patients with unresectable locally advanced adenocarcinoma of the pancreas (LAPC) is unclear. The aim of this study was to determine the outcome of patients treated with chemoradiotherapy (CRT) with or without induction chemotherapy.

MATERIALS AND METHODS

We conducted a multi-centre retrospective analysis of 48 patients with biopsy-proven LAPC treated with CRT in four regional oncology centres in the UK between March 2000 and October 2007. The prescribed radiotherapy dose was 4500-5040 cGy in 25-28 fractions and was given concurrent with gemcitabine (n=37), gemcitabine/cisplatin (n=9), 5-fluorouracil (n=1) or capecitabine (n=1).

RESULTS

Four patients (8.3%) did not complete the intended treatment due to CRT-related toxicities. The disease control rate (Objective response rate (ORR) and stable disease (SD)) was 81.3%. The median overall survival was 17 months (range 5-66 months). In subgroup analysis, a trend towards improved survival was seen in patients who completed the intended treatment (17.1 months vs 11.0 months, P=0.06) and in patients undergoing surgery (27 months vs 16 months, P=0.023).

CONCLUSIONS

This is the largest reported series from the UK focussing on patients who received CRT for pancreas cancer. It shows that it is possible to deliver pancreatic CRT with acceptable toxicity. Induction chemotherapy followed by gemcitabine-based CRT shows promising activity and should be evaluated in phase III studies.

HDAC2 attenuates TRAIL-induced apoptosis of pancreatic cancer cells

Background

Pancreatic ductal adenocarcinoma (PDAC) is one of the most malignant tumors with a dismal prognosis and no effective conservative therapeutic strategies. Although it is demonstrated that histone deacetylases (HDACs), especially the class I HDACs HDAC1, 2 and 3 are highly expressed in this disease, little is known about HDAC isoenzyme specific functions.

Results

Depletion of HDAC2, but not HDAC1, in the pancreatic cancer cell lines MiaPaCa2 and Panc1 resulted in a marked sensitization towards the tumor necrosis factor-related apoptosis-inducing ligand (TRAIL). Correspondingly, the more class I selective HDAC inhibitor (HDACI) valproic acid (VPA) synergized with TRAIL to induce apoptosis of MiaPaCa2 and Panc1 cells. At the molecular level, an increased expression of the TRAIL receptor 1 (DR5), accelerated processing of caspase 8, pronounced cleavage of the BH3-only protein Bid, and increased effector caspase activation was observed in HDAC2-depleted and TRAIL-treated MiaPaCa2 cells.

Conclusions

Our data characterize a novel HDAC2 function in PDAC cells and point to a strategy to overcome TRAIL resistance of PDAC cells, a prerequisite to succeed with a TRAIL targeted therapy in clinical settings.

Cancer survival in England and the influence of early diagnosis: what can we learn from recent EUROCARE results?

BACKGROUND

This review of the EUROCARE-4 results attempts to separate out the early and late mortality effects contributing to the widely reported poorer 5-year survival rates for cancer patients in the United Kingdom compared with other European countries for 26 cancer sites.

METHODS

Patients diagnosed with cancer in 1996-1999 in 23 European countries were included in the analyses. Comparison of 1-year, 5-year and 5|1-year (i.e. only including those patients who had survived to 1 year) survival estimates between data for England and the 'European average' was undertaken. This analysis was to highlight the relative contribution of early diagnosis, using 1-year survival as a proxy measure, on 5-year survival for the different sites of cancer. Three groups of cancer sites were identified according to whether the survival differences at 1, 5 and 5|1-years were statistically significant.

RESULTS AND CONCLUSIONS

Breast cancer showed significantly poorer 1- and 5-year survival estimates in England, but the 5|1-year survival figure was not significantly different. Thus, successful initiatives around awareness and early detection could eradicate the survival gap. In contrast, the 5|1-year survival estimates remained significantly worse for lung, colorectal and prostate cancers, showing that although early detection could make some difference, late effects such as treatment and management of the patients were also influencing long-term outcome differences between England and Europe.

Dose finding and early efficacy study of gemcitabine plus capecitabine in combination with bevacizumab plus erlotinib in advanced pancreatic cancer

PURPOSE

This study evaluated safety and efficacy of chemotherapy (gemcitabine plus capecitabine) plus bevacizumab/erlotinib in advanced pancreatic cancer because dual epidermal growth factor receptor/vascular endothelial growth factor blockade has a rational biologic basis in this malignancy.

PATIENTS AND METHODS

Patients with untreated, unresectable, locally advanced or metastatic pancreatic carcinoma were enrolled onto one of the following four sequential dose levels (DLs) of escalating capecitabine doses (days 1 to 21): DL1, 910 mg/m(2); DL2, 1,160 mg/m(2); DL3, 1,400 mg/m(2); or DL4, 1,660 mg/m(2). Doses of coadministered gemcitabine (1,000 mg/m(2) on days 1, 8, and 15), bevacizumab (5 mg/kg on days 1 and 15), and erlotinib (100 mg/d) every 28 days (up to six cycles) were fixed. Using a 3+3 study design, dose-limiting toxicity (DLT) was assessed in cycle 1. Results Twenty assessable patients were enrolled (DL1, n = 8; DL2, n = 3; DL3, n = 6; and DL4, n = 3); 97 cycles were administered. Median age was 63 years (range, 33 to 77 years), and male-to-female ratio was 10:10. Performance status was 0 and 1 in two and 17 patients, respectively; and nine and 11 patients had locally advanced and metastatic disease, respectively. DLT occurred in one patient at DL1 (grade 3 epistaxis) and two patients at DL4 (grade 3 diarrhea and grade 3 skin rash > 7 days). Common grade 3 and 4 toxicities (10% to 20%) were diarrhea, hand-foot syndrome, stomatitis, and skin rash. Grade 3 lethargy and grade 3 or 4 neutropenia occurred in 40% and 45% of patients, respectively. No GI perforation, grade 3 GI hemorrhage/hypertension, or pneumonitis occurred. Ten partial responses were observed. Median overall and progression-survival times (all patients) were 12.5 and 9.0 months, respectively.

CONCLUSION

The maximum-tolerated dose of capecitabine was 1,660 mg/m(2). The recommended capecitabine dose in this cytotoxic doublet/biologic doublet regimen is 1,440 mg/m(2); this regimen is under evaluation in an ongoing phase II study.

Pancreatic cancer: incidence, treatment and survival trends--1175 cases in Calvados (France) from 1978 to 2002

AIM

To assess the trends in incidence, therapeutic modalities and survival of pancreatic cancer between 1978 and 2002 in a well-defined population, as recorded in the Calvados digestive cancer registry database.

PATIENTS AND METHODS

All patients living in Calvados with a diagnosis of pancreatic cancer were registered. Clinical data and treatment modalities were prospectively recorded. This 25-year database was divided into five 5-year periods. Data were compared using log-rank tests and the Cox model.

RESULTS

A total of 1175 cases of pancreatic cancer (617 men, 558 women) were registered. Its incidence increased with an average annual coefficient of +2.8% in men and +5.1% in women. Therapeutic modalities changed over the five time periods: surgical resection increased from 6.8 to 13.4% (median survival 15 months) while radiation therapy and/or chemotherapy also increased from 5.5 to 13.2%. Palliative surgery decreased from 54.6 to 32.0% and favored interventional endoscopic techniques. Postoperative mortality decreased significantly. Survival increased significantly over the five time periods, although the median survival time remained stable (4 months).

CONCLUSION

From 1978 to 2002, pancreatic cancer incidence increased in Calvados (France). Therapeutic modalities changed, with endoscopic treatments preferred over palliative surgery. The improvement in survival could be explained by the decrease in postoperative mortality.

Preparation of albumin nanospheres loaded with gemcitabine and their cytotoxicity against BXPC-3 cells in vitro

AIM

To optimize formulation methods for loading gemcitabine (GEM), the main drug against pancreatic cancer, into albumin nanoparticles for extended blood circulation and improved efficacy.

METHODS

GEM was loaded into two sizes of disolvation-crosslinked bovine serum albumin nanoparticles, with a mean diameter of 109.7 nm and 405.6 nm, respectively, by co-precipitation (the direct method) and follow-up adsorption (the indirect method). The antitumor activities of the two nanoparticulate formulations, were evaluated according to their anti-proliferative effects on the human pancreatic cell line BXPC-3, which were assessed using the MTT assay.

RESULTS

The two nanoparticulate formulations, created by direct co-precipitation and indirect adsorption, possessed smooth surfaces and high drug loading efficiencies, 83% and 93% at 11% and 13% drug loading, respectively. The two formulations released GEM for 8 and 12 h, respectively, and significantly improved anti-BXPC-3 proliferation effects, as compared with the GEM solution and the drug-free albumin particles.

CONCLUSION

Co-precipitating and adsorbing GEM into albumin particles resulted in sustained-release nanoparticulate formulations with improved antitumor cytotoxicity. The result suggests that this is a useful formulation strategy for improving the antitumor efficacy of GEM.

Management and prognosis of pancreatic cancer over a 30-year period

BACKGROUND: The aim of this study was to report on changes in the diagnostic assessment, patterns of care and survival over time for pancreatic cancers.

METHODS: A total of 2986 cases of pancreatic cancer from the Digestive Cancer Registry of Burgundy (France) over a 30-year period (1976–2005) were considered. Non-conditional logistic regressions were carried out to identify the factors associated with resection for cure and with the use of chemotherapy. A multivariate relative survival analysis was carried out.

RESULTS: Diagnostic procedures have changed. Ultrasonography and computed tomography progressively have become the major diagnostic procedures. There was a slight improvement in stage: the proportion of stage I–II was 2.8% in the 1976–1980 period and 8.8% in the 2001–2005 period (P<0.001). There was a similar trend in the proportion of cases resected for cure, the corresponding percentages being 4.5 and 11.3%, respectively (P<0.001). The 5-year relative survival increased from 2.0 to 4.2% (P<0.001). In the multivariate relative survival analysis, the period remained a significant prognostic factor. Stage, sex, age and histology were independent prognostic factors.

CONCLUSION: Over a 30-year period, there were minor changes in the stage at diagnosis, resection for cure and prognosis of pancreatic cancers, although there were improvements in the diagnostic modalities. Pancreatic cancer still represents a major challenge in oncology.