Trends in pancreatic cancer incidence in nine SEER Cancer Registries, 1973-2002

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Incidence trends for twelve cancers in younger adults-a rapid review

Many cancer referral guidelines use patient’s age as a key criterium to decide who should be referred urgently. A recent rise in the incidence of colorectal cancer in younger adults has been described in high-income countries worldwide. Information on other cancers is more limited. The aim of this rapid review was to determine whether other cancers are also increasing in younger age groups, as this may have important implications for prioritising patients for investigation and referral. We searched MEDLINE, Embase and Web of Science for studies describing age-related incidence trends for colorectal, bladder, lung, oesophagus, pancreas, stomach, breast, ovarian, uterine, kidney and laryngeal cancer and myeloma. ‘Younger’ patients were defined based on NICE guidelines for cancer referral. Ninety-eight studies met the inclusion criteria. Findings show that the incidence of colorectal, breast, kidney, pancreas, uterine cancer is increasing in younger age groups, whilst the incidence of lung, laryngeal and bladder cancer is decreasing. Data for oesophageal, stomach, ovarian cancer and myeloma were inconclusive. Overall, this review provides evidence that some cancers are increasingly being diagnosed in younger age groups, although the mechanisms remain unclear. Cancer investigation and referral guidelines may need updating in light of these trends.

Pancreatic Cancer in Iran: an Epidemiological Review

PURPOSE

Pancreatic cancer is the seventh cause of death in men in the world and also is one of the most common malignancies worldwide with poor prognosis. Due to the lack of epidemiological aspects of pancreatic cancer in Iran, this study aimed to investigate the epidemiological aspects of pancreatic cancer in Iran.

METHODS

In February 2019, A search was conducted with the keywords "Pancreatic Neoplasm," "Pancreas Neoplasms," "Cancer of Pancreas," "Pancreas Cancer," "Pancreatic Cancer," "Cancer of the Pancreas," and "Iran" in their title or abstract and MeSH. The databases of Medline, Web of Science, Scopus, SID, IranMedex, and Google Scholar were searched. The title and abstract of the papers were reviewed, and articles that addressed the epidemiological aspects of pancreatic cancer were included; in total, 20 full papers were reviewed.

RESULTS

According to studies, the incidence and mortality rate of pancreatic cancer is steadily increasing with age. Actually, men are more likely to develop this carcinoma than women. Smoking, aging, and lifestyle changes are the most important risk factors for pancreatic cancer in Iran. Due to the lack of initial symptoms or a specific marker for early diagnosis of pancreatic cancer, this cancer is detected lately and therefore low survival rate is observed.

CONCLUSION

Mortality and incidence of pancreatic cancer is increasing in Iran. Pancreatic cancer is more common in men than women. Based on the results of this study, pancreatic cancer depends largely on the lifestyle. Survival of pancreatic cancer is low in untreated patients.

Interethnic differences in pancreatic cancer incidence and risk factors: The Multiethnic Cohort

While disparity in pancreatic cancer incidence between blacks and whites has been observed, few studies have examined disparity in other ethnic minorities. We evaluated variations in pancreatic cancer incidence and assessed the extent to which known risk factors account for differences in pancreatic cancer risk among African Americans, Native Hawaiians, Japanese Americans, Latino Americans, and European Americans in the Multiethnic Cohort Study. Risk factor data were obtained from the baseline questionnaire. Cox regression was used to estimate the relative risks (RRs) and 95% confidence intervals (CIs) for pancreatic cancer associated with risk factors and ethnicity. During an average 16.9-year follow-up, 1,532 incident pancreatic cancer cases were identified among 184,559 at-risk participants. Family history of pancreatic cancer (RR 1.97, 95% CI 1.50-2.58), diabetes (RR 1.32, 95% CI 1.14-1.54), body mass index ≥30 kg/m² (RR 1.25, 95% CI 1.08-1.46), current smoking (<20 pack-years RR 1.43, 95% CI 1.19-1.73; ≥20 pack-years RR 1.76, 95% CI 1.46-2.12), and red meat intake (RR 1.17, 95% CI 1.00-1.36) were associated with pancreatic cancer. After adjustment for these risk factors, Native Hawaiians (RR 1.60, 95% CI 1.30-1.98), Japanese Americans (RR 1.33, 95% CI 1.15-1.54), and African Americans (RR 1.20, 95% CI 1.01-1.42), but not Latino Americans (RR 0.90, 95% CI 0.76-1.07), had a higher risk of pancreatic cancer compared to European Americans. Interethnic differences in pancreatic cancer risk are not fully explained by differences in the distribution of known risk factors. The greater risks in Native Hawaiians and Japanese Americans are new findings and elucidating the causes of these high rates may improve our understanding and prevention of pancreatic cancer.

African-Americans and Indigenous Peoples Have Increased Burden of Diseases of the Exocrine Pancreas: A Systematic Review and Meta-Analysis

Ethnic health disparity is a well-acknowledged issue in many disease settings, but not diseases of the exocrine pancreas. A systematic review and meta-analysis was conducted to explore the race- and ethnicity-specific burden of diseases of the exocrine pancreas. Studies that compared health-related endpoints between two or more ethnicities were eligible for inclusion. Proportion meta-analyses were conducted to compare burden between groups. A total of 42 studies (24 on pancreatic cancer, 17 on pancreatitis, and one on pancreatic cyst) were included in the systematic review, of which 19 studies were suitable for meta-analyses. The incidence of pancreatic cancer was 1.4-fold higher among African-Americans, while the incidence of acute pancreatitis was 4.8-fold higher among an indigenous population (New Zealand Māori) compared with Caucasians. The prevalence of post-pancreatitis diabetes mellitus was up to 3.0-fold higher among certain ethnicities, including Asians, Pacific Islanders, and indigenous populations compared with Caucasians. The burden of diseases of the exocrine pancreas differs between ethnicities, with African-Americans and certain indigenous populations being at the greatest risk of developing these diseases. Development of race- and ethnicity-specific screening as well as protocols for lifestyle modifications may need to be considered with a view to reducing the disparities in burden of diseases of the exocrine pancreas.

Rising trends in pancreatic cancer incidence and mortality in 2000-2014

Background

The morbidity and mortality of pancreatic cancer vary considerably around the world. The aim of this study was to characterize and evaluate recent changes in incidence and incidence-based mortality in the USA.

Methods

Incidence and incidence-based mortality data were based on the 18 Surveillance, Epidemiology, and End Results (SEER) registries through SEER^*Stat software. We adopted joinpoint regression to analyze the temporal trends stratified by age, gender, ethnicity, stage, tumor site, and size.

Results

Based on 18 SEER data sets, the age-adjusted incidence of pancreatic cancer increased from 11.85/100,000 in 2000 to 14.70/100,000 in 2014, increasing by an average annual percentage change (AAPC) of 1.6 (95% CI 1.5-1.8, p<0.05). The incidence-based mortality also increased, from 9.96/100,000 in 2001 to 12.96/100,000 in 2014, increasing by an AAPC of 1.9 (95% CI 1.3-2.5, p<0.05). However, we observed a deceleration in mortality since 2005, with the annual percentage change decreasing from 4.1 (2001-2005) to 1.0 (2005-2014). These increasing trends in pancreatic cancer were observed in most subgroups (stratified by age, gender, ethnicity, stage, tumor site, and size).

Conclusion

The incidence and mortality rates of pancreatic cancer in the USA have increased significantly since 2000, highlighting the need for increased preventive, screening, and surveillance efforts.

Trends in pancreatic adenocarcinoma incidence and mortality in the United States in the last four decades; a SEER-based study

Background

Pancreatic cancer is the fourth-leading cause of cancer deaths in the United States. The silent nature of the disease and its poor prognosis, the need for further research, along with the need to assess the outcomes of current approaches necessitate an ongoing evaluation of the epidemiology and mortality-trends of this malignancy. Continuous monitoring of disease-patterns, on population-levels, may help scientists assess the quality of healthcare delivery, boost their understanding of diseases' characteristics and risk factors, and detect gaps whereby further research is needed. None of the previous reports shed light on pancreatic adenocarcinomas (PAC), the most common type of Pancreatic Cancer, as the primary outcome. In this study we aim to investigate PAC’s incidence and mortality trends over the last four decades in the United States.

Methods

We used SEER 9 database to study PAC cases during 1974-2014. Incidence and mortality rates were calculated by sex, age, race, state and stage of PAC. Annual percent change (APC) was calculated using joinpoint regression software.

Results

We reviewed 67,878 PAC cases; most of these cases were in the head of pancreas. Overall PAC incidence rates increased 1.03% (95% CI, 0.86-1.21, p <.001) per year over the study period. Rates of adenocarcinoma of the head of pancreas increased 0.87% (95% CI, 0.68-1.07, p <.001), and rates of adenocarcinoma of the body and tail of pancreas increased 3.42% (95% CI, 3.06-3.79, p <.001) per year during 1973-2014. PAC incidence-based mortality increased 2.22% (95% CI, 1.93-2.51, p <.001) per year. However, during 2012-2014 there was a statistically significant decrease in PAC incidence-based mortality; APC, -24.70% (95% CI, -31.78 - -16.88, p <.001).

Conclusion

PAC’s incidence and mortality rates have been increasing for decades. However, the last few years have shown a promising decrease in mortality. We believe that further advances in healthcare delivery and research can lead to a further mortality decrease. Future studies can use this paper as a baseline to keep monitoring the outcomes of PAC's therapy.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4610-4) contains supplementary material, which is available to authorized users.

CD44+CD24+ subset of PANC-1 cells exhibits radiation resistance via decreased levels of reactive oxygen species

Emerging evidence has suggested that pancreatic adenocarcinoma is sustained by pancreatic cancer stem cells. The present study aimed to investigate the expression patterns of the pancreatic cancer stem cell surface markers cluster of differentiation CD44 and CD24 in a pancreatic adenocarcinoma cell line, and to investigate the possible mechanisms for their radiation resistance. Flow cytometry was used to analyze the expression patterns of CD44 and CD24 in the pancreatic adenocarcinoma PANC-1 cell line. In addition, a multi-target click model was used to fit cell survival curves and determine the sensitizer enhancement ratio. The apoptosis and cycle distribution of the four cell subsets was determined using flow cytometry, and the level of reactive oxygen species (ROS) was determined using the 2',7'-dichlorofluorescin diacetate probe. The present results identified that the ratios of CD44⁺ and CD24⁺ in the sorted PANC-1 cell line were 92.0 and 4.7%, respectively. Prior to radiation, no statistically significant differences were observed among the four groups. Following treatment with 6 MV of X-rays, the rate of apoptosis was decreased in the CD44⁺CD24⁺ group compared with other subsets. The percentage of G0/G1 cells was highest in the CD44⁺CD24⁺ group compared with the three other groups, which exhibited increased radiosensitivity. In addition, the level of ROS in the CD44⁺CD24⁺ group was reduced compared with the other groups. In summary, the results of the present study indicated that CD44⁺CD24⁺ exhibited stem cell properties. The lower level of ROS and apoptosis in CD44⁺CD24⁺ cells may contribute to their resistance to radiation in pancreatic adenocarcinoma.

Impact of TP53 codon 72 and MDM2 SNP 309 polymorphisms in pancreatic ductal adenocarcinoma

Single-nucleotide polymorphisms (SNPs) of TP53 (codon 72, rs1042522) and MDM2 promoter (SNP 309, rs2279744) have been associated with risk for various human cancers. However, studies analyzing these polymorphisms in pancreatic ductal adenocarcinoma (PDAC) are lacking. We investigated TP53 codon 72 and MDM2 SNP 309 polymorphisms in 32 patients with PDAC, 16 patients with chronic pancreatitis (CP), and 32 normal controls, using formalin-fixed paraffin-embedded tissue. We also examined TP53 and MDM2 protein immunohistochemistry (IHC) to assess the involvement of these differences in malignant transformation and disease progression. TP53 Pro/Pro genotype was significantly more frequent in PDAC patients than in controls (65.6 vs. 15.6%, p < 0.001) and no significant difference was found between CP patients (37.5%) and controls. In MDM2 SNP 309, there were no significant differences among the three groups. Based on the Kaplan-Meier analysis, overall survival was significantly shorter in MDM2 G/G genotypes compared with other genotypes (G/T and T/T) (359 vs. 911 days, p = 0.016) whereas no significant differences in TP53 genotypes were observed (638 vs. 752 days, p = 0.471). Although TP53 IHC was frequent in PDAC patients (53.1%), TP53 and MDM2 protein expression was not correlated with polymorphisms. Our study demonstrated TP53 codon 72 polymorphism is potentially a genetic predisposing factor while MDM2 SNP 309 polymorphism might be useful in predicting survival outcome.

National trends in pancreatic cancer outcomes and pattern of care among Medicare beneficiaries, 2000 through 2010

BACKGROUND

Pancreatic cancer is a major cause of morbidity and mortality in the Medicare population. Whether the health care burden of pancreatic cancer has changed over the last decade is unknown.

METHODS

The authors used Medicare data from 2000 to 2010 to identify beneficiaries aged ≥ 65 years who were hospitalized for the management of pancreatic cancer. Annual trends were estimated for the age-sex-race-adjusted initial hospitalization rate, the age-sex-race-comorbidity-adjusted 1-year mortality rate after initial hospitalization, age-sex-race-comorbidity-adjusted procedure rates, 1-year all-cause rehospitalizations after initial pancreatic cancer hospitalization, and mean inflation-adjusted Medicare payment for initial hospitalization.

RESULTS

A total of 130,728 patients had ≥ 1 hospitalizations for pancreatic cancer and were identified from 56,642,071 beneficiaries during the study period. The age-sex-race-adjusted rate of initial hospitalization for pancreatic cancer was 50 per 100,000 person-years in 2010, representing a 0.5% annual increase since 2000 (95% confidence interval [95% CI], 0.3%-0.7%). In the same period, the age-sex-race-comorbidity-adjusted 1-year mortality rate decreased by 4.4% (95% CI, 3.9%-4.9%), and the age-sex-race-comorbidity-adjusted surgical resection rate increased by 6.9% (95% CI, 6.4%-7.5%). The mean inflation-adjusted Medicare payment for the initial hospitalization decreased, from $14,118 in 2000 to $13,318 in 2010, and the number of 1-year all-cause rehospitalizations after the initial hospitalization increased from 0.75 per patient in 2000 to 0.82 per patient in 2009 (all P < .001).

CONCLUSIONS

For Medicare fee-for-service beneficiaries, initial pancreatic cancer hospitalization, surgical resection, and rehospitalization rates increased, but 1-year mortality rates declined over the last decade.

Age Influences Likelihood of Pancreatic Cancer Treatment, but not Outcome

Background

Pancreatic cancer (PanCA) is predominantly diagnosed in elderly patients; nevertheless, a significant number of young patients are affected. We hypothesized more aggressive treatment of young PanCA patients would result in better overall survival (OS).

Methods

A retrospective review of our institutional cancer database identified subjects for inclusion. Age 50 years was selected to stratify patients into age groups.

Results

Of 309 PanCA patients, 54 (17%) were ≤ 50 years old. Exocrine cancer was the most common histology (90%). Patients ≤ 50 years old were more likely to have endocrine cancer (22% vs. 7%, P = 0.001). There was no difference in stage or curative intent surgery between age groups. Despite patients ≤ 50 years old receiving more chemotherapy (61% vs. 41%, P = 0.007) and radiotherapy (28% vs. 15%, P = 0.03), there was no difference in OS (24.1 months vs. 14.1 months, P = 0.08). When only exocrine cancers were considered, there was no difference between young and old patients regarding stage, grade, location or surgery. Exocrine cancer patients ≤ 50 years old received more chemotherapy (67% vs. 42%, P = 0.003) and radiation therapy (36% vs. 17%, P = 0.004), but there was no difference in OS.

Conclusions

A substantial number of PanCA patients are ≤ 50 years old. Patients ≤ 50 years old received more treatment but did not have improved OS. Significant improvements in PanCA survival await development of new treatment strategies.

Pancreatic cancer death rates by race among US men and women, 1970-2009

BACKGROUND

Few studies have examined trends in pancreatic cancer death rates in the United States, and there have been no studies examining recent trends using age-period-cohort analysis.

METHODS

Annual percentage change in pancreatic cancer death rates was calculated for 1970 to 2009 by sex and race among adults aged 35 to 84 years using US mortality data provided by the National Center for Health Statistics and Joinpoint Regression. Age-period-cohort modeling was performed to evaluate the changes in cohort and period effects. All statistical tests were two-sided.

RESULTS

In white men, pancreatic cancer death rates decreased by 0.7% per year from 1970 to 1995 and then increased by 0.4% per year through 2009. Among white women, rates increased slightly from 1970 to 1984, stabilized until the late 1990s, then increased by 0.5% per year through 2009. In contrast, the rates among blacks increased between 1970 and the late 1980s (women) or early 1990s (men) and then decreased thereafter. Age-period-cohort analysis showed that pancreatic cancer death risk was highest for the 1900 to 1910 birth cohort in men and the 1920 to 1930 birth cohort in women and there was a statistically significant increase in period effects since the late 1990s in both white men and white women (two-sided Wald test, P < .001).

CONCLUSIONS

In the United States, whites and blacks experienced opposite trends in pancreatic cancer death rates between 1970 and 2009 that are largely unexplainable by known risk factors. This study underscores the needs for urgent action to curb the increasing trends of pancreatic cancer in whites and for better understanding of the etiology of this disease.

Nationwide improvement of only short-term survival after resection for pancreatic cancer in the Netherlands

OBJECTIVES

Evaluation of incidence, treatment, and survival trends after resection of pancreatic cancer at a national level.

METHODS

Using data on patient and tumor characteristics from the nationwide Netherlands Cancer Registry trends were analyzed for the period 1989-2008.

RESULTS

A total of 30,025 patients diagnosed with pancreatic cancer were included. The incidence remained stable over the 20-year study period at approximately 9 per 100,000 inhabitants. Resection rates increased from 8% in 1989 to 12% in 2008, adjuvant chemotherapy rates increased from 7% to 29%, and palliative chemotherapy rates increased from 5% to 19% (P < 0.0001 each). Relative survival proportions did not change over time; besides a minimal, nonsignificant increase at 3 months from 53% to 55%, these remained 34% at 6 months and 4.5% at 3 years. Among the patients undergoing tumor resection, relative survival increased from 82% to 93% at 3 months and from 51% to 63% at 1 year after diagnosis. However, no improvement was seen after 3 years (23%).

CONCLUSIONS

The increased short-term survival among patients who underwent resection probably reflects decreased postoperative mortality driven by ongoing centralization efforts. However, longer-term survival remained poor irrespective of the changes in management in the past decades.

Immunohistochemical features of the gastrointestinal tract tumors

Gastrointestinal tract tumors include a wide variety of vastly different tumors and on a whole are one of the most common malignancies in western countries. These tumors often present at late stages as distant metastases which are then biopsied and may be difficult to differentiate without the aid of immunohistochemical stains. With the exception of pancreatic and biliary tumors where there are no distinct immunohistochemical patterns, most gastrointestinal tumors can be differentiated by their unique immunohistochemical profile. As the size of biopsies decrease, the role of immunohistochemical stains will become even more important in determining the origin and differentiation of gastrointestinal tract tumors.

Occurrence of pancreatic, biliary tract, and gallbladder cancers in Alaska Native people, 1973-2007

Objectives

To describe the occurrence of pancreatic, biliary tract, and gallbladder cancers within the Alaska Native (AN) population.

Study design

Population-based analysis utilizing a tumor registry and comparative population data.

Methods

Pancreaticobiliary cancers rates for AN people during 1973–2007 were determined from the Surveillance, Epidemiology, and End Results (SEER) AN Tumor Registry. Cancer incidence rates were age-adjusted to the World Standard Million and compared over 2 time periods with US white and black rates.

Results

During 1973–2007, 213 AN people developed pancreatic cancer, 73 gallbladder cancer and 61 biliary tract cancer. Pancreatic cancer occurs at similar rates in AN men and women, but data for 1993–2007 indicate that the rates among AN men may be increasing. The incidence rate in AN women (9.5/100,000) was statistically higher than in US white women (5.8/100,000). The incidence for biliary tract cancer in AN men and gallbladder cancer in AN men and women is statistically higher than that for US whites and blacks.

Conclusions

Pancreaticobiliary cancers, particularly biliary tract and gallbladder cancers, in both AN men and women and pancreatic cancer in women occur at an increased rate in AN people. Risk factors relating to the elevated rate are discussed. Certain factors are potentially modifiable, such as the use of tobacco and obesity.

Single-center experience of laparoscopic left pancreatic resection in 359 consecutive patients: changing the surgical paradigm of left pancreatic resection

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) is increasingly performed for lesions of the body and tail of the pancreas. We analyzed the clinical characteristics of the largest series of patients to date who underwent LDP at a single center, as well as their outcomes, to reassess the surgical paradigm for left pancreatic resection.

METHODS

We retrospectively reviewed the records of 359 patients who underwent LDP at Asan Medical Center, Seoul, Korea, for pancreatic neoplasms between March 2005 and December 2010.

RESULTS

Of the 359 patients, 323 (90%) had benign or low-grade malignant neoplasms and 36 (10%) had malignancies. The most common diagnosis was intraductal papillary mucinous neoplasm (IPMN) in 72 patients (21.2%). There were 24 patients (6.7%) with pancreatic ductal adenocarcinoma (PDAC). We found that 178 patients (49.6%) underwent spleen-preserving LDP (SP-LDP): 150 (84.3%) by main splenic vessel preservation, and 28 (15.7%) supported by short gastric and gastroepiploic vessels (Warshaw technique). Postoperative complications occurred in 43 (12%) patients, including 25 (7%) with pancreatic fistula (ISGPF grade B, C), but there was no death. Median operative time was 195 (range, 78-480) min, and median postoperative hospital stay was 8 (range, 4-37) days. The proportion of patients with pancreatic lesions who underwent LDP increased from 8.6% in 2005 to 66.9% in 2010. Kaplan-Meier analysis showed that the 1- and 2-year overall survival rates in the 24 patients with PDAC were 85.2% each.

CONCLUSIONS

LDP is feasible, safe, and effective for the treatment of benign and low-grade malignant lesions of the pancreas. The increased use of LDP for left-sided pancreatic lesions, including malignant lesions, represents a paradigm shift from open distal pancreatectomy.

Expression of CD44, CD24 and ESA in pancreatic adenocarcinoma cell lines varies with local microenvironment

BACKGROUND

Emerging evidence suggests that pancreatic adenocarcinoma is hierarchically organized and sustained by pancreatic cancer stem cells. Furthermore, elimination of these cells is possible and therapeutically relevant. This study aimed to investigate the expression patterns of pancreatic cancer stem cell surface markers CD44, CD24 and ESA in pancreatic adenocarcinoma cell lines and explore the influence of their local microenvironment.

METHODS

Flow cytometry was used to analyze the expression patterns of CD44, CD24 and ESA in five pancreatic adenocarcinoma cell lines (PANC-1, PC-2, MIA-Paca-2, AsPC-1 and BxPC-3). In addition, the capacity for sphere-formation in serum-free medium of four cell lines (PANC-1, PC-2, MIA-Paca-2 and BxPC-3) was assessed. Then, the same assays were performed when tumor cell spheres were developed. The role of sonic hedgehog (SHH) in cell spheres from PANC-1 and MIA-Paca-2 were also assessed by RT-PCR.

RESULTS

CD44 and CD24 were detected in PANC-1. Only CD44 expression was detected in PC-2, MIA-Paca-2 and AsPC-1. CD44, CD24 and ESA were all detected in BxPC-3. Tumor cell spheres developed in PANC-1 and MIA-Paca-2 in serum-free medium. This was accompanied by an increase in CD24 expression and a decrease in CD44 expression in PANC-1. Interestingly, the expression of CD44 and CD24 returned to initial levels once the medium was changed back from serum-free to serum-containing medium. No significant change in the expression of CD44 was detected in MIA-Paca-2. Furthermore, the relative quantification of SHH mRNA in PANC-1 cell spheres was significantly higher than that in cells cultured in the serum-containing medium.

CONCLUSION

The expression patterns of the pancreatic cancer stem cell surface markers CD44, CD24 and ESA were diverse in different pancreatic adenocarcinoma cell lines and changed with their local microenvironment.

Rising incidence of pancreatic cancer in France

OBJECTIVES

Time trends in the incidence of pancreatic cancer vary considerably between countries. The aim of this study was to provide time trends in incidence during a 25-year period in a well-defined French population.

METHODS

The cancer registry in Burgundy (France) was used to study time trends between 1981 and 2005 by sex, age, subsite, and histology. They were analyzed using an age-period cohort model.

RESULTS

Age-standardized incidence rates increased from 5.7 (1981-1985) to 7.9 per 100,000 (2001-2005) in men and from 2.6 to 4.6 in women. The mean percentage of variation by the 5-year period was +9.9% (P < 0.001, 95% confidence interval, 6.2%-13.6%) and +13.4% (P = 0.004, 95% confidence interval, 9.4%-17.5%), respectively. The increase in incidence was higher for cancers of the tail and corpus than for cancers of the head of pancreas and for malignant pancreatic endocrine tumors than for adenocarcinomas. The cumulative risk of developing a pancreatic cancer rose from 0.51% for men born in 1900 to 1.13% for those born in 1950. It was 0.34% and 0.55% for women, respectively.

CONCLUSIONS

The incidence of pancreatic cancer has increased sharply in France both by period and by birth cohort. Etiological studies are required to explain the increase in the incidence.

[The epidemiology of pancreatic cancer]

Pancreatic cancer is a relatively uncommon tumor, but even with early diagnosis, mortality rates are high, explaining why this form of cancer has now become a common cause of cancer mortality. There are no screening tests for early detection of pancreatic cancer. It is more common in men than women and is predominantly a disease of elderly people. There is wide variation in the incidence of pancreatic cancer around the world, suggesting that environmental factors are important in the pathogenesis. Smoking is the major known risk factor for pancreatic cancer, while dietary factors seem to be less important. Other possible risk factors include chronic pancreatitis, obesity and type 2 diabetes. Numerous inherited germ line mutations are associated with pancreatic cancer. Of these, hereditary pancreatitis confers the greatest risk, while BRCA2 mutations are the commonest inherited disorder. Polymorphisms in genes that control detoxification of environmental carcinogens and metabolic pathways may alter the risk of pancreatic cancer.

Incidence and survival of pancreatic head and body and tail cancers: a population-based study in the United States

OBJECTIVES

Cancer of the body/tail of the pancreas is frequently separated from pancreatic head tumors. No studies have examined whether the demographics, disease characteristics, and patient survival with pancreatic body/tail cancers are different from pancreatic head tumors.

METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) registry to identify 43,946 cases of pancreatic cancer. The yearly incidence and survival rates were calculated. Cox proportional hazards model examined temporal trends in survival.

RESULTS

The incidence rate for pancreatic head cancer has remained at 5.6% per 100,000, whereas the rate for pancreatic body/tail cancers has increased by 46% between 1973 and 2002. The 3-year survival rate has increased slightly for both groups. The Cox proportional hazards model analysis confirms this improvement. The 3-year survival rate for local-stage pancreatic body/tail cancer is 20.0% compared with 9% for local-stage pancreatic head cancer.

CONCLUSIONS

This study indicates that the incidence of pancreatic head cancer has remained stable, whereas the incidence of pancreatic body/tail cancers is rising. Despite higher survival rates among patients with pancreatic head cancer compared with those with pancreatic body/tail cancers in several variables, patients with local-stage pancreatic body/tail cancers had higher survival rates compared with local-stage pancreatic head cancer.

Epidemiology of pancreatic cancer in Norway: trends in incidence, basis of diagnosis and survival 1965-2007

OBJECTIVE

Pancreatic cancer is the second most frequent gastrointestinal cancer in the Western world. Few reports on concomitant trends in pancreatic cancer incidence, diagnosis, mortality and survival exist at the national level. This study provides a baseline overview of the temporal patterns in these four indicators over the past four decades in Norway.

MATERIAL AND METHODS

We analysed trends in incidence, basis of diagnosis, relative survival and mortality from the Cancer Registry of Norway for the period 1965-2007.

RESULTS

Included were 21,663 patients with pancreatic cancers. Incidence and mortality rates remained at around 6-8 per 100,000 over the study period. Diagnoses based on clinical examination alone dropped from 12.5% (in the 1950s) to <1% (in the 2000s), while use of imaging techniques, such as CT and MRI, increased from 3.6% to >30%. Previously high rates of autopsy-verified diagnosis and non-therapeutic surgery decreased accordingly. Consistently more primary tumours (from 12.9% to 19.4%) and metastases (from 12.5% to 22.4%) had histological examination, and use of endoscopy increased to approximately 10%. Relative survival after diagnosis of pancreatic cancer remains very low. However, in recent years, a modest improvement in short-term survival has been noted, with 1-year survival rates of 18% and 16% for males and females, respectively.

CONCLUSIONS

The incidence and mortality for pancreatic cancer remain largely unchanged, with few 5-year survivors. Improved short-term survival may reflect more aggressive use of surgery and chemotherapy. Further elucidation of risk factors in pancreatic cancer is needed to enable effective prevention, early detection and improved treatment strategies.

Incidence rates of exocrine and endocrine pancreatic cancers in the United States

Descriptive studies of pancreatic cancer incidence have been sparse particularly in terms of tumor histology and stage. The purpose of this study was to examine the incidence rate trends of exocrine and endocrine pancreatic cancers by demographic and tumor characteristics using data from the Surveillance, Epidemiology, and End Results (SEER) program from 1977 to 2005. During this period, the incidence of exocrine pancreatic cancer generally decreased whereas the incidence of endocrine pancreatic cancer increased. This difference in trends by histology was evident across age, gender, and racial groups. It was also evident among different racial/ethnic groups using data from 1992 to 2005. Variation in trends was observed by stage. The incidence of exocrine cancers declined for all stages except regional. Endocrine cancer incidence increased for all tumor stages, and the increase was most prominent for localized tumors. When exocrine tumors were stratified by tumor subsite, the incidence of cancers in the tail and body regions increased while the incidence in other regions decreased. While better detection and classification of tumors through improved diagnostic procedures may be related to these changing trends, etiologic factors warrant study.

Should all distal pancreatectomies be performed laparoscopically?

Despite the relatively slow start of laparoscopic pancreatectomy relative to other laparoscopic resections, an increasing number of these procedures are being performed around the world. Operations that were once considered impossible to perform laparoscopically, such as pancreaticoduodenectomy and central pancreatectomy are gaining momentum. Technology continues to improve, as does surgical experience and prowess. There are both enough experience and data (though retrospective) to confirm that LDP with or without spleen preservation appears to be a safe treatment for benign or noninvasive lesions of the pancreas. Based on the fact that LDP can be performed with similar or shorter operative times, blood loss, complication rates, and length of hospital stay than ODP, it can be recommended as the treatment of choice for benign and noninvasive lesions in experienced hands when clinically indicated. It is very difficult to make clear recommendations with regard to laparoscopic resection of malignant pancreatic tumors due to the lack of conclusive data. As long as margins are negative and lymph node clearance is within accepted standards, LDP appears to have no untoward oncologic effects on outcome. Certainly more data, preferably in the manner of a randomized clinical trial, are needed before additional recommendations can be made. Potential benefits of laparoscopic resection for cancer include the ability to inspect the abdomen and abort the procedure with minimal damage if occult metastases are identified. This does not delay the onset of palliative chemotherapy, which would be the primary treatment in that circumstance. In fact, there is evidence to suggest that there is a greater likelihood of receiving systemic therapy if a laparotomy is avoided in patients who have radiologically occult metastases. Patients may also undergo palliative laparoscopic gastric and biliary bypass if indicated. Faster wound healing may also translate into a shorter waiting time before initiating adjuvant chemotherapy and/or radiation therapy. If the patient develops a wound infection, the infection should be more readily manageable with smaller incisions. Although not proven clinically relevant in humans, the reduction in perioperative stress associated with laparoscopic resection may translate to a cancer benefit for some patients. One report compared markers of systemic inflammatory response in 15 subjects undergoing left pancreatectomy. Eight had hand-access laparoscopic procedures and the rest had standard open surgery. The subjects in the laparoscopic group had statistically lower C-reactive protein levels than the open group on postoperative days one (5.5 mg/dL versus 9.7 mg/dL, P = .006) and three (8.5 mg/dL versus 17.7 mg/dL, P = .003), suggesting that the laparoscopic approach to left pancreatectomy is associated with less inflammation. While this report is underpowered, it supports the notion that MIS cancer surgery may induce less of a systemic insult to the body than standard open cancer surgery. More work in this area is necessary before any firm conclusions can be drawn. An important issue to consider is that of training surgeons to perform these complex procedures laparoscopically. Not all pancreatectomies are amenable to the laparoscopic approach, even in the most skilled hands. As such, only a percentage of cases will be performed this way and expectations to educate surgeons adequately to perform advanced laparoscopic procedures can be unrealistic, resulting in more "on-the-job" training. Another aspect that draws some controversy is that of the totally laparoscopic procedure versus the hand-access approach. No laparoscopic instrument provides the tactile feedback possible to obtain with the hand. The HALS approach allows for this, and the opportunity to control bleeding during the procedure. HALS also provides a way to improve confidence during the learning-curve phase of these operations. Finally, it is important to remember that if the procedure is failing to progress laparoscopically, or if cancer surgery principles are likely to be violated, the surgeon (and the patient) must be willing to abort the laparoscopic approach and complete the operation using standard open technique. During the next few years we can expect to see more robust outcome data with laparoscopic pancreatectomy. The expectation is that more data will come to light demonstrating benefits of laparoscopic pancreatic resection as compared with open technique for selected patients. Several groups are considering randomized trials to look at these endpoints. Although more retrospective and prospectively maintained data will certainly be presented, it is less likely that randomized data specifically examining the question oflaparoscopic versus open pancreatectomy for cancer will mature, due to some of the limitations discussed above. Additional areas of discovery are in staple line reinforcement for left pancreatectomy and suturing technology for pancreatico-intestinal anastomosis. Robotic surgery may have a role in pancreatic surgery. Improving optics and visualization with flexible endoscopes with provide novel surgical views potentially improving the safety of laparoscopy. Another area in laparoscopic surgery that is gaining momentum is that of Natural Orifice Transluminal Endoscopic Surgery (NOTES). NOTES represents the "holy grail" of incisionless surgery. Can we enucleate a small tumor off the pancreatic body by passing an endoscope through the gastric (or colonic) wall, and bring the specimen out via the mouth or anus? Can we use this approach for formal left pancreatectomies? Pioneers have already developed a porcine model of left pancreatectomy. This technology must clear several hurdles before it is cancer ready; however, technology is moving at a rapid pace.

Bone marrow-derived progenitor cells could modulate pancreatic cancer tumorigenesis via peritumoral microenvironment in a rat model

Metaplastic tubular complexes (MTC) have been proposed as precursor lesions for pancreatic adenocarcinoma (PDAC). In this study, we investigated the potential role of bone marrow-derived progenitor cells (BMPC) in the formation of MTC and PDAC in a rat model. F344 rats defective for CD26 (dipeptidyl peptidase IV, DPPIV) expression were sublethally irradiated and received rescue bone marrow cells from wild-type F344 rats that express CD26. After confirming engraftment, recipient animals received dimethylbenzanthracene (DMBA) implantation in their pancreas. Animals were sacrificed monthly from 3 to 7 months. We observed both MTC and tumors in animals that received DMBA. These MTC were ductal complexes because they stained positive for cytokeratin but were negative for chymotrypsin and chromogranin A. Cells that expressed both CD26 and cytokeratin were rarely observed in the MTC. Cells expressing either both CD26 and CD45 or CD26 and smooth muscle actin were also found near the MTC. However, no CD26 signal was detected in the tumors. Within this model, there appeared to be no evidence supporting that BMPC turned into tumor cells directly. BMPC could modulate pancreatic cancer growth through tumor microenvironment.

Pancreatic adenocarcinoma in a young patient population--12-year experience at Memorial Sloan Kettering Cancer Center

BACKGROUND

There is a dearth of data in a younger population of patients with pancreatic ductal adenocarcinoma (PAC) regarding epidemiology, genetics, prognosis, and outcome. This report examines a large cohort of patients with PAC <or=45 years of age evaluated at MSKCC over a 12-year period.

METHODS

A retrospective analysis of patients referred to MSKCC with PAC identified from the institutional tumor registry, who were <or=45 years on the date of the diagnostic biopsy, between January 1995 and February 2008, was performed. Information reviewed included demographics, clinical and pathological staging, surgical management, therapy, date of relapse, death or last follow-up. Survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test.

RESULTS

One hundred thirty-six cases of PAC, age <or=45 years at diagnosis, were identified. Seventy-four (54%) females, 62 (46%) males. Age range: 24-45; 4, 38, and 94 patients in age groups 20-29, 30-39, 40-45 years, respectively. Fifty (37%) had a smoking history. Fourteen (10.3%) had a positive family history of PAC. Thirty-five (25.7%) underwent a curative resection for localized disease. Twenty-eight (20.1%) presented with locally advanced, inoperable disease. Sixty-eight (50%) presented as AJCC Stage IV. Twenty-three (37%) of those resected underwent adjuvant chemoradiation. Thirteen received adjuvant gemcitabine. The median overall survival for the entire cohort was 12.3 months (95% CI 10.2-14.0 months). The median overall survival for the patients with locally resectable disease was 41.8 months (95% CI 20.3-47 months). The median overall survival for the patients who presented with locally advanced, unresectable disease was 15.3 months (95% CI 12-19.3 months). The median overall survival for those who presented with metastatic disease was 7.2 months (95% CI 5.2-9.5 months).

CONCLUSIONS

This is the largest reported cohort of young patients with PAC <or=45 years of age. The data suggest that patients with stages I-II disease may have an improved prognosis, however the prognosis for stages III-IV patients appears to be similar to the typical (older) patient population with PAC.

Sixty-one years of pancreatic cancer in Denmark from 1943 to 2003: a nationwide study

OBJECTIVES

We report the incidence rates of pancreatic cancer in Denmark during 61 years of data registration, from 1943 to 2003.

METHODS

On the basis of reports in the nationwide, population-based Danish Cancer Registry, we calculated age-standardized, period-specific incidence rates of pancreatic cancer.

RESULTS

A total of 32,654 incident cases of pancreatic cancer were evaluated (male-female ratio, 1.4). The age-standardized incidence rate of pancreatic cancer increased steadily in the beginning of the study period from 3.75/100,000 person-years in 1943 to 1947 to the maximum of 9.96/100,000 person-years in 1968 to 1972 among men and from 2.95 in 1943 to 1947 to the maximum of 7.04 in 1978 to 1982 among women. The incidence rates declined between 1968 to 1972 and 1988 to 1992 for men and between 1978 to 1982 and 2003 for women. Most tumors were located in the exocrine pancreas, and most were adenocarcinomas. More than 40% were located in the head of the pancreas; 14% were localized, 21% were regionally spread, and 36% were metastatic at the time of diagnosis. During the period 1978 to 2003, the percentages of histologically or cytologically verified adenocarcinomas remained relatively steady, approximately 30%.

CONCLUSIONS

The incidence rate of pancreatic cancer increased at the beginning of the 61 years of registration and declined slightly thereafter.

Laparoscopic pancreatic resection for cancer

Laparoscopic (lap) organ resection is now commonly performed for the management of solid tumors of the kidney, colon, adrenal glands and prostate. Surgeons have been slower to adopt minimally invasive approaches to the pancreas owing to operative complexity and complication potential. The majority of existing reports concerning lap pancreatectomy are single-center studies that describe experience with fewer than 20 cases. Only recently have larger experiences surfaced demonstrating the safety and efficacy of lap tumor enucleation and lap left pancreatectomy. As neoplastic disease is the most common indication for pancreatic resection, understanding the effects of the lap approach to pancreatectomy on cancer outcome is crucial. In addition to concerns of port-site tumor recurrence and tumor dissemination due to lap manipulation in the setting of pneumoperitoneum, adequacy of resection as defined by margin status and nodal assessment must be considered. This review covers the development and current state-of-the-art of lap pancreatic surgery for cancer. Existing data are reviewed for both open and lap pancreatic resections, with particular attention to pancreatic ductal adenocarcinoma. Projections of future advances in the field of lap pancreatic surgery are provided.

Bone marrow-derived progenitor cells could modulate pancreatic cancer tumorigenesis via peritumoral microenvironment in a rat model

Metaplastic tubular complexes (MTC) have been proposed as precursor lesions for pancreatic adenocarcinoma (PDAC). In this study, we investigated the potential role of bone marrow-derived progenitor cells (BMPC) in the formation of MTC and PDAC in a rat model. F344 rats defective for CD26 (dipeptidyl peptidase IV, DPPIV) expression were sublethally irradiated and received rescue bone marrow cells from wild-type F344 rats that express CD26. After confirming engraftment, recipient animals received dimethylbenzanthracene (DMBA) implantation in their pancreas. Animals were sacrificed monthly from 3 to 7 months. We observed both MTC and tumors in animals that received DMBA. These MTC were ductal complexes because they stained positive for cytokeratin but were negative for chymotrypsin and chromogranin A. Cells that expressed both CD26 and cytokeratin were rarely observed in the MTC. Cells expressing either both CD26 and CD45 or CD26 and smooth muscle actin were also found near the MTC. However, no CD26 signal was detected in the tumors. Within this model, there appeared to be no evidence supporting that BMPC turned into tumor cells directly. BMPC could modulate pancreatic cancer growth through tumor microenvironment.