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Imamura T, Ohgi K, Mori K, Ashida R, Yamada M, Otsuka S, Uesaka K, Sugiura T. Surrogacy of Recurrence-free Survival for Overall Survival as an Endpoint of Clinical Trials of Perioperative Adjuvant Therapy in Hepatobiliary-pancreatic Cancers: A Retrospective Study and Meta-analysis. Ann Surg 2024; 279:1025-1035. [PMID: 37638472 DOI: 10.1097/sla.0000000000006084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
OBJECTIVE To assess the correlation between recurrence-free survival (RFS) and overall survival (OS) in the hepatobiliary-pancreatic (HBP) surgical setting to validate RFS as a surrogate endpoint. BACKGROUND Reliable surrogate endpoints for OS are still limited in the field of HBP surgery. METHODS We analyzed patients who underwent curative resection for HBP disease [986 patients with pancreatic ductal adenocarcinoma (PDAC), 1168 with biliary tract cancer (BTC), 1043 with hepatocellular carcinoma, and 1071 with colorectal liver metastasis] from September 2002 to June 2022. We also conducted meta-analyses of randomized controlled trials of neoadjuvant or adjuvant therapy to validate the surrogacy in PDAC and BTC. RESULTS Correlation coefficients between RFS and OS were low for hepatocellular carcinoma ( p = 0.67) and colorectal liver metastasis ( p = 0.53) but strong for PDAC ( p = 0.80) and BTC ( p = 0.75). In a landmark analysis, the concordance rates between survival or death at 5 years postoperatively and the presence or absence of recurrence at each time point (1, 2, 3, and 4 years) were 50%, 70%, 74%, and 77% for PDAC and 54%, 67%, 73%, and 78% for BTC, respectively, both increasing and reaching a plateau at 3 years. In a meta-analysis, the correlation coefficients for the RFS hazard ratio and OS hazard ratio in PDAC and BTC were p = 0.88 ( P < 0.001) and p = 0.87 ( P < 0.001), respectively. CONCLUSIONS Three-year RFS can be a reliable surrogate endpoint for OS in clinical trials of neoadjuvant or adjuvant therapy for PDAC and BTC.
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Affiliation(s)
- Taisuke Imamura
- Division of HepatoBiliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhisa Ohgi
- Division of HepatoBiliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Keita Mori
- Clinical Research Center, Shizuoka Cancer Center, Shizuoka, Japan
| | - Ryo Ashida
- Division of HepatoBiliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Mihoko Yamada
- Division of HepatoBiliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Shimpei Otsuka
- Division of HepatoBiliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of HepatoBiliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Teiichi Sugiura
- Division of HepatoBiliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
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Evans D, Ghassemi N, Hajibandeh S, Hajibandeh S, Romman S, Laing RW, Durkin D, Athwal TS. Meta-analysis of adjuvant chemotherapy versus no adjuvant chemotherapy for resected stage I pancreatic cancer. Surgery 2024; 175:1470-1479. [PMID: 38160086 DOI: 10.1016/j.surg.2023.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/06/2023] [Accepted: 11/19/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND To evaluate comparative outcomes of pancreatic cancer resection with or without adjuvant chemotherapy in patients with stage I pancreatic cancer. METHODS A systematic search of MEDLINE, CENTRAL, and Web of Science and bibliographic reference lists were conducted. All comparative studies reporting outcomes of pancreatic cancer resection for stage I cancer with or without adjuvant chemotherapy were included, and their risk of bias was assessed using the Risk Of Bias In Non-randomized Studies-of Interventions tool. Survival outcomes were analyzed using the hazard ratio and odds ratio for the time-to-event and dichotomous outcomes, respectively. RESULTS We included 6 comparative studies reporting a total of 6,874 patients with resected stage 1 pancreatic cancer, of whom 3,951 patients had no adjuvant chemotherapy, and the remaining 2,923 patients received adjuvant chemotherapy. The use of adjuvant chemotherapy was associated with significantly higher overall survival (hazard ratio 0.71, 95% confidence interval 0.62-0.82, P < .00001) and 2-year survival (65.1% vs 57.4%, odds ratio 1.99; 95% confidence interval 1.01-1.41, P = .04) compared to no use of adjuvant chemotherapy. However, there was no statistically significant difference in 1-year (86.8% vs 78.4%, odds ratio 1.60; 95% confidence interval 0.72-3.57, P = .25), 3-year (46.0% vs 44.0%, odds ratio 1.07; 95% confidence interval 0.90-1.29, P = .43), or 5-year survival (24.8% vs 23.3%, odds ratio 1.03; 95% confidence interval 0.80-1.33, P = .81) between the 2 groups. CONCLUSION Meta-analysis of best available evidence (level 2a with low to moderate certainty) demonstrates that adjuvant chemotherapy may confer survival benefits for stage I pancreatic cancer when compared to the use of surgery alone. Randomized control trials are required to escalate the level of evidence and confirm these findings with consideration of contemporary chemotherapy agents and regimens.
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Affiliation(s)
- Daisy Evans
- Department of Hepatobiliary and Pancreatic Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Nader Ghassemi
- Department of Hepatobiliary and Pancreatic Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Shahab Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Shahin Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom.
| | - Saleh Romman
- Department of Hepatobiliary and Pancreatic Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Richard W Laing
- Department of Hepatobiliary and Pancreatic Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Damien Durkin
- Department of Hepatobiliary and Pancreatic Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Tejinderjit S Athwal
- Department of Hepatobiliary and Pancreatic Surgery, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
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Lucocq J, Hawkyard J, Haugk B, Mownah O, Menon K, Furukawa T, Inoue Y, Hirose Y, Sasahira N, Feretis M, Balakrishnan A, Ceresa C, Davidson B, Pande R, Dasari B, Tanno L, Karavias D, Helliwell J, Young A, Nunes Q, Urbonas T, Silva M, Gordon-Weeks A, Barrie J, Gomez D, Van Laarhoven S, Robertson F, Nawara H, Doyle J, Bhogal R, Harrison E, Roalso M, Ciprani D, Aroori S, Ratnayake B, Koea J, Capurso G, Bellotti R, Stättner S, Alsaoudi T, Bhardwaj N, Rajesh S, Jeffery F, Connor S, Cameron A, Jamieson N, Sheen A, Mittal A, Samra J, Gill A, Roberts K, Søreide K, Pandanaboyana S. Adjuvant chemotherapy for adenocarcinoma arising from intraductal papillary mucinous neoplasia: multicentre ADENO-IPMN study. Br J Surg 2024; 111:znae100. [PMID: 38659247 DOI: 10.1093/bjs/znae100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 03/23/2024] [Accepted: 03/26/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND The clinical impact of adjuvant chemotherapy after resection for adenocarcinoma arising from intraductal papillary mucinous neoplasia is unclear. The aim of this study was to identify factors related to receipt of adjuvant chemotherapy and its impact on recurrence and survival. METHODS This was a multicentre retrospective study of patients undergoing pancreatic resection for adenocarcinoma arising from intraductal papillary mucinous neoplasia between January 2010 and December 2020 at 18 centres. Recurrence and survival outcomes for patients who did and did not receive adjuvant chemotherapy were compared using propensity score matching. RESULTS Of 459 patients who underwent pancreatic resection, 275 (59.9%) received adjuvant chemotherapy (gemcitabine 51.3%, gemcitabine-capecitabine 21.8%, FOLFIRINOX 8.0%, other 18.9%). Median follow-up was 78 months. The overall recurrence rate was 45.5% and the median time to recurrence was 33 months. In univariable analysis in the matched cohort, adjuvant chemotherapy was not associated with reduced overall (P = 0.713), locoregional (P = 0.283) or systemic (P = 0.592) recurrence, disease-free survival (P = 0.284) or overall survival (P = 0.455). Adjuvant chemotherapy was not associated with reduced site-specific recurrence. In multivariable analysis, there was no association between adjuvant chemotherapy and overall recurrence (HR 0.89, 95% c.i. 0.57 to 1.40), disease-free survival (HR 0.86, 0.59 to 1.30) or overall survival (HR 0.77, 0.50 to 1.20). Adjuvant chemotherapy was not associated with reduced recurrence in any high-risk subgroup (for example, lymph node-positive, higher AJCC stage, poor differentiation). No particular chemotherapy regimen resulted in superior outcomes. CONCLUSION Chemotherapy following resection of adenocarcinoma arising from intraductal papillary mucinous neoplasia does not appear to influence recurrence rates, recurrence patterns or survival.
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MESH Headings
- Humans
- Female
- Male
- Retrospective Studies
- Aged
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/drug therapy
- Pancreatic Neoplasms/mortality
- Pancreatic Neoplasms/therapy
- Pancreatic Neoplasms/surgery
- Chemotherapy, Adjuvant
- Middle Aged
- Neoplasm Recurrence, Local/epidemiology
- Pancreatectomy
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Adenocarcinoma, Mucinous/pathology
- Adenocarcinoma, Mucinous/drug therapy
- Adenocarcinoma, Mucinous/therapy
- Adenocarcinoma, Mucinous/mortality
- Gemcitabine
- Deoxycytidine/analogs & derivatives
- Deoxycytidine/therapeutic use
- Deoxycytidine/administration & dosage
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Pancreatic Ductal/mortality
- Carcinoma, Pancreatic Ductal/drug therapy
- Carcinoma, Pancreatic Ductal/therapy
- Carcinoma, Pancreatic Ductal/surgery
- Capecitabine/administration & dosage
- Capecitabine/therapeutic use
- Pancreatic Intraductal Neoplasms/pathology
- Pancreatic Intraductal Neoplasms/therapy
- Pancreatic Intraductal Neoplasms/mortality
- Pancreatic Intraductal Neoplasms/surgery
- Adenocarcinoma/pathology
- Adenocarcinoma/drug therapy
- Adenocarcinoma/mortality
- Adenocarcinoma/therapy
- Propensity Score
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Affiliation(s)
- James Lucocq
- Department of General Surgery, NHS Lothian, Edinburgh, UK
| | - Jake Hawkyard
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Beate Haugk
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Omar Mownah
- Department of Hepatobiliary and Pancreatic Surgery, King's College Hospital, London, UK
| | - Krishna Menon
- Department of Hepatobiliary and Pancreatic Surgery, King's College Hospital, London, UK
| | - Takaki Furukawa
- Hepato-Biliary-Pancreatic Medicine Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Inoue
- Hepato-Biliary-Pancreatic Medicine Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yuki Hirose
- Hepato-Biliary-Pancreatic Medicine Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Naoki Sasahira
- Hepato-Biliary-Pancreatic Medicine Department, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Michael Feretis
- Cambridge Hepatobiliary and Pancreatic Surgery Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Anita Balakrishnan
- Cambridge Hepatobiliary and Pancreatic Surgery Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Carlo Ceresa
- Hepatobiliary and Pancreatic Surgery Unit, Royal Free Hospital, London, UK
| | - Brian Davidson
- Hepatobiliary and Pancreatic Surgery Unit, Royal Free Hospital, London, UK
| | - Rupaly Pande
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Bobby Dasari
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Lulu Tanno
- Hepatobiliary and Pancreatic Surgery Unit, University Hospital Southampton, Southampton, UK
| | - Dimitrios Karavias
- Hepatobiliary and Pancreatic Surgery Unit, University Hospital Southampton, Southampton, UK
| | - Jack Helliwell
- Hepatobiliary and Pancreatic Surgery Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alistair Young
- Hepatobiliary and Pancreatic Surgery Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Quentin Nunes
- Department of Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, UK
| | - Tomas Urbonas
- Oxford Hepato-Pancreato-Biliary Surgical Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Michael Silva
- Oxford Hepato-Pancreato-Biliary Surgical Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alex Gordon-Weeks
- Oxford Hepato-Pancreato-Biliary Surgical Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jenifer Barrie
- Nottingham Hepato-Pancreatico-Biliary Service, Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - Dhanny Gomez
- Nottingham Hepato-Pancreatico-Biliary Service, Nottingham University Hospitals NHS Foundation Trust, Nottingham, UK
| | - Stijn Van Laarhoven
- Department of General Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Francis Robertson
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Hossain Nawara
- Department of General Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Joseph Doyle
- Gastrointestinal Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Ricky Bhogal
- Gastrointestinal Unit, Royal Marsden NHS Foundation Trust, London, UK
| | - Ewen Harrison
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Marcus Roalso
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Debora Ciprani
- Hepatopancreatobiliary Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Somaiah Aroori
- Hepatopancreatobiliary Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Bathiya Ratnayake
- Hepato-pancreatico-biliary/Upper Gastrointestinal Unit, North Shore Hospital, Auckland, New Zealand
| | - Jonathan Koea
- Hepato-pancreatico-biliary/Upper Gastrointestinal Unit, North Shore Hospital, Auckland, New Zealand
| | - Gabriele Capurso
- Pancreatico-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Ruben Bellotti
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Stefan Stättner
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Tareq Alsaoudi
- Leicester Hepatopancreatobiliary Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Neil Bhardwaj
- Leicester Hepatopancreatobiliary Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Srujan Rajesh
- Leicester Hepatopancreatobiliary Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Fraser Jeffery
- Department of General and Vascular Surgery, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Saxon Connor
- Department of General and Vascular Surgery, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Andrew Cameron
- Wolfson Wohl Cancer Research Centre, Research Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Nigel Jamieson
- Wolfson Wohl Cancer Research Centre, Research Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Amy Sheen
- New South Wales Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Anubhav Mittal
- Department of Hepatopancreatobiliary Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jas Samra
- Department of Hepatopancreatobiliary Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Anthony Gill
- New South Wales Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Department of Hepatopancreatobiliary Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Keith Roberts
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Sanjay Pandanaboyana
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Jabbour SK, Kumar R, Anderson B, Chino JP, Jethwa KR, McDowell L, Lo AC, Owen D, Pollom EL, Tree AC, Tsang DS, Yom SS. Combinatorial Approaches for Chemotherapies and Targeted Therapies With Radiation: United Efforts to Innovate in Patient Care. Int J Radiat Oncol Biol Phys 2024; 118:1240-1261. [PMID: 38216094 DOI: 10.1016/j.ijrobp.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/05/2024] [Indexed: 01/14/2024]
Abstract
Combinatorial therapies consisting of radiation therapy (RT) with systemic therapies, particularly chemotherapy and targeted therapies, have moved the needle to augment disease control across nearly all disease sites for locally advanced disease. Evaluating these important combinations to incorporate more potent therapies with RT will aid our understanding of toxicity and efficacy for patients. This article discusses multiple disease sites and includes a compilation of contributions from expert Red Journal editors from each disease site. Leveraging improved systemic control with novel agents, we must continue efforts to study novel treatment combinations with RT.
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Affiliation(s)
- Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Jersey.
| | - Ritesh Kumar
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Jersey
| | - Bethany Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Junzo P Chino
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina
| | - Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Lachlan McDowell
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia
| | - Andrea C Lo
- Department of Radiation Oncology, BC Cancer Vancouver Centre, Vancouver, British Columbia, Canada
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Erqi L Pollom
- Department of Radiation Oncology, Stanford University School of Medicine, Palo Alto, California
| | - Alison C Tree
- Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Derek S Tsang
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Sue S Yom
- Department of Radiation Oncology, University of California San Francisco, California
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5
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Liu XY, Pan HN, Yu Y. Clinical efficacy and safety of erlotinib combined with chemotherapy in the treatment of advanced pancreatic cancer: A meta-analysis. World J Gastrointest Surg 2024; 16:921-931. [PMID: 38577077 PMCID: PMC10989324 DOI: 10.4240/wjgs.v16.i3.921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/25/2024] [Accepted: 02/07/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Advanced pancreatic cancer is resistant to chemotherapeutic drugs, resulting in limited treatment efficacy and poor prognosis. Combined administration of the chemotherapeutic gemcitabine and erlotinib is considered a potential first-line treatment for advanced pancreatic cancer. However, their comparative benefits and potential risks remain unclear. AIM To assess the clinical efficacy and safety of erlotinib combined with other chemotherapy regimens for the treatment of advanced pancreatic cancer. METHODS Literature on the clinical efficacy and safety of erlotinib combined with chemotherapy for advanced pancreatic cancer was retrieved through an online search. The retrieved literature was subjected to a methodological qualitative assessment and was analyzed using the RevMan 5.3 software. Ten randomized controlled trials involving 2444 patients with advanced pancreatic cancer were included in the meta-analysis. RESULTS Compared with chemotherapeutic treatment, erlotinib combined with chemotherapy significantly prolonged the progression-free survival time of pancreatic cancer patients [hazard ratio (HR) = 0.78, 95%CI: 0.66-0.92, P = 0.003]. Meanwhile, the overall survival (HR= 0.99, 95%CI: 0.72-1.37, and P = 0.95) and disease control rate (OR = 0.93, 95%CI: 0.45-0.91, P = 0.84) were not significantly favorable. In terms of safety, the erlotinib and chemotherapy combination was associated with a significantly higher risk of diarrhea (OR = 3.59, 95%CI: 1.63-7.90, P < 0.05) and rash (OR = 3.63, 95%CI: 1.64-8.01, P < 0.05) compared with single-agent chemotherapy. Moreover, the risk of vomiting (OR = 1.27, 95%CI: 0.62-2.59, P = 0.51), regurgitation/anorexia (OR = 1.61, 95%CI: 0.25-10.31, P = 0.62), and infection (OR = 0.72, 95%CI: 0.28-1.87, P = 0.50) were not significant in either group. CONCLUSION Compared with a single chemotherapeutic modality, erlotinib combined with gemcitabine can prolong progression-free survival in pancreatic cancer, but does not improve survival benefit or disease control rate, and can increase the risk of diarrhea and rash.
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Affiliation(s)
- Xiao-Yan Liu
- Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong Province, China
- Department of Gastroenterology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China
- Department of Gastroenterology, The Lu’an Hospital Affiliated to Anhui Medical University, The Lu’an People's Hospital, Lu’an 237000, Anhui Province, China
| | - Hong-Nian Pan
- Department of Gastroenterology, The Lu’an Hospital Affiliated to Anhui Medical University, The Lu’an People's Hospital, Lu’an 237000, Anhui Province, China
| | - Yue Yu
- Cheeloo College of Medicine, Shandong University, Jinan 250012, Shandong Province, China
- Department of Gastroenterology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230001, Anhui Province, China
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6
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Tchelebi LT, Winter KA, Abrams RA, Safran HP, Regine WF, McNulty S, Wu A, Du KL, Seaward SA, Bian SX, Aljumaily R, Shivnani A, Knoble JL, Crocenzi TS, DiPetrillo TA, Roof KS, Crane CH, Goodman KA. Analysis of Radiation Therapy Quality Assurance in NRG Oncology RTOG 0848. Int J Radiat Oncol Biol Phys 2024; 118:107-114. [PMID: 37598723 PMCID: PMC10843017 DOI: 10.1016/j.ijrobp.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 07/07/2023] [Accepted: 08/07/2023] [Indexed: 08/22/2023]
Abstract
PURPOSE NRG/Radiation Therapy Oncology Group 0848 is a 2-step randomized trial to evaluate the benefit of the addition of concurrent fluoropyrimidine and radiation therapy (RT) after adjuvant chemotherapy (second step) for patients with resected pancreatic head adenocarcinoma. Real-time quality assurance (QA) was performed on each patient who underwent RT. This analysis aims to evaluate adherence to protocol-specified contouring and treatment planning and to report the types and frequencies of deviations requiring revisions. METHODS AND MATERIALS In addition to a web-based contouring atlas, the protocol outlined step-by-step instructions for generating the clinical treatment volume through the creation of specific regions of interest. The planning target volume was a uniform 0.5 cm clinical treatment volume expansion. One of 2 radiation oncology study chairs independently reviewed each plan. Plans with unacceptable deviations were returned for revision and resubmitted until approved. Treatment started after final approval of the RT plan. RESULTS From 2014 to 2018, 354 patients were enrolled in the second randomization. Of these, 160 patients received RT and were included in the QA analysis. Resubmissions were more common for patients planned with 3-dimensional conformal RT (43%) than with intensity modulated RT (31%). In total, at least 1 resubmission of the treatment plan was required for 33% of patients. Among patients requiring resubmission, most only needed 1 resubmission (87%). The most common reasons for resubmission were unacceptable deviations with respect to the preoperative gross target volume (60.7%) and the pancreaticojejunostomy (47.5%). CONCLUSION One-third of patients required resubmission to meet protocol compliance criteria, demonstrating the continued need for expending resources on real-time, pretreatment QA in trials evaluating the use of RT, particularly for pancreas cancer. Rigorous QA is critically important for clinical trials involving RT to ensure that the true effect of RT is assessed. Moreover, RT QA serves as an educational process through providing feedback from specialists to practicing radiation oncologists on best practices.
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Affiliation(s)
- Leila T Tchelebi
- Northwell, New Hyde Park, New York; Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.
| | - Kathryn A Winter
- Statistics and Data Management Center, NRG Oncology, Philadelphia, Pennsylvania
| | - Ross A Abrams
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois
| | - Howard P Safran
- Department of Hematology & Oncology, Rhode Island Hospital, Providence, Rhode Island
| | - William F Regine
- Department of Radiation Oncology, University of Maryland/Greenebaum Cancer Center, Baltimore, Maryland
| | - Susan McNulty
- Department of Clinical Research, NRG Oncology/IROC, Philadelphia, Pennsylvania
| | - Abraham Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kevin L Du
- Department of Radiation Oncology, Yale School of Medicine, Smilow Cancer Hospital, New Haven, Connecticut
| | - Samantha A Seaward
- Department of Radiation Oncology, Kaiser Permanente NCI Community Oncology Research Program, Vallejo, California
| | - Shelly X Bian
- Department of Radiation Oncology, USC / Norris Comprehensive Cancer Center, Los Angeles, California
| | - Raid Aljumaily
- Department of Hematology & Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Anand Shivnani
- Department of Radiation Oncology, The US Oncology Network, McKinney, Texas
| | - Jeanna L Knoble
- Department of Hematology & Oncology, Columbus NCI Community Oncology Research Program, Columbus, Ohio
| | - Todd S Crocenzi
- Department of Hematology & Oncology, Providence Portland Medical Center, Portland, Oregon
| | | | - Kevin S Roof
- Department of Radiation Oncology, Novant Health Presbyterian Center, Charlotte, North Carolina
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Karyn A Goodman
- Department of Radiation Oncology, Mount Sinai Hospital, New York, New York.
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7
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Ei S, Takahashi S, Ogasawara T, Mashiko T, Masuoka Y, Nakagohri T. Neoadjuvant and Adjuvant Treatments for Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma: The Current Status of Pancreatic Ductal Adenocarcinoma Treatment in Japan. Gut Liver 2023; 17:698-710. [PMID: 36843421 PMCID: PMC10502496 DOI: 10.5009/gnl220311] [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: 07/18/2022] [Revised: 10/30/2022] [Accepted: 10/30/2022] [Indexed: 02/28/2023] Open
Abstract
Resection is the only curative treatment for pancreatic ductal adenocarcinoma (PDAC). Although the outcome of technically resectable PDAC has improved with advances in surgery and adjuvant therapy, the 5-year survival rate remains low at 20% to 40%. More effective therapy is needed. Almost 15 years ago, the National Comprehensive Cancer Network guidelines proposed a resectability classification of PDAC based on preoperative imaging. Since then, treatment strategies for PDAC have been devised based on resectability. The standard of care for resectable PDAC is adjuvant chemotherapy after R0 resection, as shown by the results of pivotal clinical trials. With regard to neoadjuvant treatment, several recent clinical trials comparing neoadjuvant treatment with upfront resection have been conducted on resectable PDAC and borderline resectable PDAC, and the benefits and efficacy of neoadjuvant treatment for pancreatic cancer has become clearer. The significance of neoadjuvant treatment for resectable PDAC remains controversial, but in borderline resectable PDAC the efficacy of neoadjuvant treatment has been further recognised, although the standard of care has not yet been established. Several promising clinical trials for PDAC are ongoing. This review presents previous and ongoing trials of perioperative treatment for resectable and borderline resectable PDAC, focusing on the difference between Asian and Western countries.
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Affiliation(s)
- Shigenori Ei
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Shinichiro Takahashi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Toshihito Ogasawara
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Taro Mashiko
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Yoshihito Masuoka
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
| | - Toshio Nakagohri
- Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan
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8
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Wu L, Xu Y, Zhou Y, Zeng Z, Fan Y, Wang D, Wu W, Guo X, Lv M, Ouyang Y, Du S, Lou W. Additional adjuvant radiotherapy improves survival at 1 year after surgical treatment for pancreatic cancer patients with T 4, N 2 disease, positive resection margin, and receiving adjuvant chemotherapy. Front Oncol 2023; 13:1109068. [PMID: 37534251 PMCID: PMC10391548 DOI: 10.3389/fonc.2023.1109068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 06/27/2023] [Indexed: 08/04/2023] Open
Abstract
Background While adjuvant chemotherapy has been established as standard practice following radical resection of pancreatic ductal adenocarcinoma (PDAC), the role of adjuvant radiation therapy (RT) and which patients may benefit remains unclear. Methods This retrospective study included PDAC patients who received pancreatic surgery from April 2012 to December 2019 in Zhongshan Hospital Fudan University. Patients with carcinoma in situ, distant metastasis, and without adjuvant chemotherapy were excluded. Cox proportional hazards modeling of survival were constructed to find potential prognostic factors. Propensity score matching (PSM) and exploratory subgroup analyses were used to create a balanced covariate distribution between groups and to investigate therapeutic effect of radiotherapy in certain subgroups. Results A total of 399 patients were finally included, 93 of them receiving adjuvant chemoradiotherapy (C+R+) and 306 of them receiving chemotherapy only. Patients in C+R+ group were more likely to be male patients with T3-4 disease. Lymph node metastases was the only negative prognostic factor associated with overall survival (OS). Additional adjuvant RT was not associated with an OS benefit both before and after PSM. Surprisingly, a trend towards improved OS with RT among patients with either T4, N2 disease or R1 resection becomes significant in patients alive more than 1 year after surgery. Conclusion Adjuvant RT was not associated with an OS benefit across all patients, though did show a possible OS benefit for the subgroup with T4N2 disease or R1 resection at 1 year after surgery.
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Affiliation(s)
- Lili Wu
- Department of Radiotherapy, Zhongshan Hospital Fudan University, Shanghai, China
| | - Yaolin Xu
- Department of Pancreatic Surgery, Zhongshan Hospital Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital Fudan University, Shanghai, China
- Department of General Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Yuhong Zhou
- Department of Medical Oncology, Zhongshan Hospital Fudan University, Shanghai, China
| | - Zhaochong Zeng
- Department of Radiotherapy, Zhongshan Hospital Fudan University, Shanghai, China
| | - Yue Fan
- Department of Traditional Chinese Medicine, Zhongshan Hospital Fudan University, Shanghai, China
| | - Dansong Wang
- Department of Pancreatic Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Wenchuan Wu
- Department of Pancreatic Surgery, Zhongshan Hospital Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital Fudan University, Shanghai, China
- Department of General Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Xi Guo
- Department of Medical Oncology, Zhongshan Hospital Fudan University, Shanghai, China
| | - Minzhi Lv
- Department of Biostatistics, Zhongshan Hospital Fudan University, Shanghai, China
| | - Yuxiu Ouyang
- Department of Abdominal Tumor Radiotherapy, Guangdong Province Zhongshan City People's Hospital, Zhongshan, Guangdong, China
| | - Shisuo Du
- Department of Radiotherapy, Zhongshan Hospital Fudan University, Shanghai, China
| | - Wenhui Lou
- Department of Pancreatic Surgery, Zhongshan Hospital Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital Fudan University, Shanghai, China
- Department of General Surgery, Zhongshan Hospital Fudan University, Shanghai, China
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9
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Biagi JJ, Cosby R, Bahl M, Elfiki T, Goodwin R, Hallet J, Hirmiz K, Mahmud A. Adjuvant Chemotherapy and Radiotherapy in Resected Pancreatic Ductal Adenocarcinoma: A Systematic Review and Clinical Practice Guideline. Curr Oncol 2023; 30:6575-6586. [PMID: 37504342 PMCID: PMC10378160 DOI: 10.3390/curroncol30070482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/26/2023] [Accepted: 07/07/2023] [Indexed: 07/29/2023] Open
Abstract
Pancreatic cancer is the seventh leading cause of cancer deaths worldwide, accounting for 4.7% of all cancer deaths, and is expected to climb significantly over the next decade. The purpose of this systematic review and guidance document was to synthesize the evidence surrounding the role of adjuvant treatment (chemotherapy and chemoradiation therapy [CRT], and stereotactic body radiation therapy [SBRT]) in resected pancreatic ductal adenocarcinoma (PDAC). Systematic literature searches of MEDLINE, EMBASE, and 11 guideline databases were conducted. Both direct and indirect comparisons indicate adjuvant chemotherapy offers a survival advantage over surgery alone. The optimal regimens recommended are mFOLFIRINOX with alternative options of gemcitabine plus capecitabine, gemcitabine alone, or S-1 (which is not available in North America). Trials comparing a CRT strategy to modern chemotherapy regimens are lacking. However, current evidence demonstrates that the addition of CRT to chemotherapy does not result in a survival advantage over chemotherapy alone and is therefore not recommended. Trials evaluating SBRT in PDAC are also lacking. SBRT should only be used within a clinical trial or multi-institutional registry.
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Affiliation(s)
- James J Biagi
- Cancer Centre of Southeastern Ontario, 25 King Street West, Kingston, ON K7L 5P9, Canada
| | - Roxanne Cosby
- Program in Evidence-Based Care, Department of Oncology, Juravinski Campus, McMaster University, 711 Concession Street, Hamilton, ON L8V 1C3, Canada
| | - Mala Bahl
- Trillium Health Partners, 2200 Ellington Avenue West, Mississauga, ON L5M 2N1, Canada
| | - Tarek Elfiki
- Windsor Regional Cancer Centre, 2220 Kildare Road, Windsor, ON N8W 2X3, Canada
| | - Rachel Goodwin
- The Ottawa Hospital Cancer Centre, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada
| | - Julie Hallet
- Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M4, Canada
| | - Khalid Hirmiz
- Windsor Regional Cancer Centre, 2220 Kildare Road, Windsor, ON N8W 2X3, Canada
| | - Aamer Mahmud
- Cancer Centre of Southeastern Ontario, 25 King Street West, Kingston, ON K7L 5P9, Canada
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10
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Springfeld C, Ferrone CR, Katz MHG, Philip PA, Hong TS, Hackert T, Büchler MW, Neoptolemos J. Neoadjuvant therapy for pancreatic cancer. Nat Rev Clin Oncol 2023; 20:318-337. [PMID: 36932224 DOI: 10.1038/s41571-023-00746-1] [Citation(s) in RCA: 67] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 03/19/2023]
Abstract
Patients with localized pancreatic ductal adenocarcinoma (PDAC) are best treated with surgical resection of the primary tumour and systemic chemotherapy, which provides considerably longer overall survival (OS) durations than either modality alone. Regardless, most patients will have disease relapse owing to micrometastatic disease. Although currently a matter of some debate, considerable research interest has been focused on the role of neoadjuvant therapy for all forms of resectable PDAC. Whilst adjuvant combination chemotherapy remains the standard of care for patients with resectable PDAC, neoadjuvant chemotherapy seems to improve OS without necessarily increasing the resection rate in those with borderline-resectable disease. Furthermore, around 20% of patients with unresectable non-metastatic PDAC might undergo resection following 4-6 months of induction combination chemotherapy with or without radiotherapy, even in the absence of a clear radiological response, leading to improved OS outcomes in this group. Distinct molecular and biological responses to different types of therapies need to be better understood in order to enable the optimal sequencing of specific treatment modalities to further improve OS. In this Review, we describe current treatment strategies for the various clinical stages of PDAC and discuss developments that are likely to determine the optimal sequence of multimodality therapies by integrating the fundamental clinical and molecular features of the cancer.
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Affiliation(s)
- Christoph Springfeld
- Department of Medical Oncology, National Center for Tumour Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Philip A Philip
- Wayne State University School of Medicine, Department of Oncology, Henry Ford Cancer Institute, Detroit, MI, USA
| | - Theodore S Hong
- Research and Scientific Affairs, Gastrointestinal Service Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - John Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
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11
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Hill CS, Herman JM. The Current Role of Radiation in Pancreatic Cancer and Future Directions. Clin Colorectal Cancer 2023; 22:12-23. [PMID: 36804206 DOI: 10.1016/j.clcc.2023.01.002] [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: 07/25/2022] [Revised: 12/15/2022] [Accepted: 01/24/2023] [Indexed: 02/01/2023]
Abstract
Survival outcomes for localized pancreatic adenocarcinoma remains poor. Multimodality therapeutic regimens are critical to maximizing survival outcomes for these patients, which includes the use of systemic therapy, surgery, and radiation. In this review, the evolution of radiation techniques are discussed with a focus on modern techniques such as intensity modulated radiation and stereotactic body radiation therapy. However, the current role of radiation within the most common clinical scenarios for pancreatic cancer in the neoadjuvant, definitive, and adjuvant settings continues to be highly debated. The role of radiation in these settings is reviewed in the context of historical and modern clinical studies. In addition, emerging concepts including dose-escalated radiation, magnetic resonance-guided radiation therapy, and particle therapy are discussed to promote an understanding of how such concepts may change the role of radiation in the future.
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Affiliation(s)
- Colin S Hill
- Department of Radiation Oncology, Perlmutter Cancer Center, New York University Grossman School of Medicine, New York, NY.
| | - Joseph M Herman
- Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY
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12
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Malla M, Fekrmandi F, Malik N, Hatoum H, George S, Goldberg RM, Mukherjee S. The evolving role of radiation in pancreatic cancer. Front Oncol 2023; 12:1060885. [PMID: 36713520 PMCID: PMC9875560 DOI: 10.3389/fonc.2022.1060885] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/22/2022] [Indexed: 01/13/2023] Open
Abstract
Pancreatic cancer is the fourth leading cause of cancer mortality in the United States. Chemotherapy in resectable pancreatic cancer has improved survival by 10-20%. It only converted 10-30% of the borderline resectable and locally advanced pancreatic cancers to be surgically resectable. Radiation therapy has a documented role in managing localized pancreatic cancer, more so for borderline and locally advanced pancreatic cancer, where it can potentially improve the resectability rate of a given neoadjuvant treatment. The role of radiation therapy in resected pancreatic cancer is controversial, but it is used routinely to treat positive margins after pancreatic cancer surgery. Radiation therapy paradigms continue to evolve with advancements in treatment modalities, delivery techniques, and combination approaches. Despite the advances, there continues to be a controversy on the role of radiation therapy in managing this disease. In this review article, we discuss the recent updates, delivery techniques, and motion management in radiation therapy and dissect the applicability of this therapy in pancreatic cancer.
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Affiliation(s)
- Midhun Malla
- West Virginia University Cancer Institute, Morgantown, WV, United States
| | - Fatemeh Fekrmandi
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Nadia Malik
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
| | - Hassan Hatoum
- Hematology/Oncology, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Sagila George
- Hematology/Oncology, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | | | - Sarbajit Mukherjee
- Department of Medicine, GI Medical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States,*Correspondence: Sarbajit Mukherjee,
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13
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Bashir B, Mueller AC. Pancreatic Adenocarcinoma: An Evolving Yet Unimpressive Treatment Landscape. JCO Oncol Pract 2023; 19:33-34. [PMID: 36206500 DOI: 10.1200/op.22.00620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Babar Bashir
- Department of Medical Oncology & Pharmacology, Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA
| | - Adam C Mueller
- Department of Radiation Oncology, Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA
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14
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de Jesus VHF, Riechelmann RP. Current Treatment of Potentially Resectable Pancreatic Ductal Adenocarcinoma: A Medical Oncologist's Perspective. Cancer Control 2023; 30:10732748231173212. [PMID: 37115533 PMCID: PMC10155028 DOI: 10.1177/10732748231173212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
Pancreatic cancer has traditionally been associated with a dismal prognosis, even in early stages of the disease. In recent years, the introduction of newer generation chemotherapy regimens in the adjuvant setting has improved the survival of patients treated with upfront resection. However, there are multiple theoretical advantages to deliver early systemic therapy in patients with localized pancreatic cancer. So far, the evidence supports the use of neoadjuvant therapy for patients with borderline resectable pancreatic cancer. The benefit of this treatment sequence for patients with resectable disease remains elusive. In this review, we summarize the data on adjuvant therapy for pancreatic cancer and describe which evidence backs the use of neoadjuvant therapy. Additionally, we address important issues faced in clinical practice when treating patients with localized pancreatic cancer.
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15
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Kim H, Olsen JR, Green OL, Chin RI, Hawkins WG, Fields RC, Hammill C, Doyle MB, Chapman W, Suresh R, Tan B, Pedersen K, Jansen B, DeWees TA, Lu E, Henke LE, Badiyan S, Parikh PJ, Roach MC, Wang-Gillam A, Lim KH. MR-Guided Radiation Therapy With Concurrent Gemcitabine/Nab-Paclitaxel Chemotherapy in Inoperable Pancreatic Cancer: A TITE-CRM Phase I Trial. Int J Radiat Oncol Biol Phys 2023; 115:214-223. [PMID: 35878713 DOI: 10.1016/j.ijrobp.2022.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/06/2022] [Accepted: 07/13/2022] [Indexed: 02/09/2023]
Abstract
PURPOSE Ablative radiation therapy for borderline resectable or locally advanced pancreatic ductal adenocarcinoma (BR/LA-PDAC) may limit concurrent chemotherapy dosing and usually is only safely deliverable to tumors distant from gastrointestinal organs. Magnetic resonance guided radiation therapy may safely permit radiation and chemotherapy dose escalation. METHODS AND MATERIALS We conducted a single-arm phase I study to determine the maximum tolerated dose of ablative hypofractionated radiation with full-dose gemcitabine/nab-paclitaxel in patients with BR/LA-PDAC. Patients were treated with gemcitabine/nab-paclitaxel (1000/125 mg/m2) x 1c then concurrent gemcitabine/nab-paclitaxel and radiation. Gemcitabine/nab-paclitaxel and radiation doses were escalated per time-to-event continual reassessment method from 40 to 45 Gy 25 fxs with chemotherapy (600-800/75 mg/m2) to 60 to 67.5 Gy/15 fractions and concurrent gemcitabine/nab-paclitaxel (1000/100 mg/m2). The primary endpoint was maximum tolerated dose of radiation as defined by 60-day dose limiting toxicity (DLT). DLT was treatment-related G5, G4 hematologic, or G3 gastrointestinal requiring hospitalization >3 days. Secondary endpoints included resection rates, local progression free survival (LPFS), distant metastasis free survival (DMFS), and overall survival (OS). RESULTS Thirty patients enrolled (March 2015-February 2019), with 26 evaluable patients (2 progressed before radiation, 1 was determined ineligible for radiation during planning, 1 withdrew consent). One DLT was observed. The DLT rate was 14.1% (3.3%-24.9%) with a maximum tolerated dose of gemcitabine/nab-paclitaxel (1000/100 mg/m2) and 67.5 Gy/15 fractions. At a median follow-up of 40.6 months for living patients the median OS was 14.5 months (95% confidence interval [CI], 10.9-28.2 months). The median OS for patients with Eastern Collaborative Oncology Group 0 and carbohydrate antigen 19-9 <90 were 34.1 (95% CI, 13.6-54.1) and 43.0 (95% CI, 8.0-not reached) months, respectively. Two-year LPFS and DMFS were 85% (95% CI, 63%-94%) and 57% (95% CI, 34%-73%), respectively. CONCLUSIONS Full-dose gemcitabine/nab-paclitaxel with ablative magnetic resonance guided radiation therapy dosing is safe in patients with BR/LA-PDAC, with promising LPFS and DMFS.
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Affiliation(s)
- Hyun Kim
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri.
| | - Jeffrey R Olsen
- University of Colorado School of Medicine, Department of Radiation Oncology, Denver, Colorado
| | - Olga L Green
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - Re-I Chin
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - William G Hawkins
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - Ryan C Fields
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - Chet Hammill
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - Majella B Doyle
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - William Chapman
- Washington University School of Medicine, Department of Surgery, Division of General Surgery, Section of Pancreatic, Hepatobiliary and Gastrointestinal Surgery, St. Louis, Missouri
| | - Rama Suresh
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
| | - Benjamin Tan
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
| | - Katrina Pedersen
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
| | - Brandi Jansen
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - Todd A DeWees
- Mayo Clinic, Scottsdale, Division of Biomedical Statistics and Informatics, Scottsdale, Arizona
| | - Esther Lu
- Washington University School of Medicine, Division of Public Health Sciences, Department of Surgery, St. Louis, Missouri
| | - Lauren E Henke
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - Shahed Badiyan
- Washington University School of Medicine, Department of Radiation Oncology, St. Louis, Missouri
| | - Parag J Parikh
- Henry Ford Health System, Department of Radiation Oncology, Detroit, Michigan
| | - Michael C Roach
- Hawai'i Pacific Health, Department of Radiation Oncology, Honolulu, Hawaii
| | - Andrea Wang-Gillam
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
| | - Kian-Huat Lim
- Washington University School of Medicine, Department of Medicine, Division of Oncology, Section of Medical Oncology, St. Louis, Missouri
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16
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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17
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Seo YD, Katz MHG. Preoperative therapy for pancreatic adenocarcinoma-precision beyond anatomy. Cancer 2022; 128:3041-3056. [PMID: 35679197 DOI: 10.1002/cncr.34273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 12/16/2022]
Abstract
Despite recent advances in the systemic treatment of gastrointestinal tumors, pancreatic adenocarcinoma (PDAC) remains a challenging disease, with 5-year survival just over 10%. Pancreatectomy in patients meeting defined anatomic criteria can result in cure; however, perioperative morbidity and mortality, as well as high rates of both local and distant recurrence even after "potentially curative" resection, have limited survival. Although perioperative chemotherapy has been shown to improve patients' longevity and chance for cure, debate continues about whether the preoperative or adjuvant approach is most effective in treatment of localized PDAC. Large, randomized multicenter trials in patients with resectable and borderline resectable PDAC have evaluated an evolving therapeutic landscape with mixed results. Importantly, these landmark studies share the fundamentally flawed assumption that tumor anatomical characteristics are an indicator of behavior and natural history. Concurrent biologic and translational research has revealed that rather than a single disease, PDAC represents a phenotypically variable group of malignancies arising in physiologically diverse patients. Ongoing novel trials have begun to capture this heterogeneity both in patient selection as well as the measurement of response by using genomic, transcriptional and radiomic markers. By moving away from classic anatomic descriptors to a more nuanced landscape of biomarkers predictive of tumor behavior and response, we can further refine the questions asked in preoperative trials and translate the answers to clinically meaningful precision therapy in localized PDAC.
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Affiliation(s)
- Y David Seo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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18
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Ulanja MB, Moody AE, Beutler BD, Antwi-Amoabeng D, Rahman GA, Alese OB. Early-onset pancreatic cancer: a review of molecular mechanisms, management, and survival. Oncotarget 2022; 13:828-841. [PMID: 35720978 PMCID: PMC9200435 DOI: 10.18632/oncotarget.28242] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 05/30/2022] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Early-onset pancreatic cancer (EOPC) - defined as pancreatic cancer diagnosed before the age of 50 years - is associated with a poor prognosis as compared to later-onset pancreatic cancer (LOPC). Emerging evidence suggests that EOPC may exhibit a genetic signature and tumor biology that is distinct from that of LOPC. We review genetic mutations that are more prevalent in EOPC relative to LOPC and discuss the potential impact of these mutations on treatment and survival. MATERIALS AND METHODS Using PubMed and Medline, the following terms were searched and relevant citations assessed: "early onset pancreatic cancer," "late onset pancreatic cancer," "pancreatic cancer," "pancreatic cancer genes," and "pancreatic cancer targeted therapy." RESULTS Mutations in CDKN2, FOXC2, and SMAD4 are significantly more common in EOPC as compared to LOPC. In addition, limited data suggest that PI3KCA mutations are more frequently observed in EOPC as compared to LOPC. KRAS mutations are relatively rare in EOPC. CONCLUSIONS Genetic mutations associated with EOPC are distinct from those of LOPC. The preponderance of the evidence suggest that poor outcomes in EOPC are related both to advanced stage of presentation and unique tumor biology. The molecular and genetic features of EOPC warrant further investigation in order to optimize management.
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Affiliation(s)
- Mark B. Ulanja
- Christus Ochsner Saint Patrick Hospital, Lake Charles, LA 70601, USA
| | - Alastair E. Moody
- Department of Anesthesiology, University of Utah, Salt Lake City, UT 84112, USA
| | - Bryce D. Beutler
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, CA 90033, USA
| | | | - Ganiyu A. Rahman
- Department of Surgery, University of Cape Coast, School of Medical Sciences, Cape Coast, Ghana
| | - Olatunji B. Alese
- Department of Hematology and Oncology, Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
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19
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Pijnappel EN, Suurmeijer JA, Koerkamp BG, Kos M, Siveke JT, Salvia R, Ghaneh P, van Eijck CHJ, van Etten-Jamaludin FS, Abrams R, Brasiuniene B, Büchler MW, Casadei R, van Laethem JL, Berlin J, Boku N, Conroy T, Golcher H, Sinn M, Neoptolemos JP, van Tienhoven G, Besselink MG, Wilmink JW, van Laarhoven HWM. Consensus Statement on Mandatory Measurements for Pancreatic Cancer Trials for Patients With Resectable or Borderline Resectable Disease (COMM-PACT-RB): A Systematic Review and Delphi Consensus Statement. JAMA Oncol 2022; 8:929-937. [PMID: 35446336 DOI: 10.1001/jamaoncol.2022.0168] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Pancreatic cancer is the third most common cause of cancer death; however, randomized clinical trials (RCTs) of survival in patients with resectable pancreatic cancer lack mandatory measures for reporting baseline and prognostic factors, which hampers comparisons between outcome measures. Objective To develop a consensus on baseline and prognostic factors to be used as mandatory measurements in RCTs of resectable and borderline resectable pancreatic cancer. Evidence Review We performed a systematic literature search of the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and Embase for RCTs on resectable and borderline resectable pancreatic cancer with overall survival as the primary outcome. We produced a systematic summary of all baseline and prognostic factors identified in the RCTs. A Delphi panel that included 13 experts was surveyed to reach a consensus on mandatory and recommended baseline and prognostic factors. Findings The 42 RCTs that met inclusion criteria reported a total of 60 baseline and 19 prognostic factors. After 2 Delphi rounds, agreement was reached on 50 mandatory baseline and 20 mandatory prognostic factors for future RCTs, with a distinction between studies of neoadjuvant vs adjuvant treatment. Conclusion and Relevance This findings of this systematic review and international expert consensus have produced this Consensus Statement on Mandatory Measurements in Pancreatic Cancer Trials for Resectable and Borderline Resectable Disease (COMM-PACT-RB). The baseline and prognostic factors comprising the mandatory measures will facilitate better comparison across RCTs and eventually will enable improved clinical practice among patients with resectable and borderline resectable pancreatic cancer.
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Affiliation(s)
- Esther N Pijnappel
- Department of Medical Oncology, Cancer Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - J Annelie Suurmeijer
- Department of Surgery, Cancer Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Milan Kos
- Department of Medical Oncology, Cancer Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jens T Siveke
- Institute for Developmental Cancer Therapeutics, West German Cancer Center, University Medicine Essen, Essen, Germany
- Division of Solid Tumor Translational Oncology, German Cancer Consortium and German Cancer Research Center, Heidelberg, Germany
| | | | - Paula Ghaneh
- Department of Molecular and Clinical Cancer Medicine University of Liverpool, Liverpool, UK
| | | | | | - Ross Abrams
- Sharett Institute of Oncology, Hadassah Medical Center, Jerusalem, Israel
| | - Birute Brasiuniene
- Department of Medical Oncology, National Cancer Institute, Faculty of Medicine, Vilnius University, Lithuania
| | - Markus W Büchler
- Department of General Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Jean-Luc van Laethem
- Department of Gastroenterology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jordan Berlin
- Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, US
| | - Narikazu Boku
- Division of Gastrointestinal Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Thierry Conroy
- Department of Medical Oncology, Institut de Cancérologie de Lorraine, Vandoeuvre-lès-Nancy, France
| | - Henriette Golcher
- Department of Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Marianne Sinn
- Charite-Universitatsmedizin Berlin, CONKO study group, Berlin, Germany
- University Medical Center of Hamburg-Eppendorf, Hamburg, Germany
| | - John P Neoptolemos
- Department of General Surgery, University of Heidelberg, Heidelberg, Germany
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Hanneke W M van Laarhoven
- Department of Medical Oncology, Cancer Center, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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20
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Turner KM, Delman AM, Ammann AM, Sohal D, Olowokure O, Choe KA, Smith MT, Kharofa JR, Ahmad SA, Wilson GC, Patel SH. Is There a Benefit to Adjuvant Chemotherapy in Resected, Early Stage Pancreatic Ductal Adenocarcinoma? Ann Surg Oncol 2022; 29:10.1245/s10434-022-11580-7. [PMID: 35357614 DOI: 10.1245/s10434-022-11580-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/21/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of systemic therapy for Stage IA pancreatic ductal adenocarcinoma (PDAC) is unclear. The aim of our study was to evaluate the impact of adjuvant chemotherapy (AC) on survival in patients with early stage disease. METHODS The National Cancer Database was queried from 2006 to 2017 for resected pT1N0M0 (Stage 1A) PDAC. Exclusion criteria included neoadjuvant therapy, radiation, or those who suffered a 90-day mortality. RESULTS Of the 1526 patients included in the study, 42.2% received AC and 57.8% underwent surgery alone. Patients who received AC were younger, had fewer comorbidities, and were more likely to have private insurance, compared with those treated with surgery alone. Patients who received AC had longer median overall survival (OS) compared with those who underwent surgery alone (105.7 months vs 72.0 months, p < 0.01). Subset analyses based on individual "good" prognostic features (size ≤ 1.0 cm, lymphovascular invasion negative, well/moderately differentiated, margin negative resection) demonstrated improved OS with AC. Following propensity score matching based on key clinicopathologic features, AC remained associated with improved median OS (83.7 months vs 59.8 months, p < 0.01). However, in the cohort with body/tail tumors (101.2 months vs 95.0 months, p = 0.19) and those with all "good" prognostic features (95.9 months vs 90.6 months, p = 0.15), AC was not associated with improved survival. CONCLUSIONS In resected, Stage IA PDAC, AC is associated with improved overall survival in the vast majority of patients; however, in select cohorts the role of AC is unclear. Further study is needed to tailor treatment to individual patients with PDAC.
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Affiliation(s)
- Kevin M Turner
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Aaron M Delman
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Allison M Ammann
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Davendra Sohal
- Department of Internal Medicine, Division of Hematology & Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Olugbenga Olowokure
- Department of Internal Medicine, Division of Hematology & Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kyuran A Choe
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Milton T Smith
- Department of Internal Medicine, Division of Digestive Diseases, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jordan R Kharofa
- Department of Radiation Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Syed A Ahmad
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregory C Wilson
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameer H Patel
- Department of Surgery, Division of Surgical Oncology, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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21
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Adjuvant Chemoradiotherapy in Resected Pancreatic Ductal Adenocarcinoma: Where Does the Benefit Lie? A Nomogram for Risk Stratification and Patient Selection. J Gastrointest Surg 2022; 26:376-386. [PMID: 34506031 DOI: 10.1007/s11605-021-05130-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 08/13/2021] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The impact of adjuvant sequential chemoradiotherapy (CRT) on survival in resected pancreatic ductal adenocarcinoma (PDAC) remains unclear and warrants further investigation. METHODS NCDB patients with R0/R1 resected PDAC who received adjuvant chemotherapy without CRT or followed by CRT per RTOG-0848 protocol were included. Cox regression for 5-year overall survival (OS) was performed and used to construct a pathologic nomogram in patients who did not receive CRT. A risk score was calculated and patients were divided into low-risk and high-risk groups. Patients from each risk stratum were matched for the receipt of CRT to assess the added benefit of CRT on survival. The Kaplan-Meier analysis was performed to compare OS. RESULTS A total of 7146 patients were selected, 1308 (18.3%) received CRT per RTOG-0848. Cox regression concluded grade, T stage, N stage, node yield < 12, R1, and LVI as significant predictors of 5-year OS which were used to construct the risk score. Matched analysis in low-risk patients (score 0-79) showed no difference in OS between CRT vs. no CRT (47.6 ± 5.7 vs. 45.1 ± 3.9 months; p = 0.847). OS benefit was 3% at 1 year, - 4% at 2 years, and 4% at 5 years. In high-risk patients (score 80-100), median OS was higher in CRT vs. no CRT (24.8 ± 0.7 vs. 21.7 ± 0.8 months; p = 0.043). Absolute OS benefit was 13% at 1 year, 5% at 2 years, and - 1% at 5 years. CONCLUSION CRT has a short-lived impact on OS in resected PDAC that is only evident in high-risk patients. In this subset, survival benefit peaks at 1 year and subsides at 3 to 5 years following PDAC resection.
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22
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Elective Target Coverage for Pancreatic Cancer: When Less Does Not Clearly Achieve More. Int J Radiat Oncol Biol Phys 2022; 112:143-145. [PMID: 34919872 DOI: 10.1016/j.ijrobp.2021.08.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/15/2021] [Indexed: 01/08/2023]
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23
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Cusano E, Wong C, Taguedong E, Vaska M, Abedin T, Nixon N, Karim S, Tang P, Heng DYC, Ezeife D. Impact of Value Frameworks on the Magnitude of Clinical Benefit: Evaluating a Decade of Randomized Trials for Systemic Therapy in Solid Malignancies. Curr Oncol 2021; 28:4894-4928. [PMID: 34898590 PMCID: PMC8628676 DOI: 10.3390/curroncol28060412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 11/23/2022] Open
Abstract
In the era of rapid development of new, expensive cancer therapies, value frameworks have been developed to quantify clinical benefit (CB). We assessed the evolution of CB since the 2015 introduction of The American Society of Clinical Oncology and The European Society of Medical Oncology value frameworks. Randomized clinical trials (RCTs) assessing systemic therapies for solid malignancies from 2010 to 2020 were evaluated and CB (Δ) in 2010–2014 (pre-value frameworks (PRE)) were compared to 2015–2020 (POST) for overall survival (OS), progression-free survival (PFS), response rate (RR), and quality of life (QoL). In the 485 studies analyzed (12% PRE and 88% POST), the most common primary endpoint was PFS (49%), followed by OS (20%), RR (12%), and QoL (6%), with a significant increase in OS and decrease in RR as primary endpoints in the POST era (p = 0.011). Multivariable analyses revealed significant improvement in ΔOS POST (OR 2.86, 95% CI 0.46 to 5.26, p = 0.02) while controlling for other variables. After the development of value frameworks, median ΔOS improved minimally. The impact of value frameworks has yet to be fully realized in RCTs. Efforts to include endpoints shown to impact value, such as QoL, into clinical trials are warranted.
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Affiliation(s)
- Ellen Cusano
- Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Correspondence:
| | - Chelsea Wong
- Faculty of Science, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - Eddy Taguedong
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3A 0G4, Canada;
| | - Marcus Vaska
- Tom Baker Cancer Centre, Calgary, AB T2N 4N2, Canada; (M.V.); (T.A.); (N.N.); (S.K.); (P.T.); (D.Y.C.H.); (D.E.)
| | - Tasnima Abedin
- Tom Baker Cancer Centre, Calgary, AB T2N 4N2, Canada; (M.V.); (T.A.); (N.N.); (S.K.); (P.T.); (D.Y.C.H.); (D.E.)
| | - Nancy Nixon
- Tom Baker Cancer Centre, Calgary, AB T2N 4N2, Canada; (M.V.); (T.A.); (N.N.); (S.K.); (P.T.); (D.Y.C.H.); (D.E.)
| | - Safiya Karim
- Tom Baker Cancer Centre, Calgary, AB T2N 4N2, Canada; (M.V.); (T.A.); (N.N.); (S.K.); (P.T.); (D.Y.C.H.); (D.E.)
| | - Patricia Tang
- Tom Baker Cancer Centre, Calgary, AB T2N 4N2, Canada; (M.V.); (T.A.); (N.N.); (S.K.); (P.T.); (D.Y.C.H.); (D.E.)
| | - Daniel Y. C. Heng
- Tom Baker Cancer Centre, Calgary, AB T2N 4N2, Canada; (M.V.); (T.A.); (N.N.); (S.K.); (P.T.); (D.Y.C.H.); (D.E.)
| | - Doreen Ezeife
- Tom Baker Cancer Centre, Calgary, AB T2N 4N2, Canada; (M.V.); (T.A.); (N.N.); (S.K.); (P.T.); (D.Y.C.H.); (D.E.)
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Snyder RA, Ahmad S, Katz MHG. Pancreas cancer trials for early stage disease: Surgeons leading therapeutic cooperative group trials. J Surg Oncol 2021; 125:75-83. [PMID: 34586635 DOI: 10.1002/jso.26701] [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: 09/16/2021] [Revised: 09/21/2021] [Accepted: 09/21/2021] [Indexed: 01/17/2023]
Abstract
Surgeon-led clinical trials have defined the standard of care for locoregional pancreatic cancer to date. The infrastructure and collaborative nature of cooperative oncology groups offer many advantages, such as providing an ideal mechanism through which multidisciplinary pancreatic cancer trials are performed. As key members of the treatment team, surgeons bring experience and expertise to the design of surgical and multidisciplinary trials and are uniquely poised to be leaders of future pancreatic cancer trials.
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Affiliation(s)
- Rebecca A Snyder
- Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Syed Ahmad
- Department of Surgery, University of Cincinnati Cancer Center, Cincinnati, Ohio, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas at MD Anderson Cancer Center, Houston, Texas, USA
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25
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Pappalardo A, Giunta EF, Tirino G, Pompella L, Federico P, Daniele B, De Vita F, Petrillo A. Adjuvant Treatment in Pancreatic Cancer: Shaping the Future of the Curative Setting. Front Oncol 2021; 11:695627. [PMID: 34485130 PMCID: PMC8415474 DOI: 10.3389/fonc.2021.695627] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/16/2021] [Indexed: 12/19/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease even in the early stages, despite progresses in surgical and pharmacological treatment in recent years. High potential for metastases is the main cause of therapeutic failure in localized disease, highlighting the current limited knowledge of underlying pathological processes. However, nowadays research is focusing on the search for personalized approaches also in the adjuvant setting for PDAC, by implementing the use of biomarkers and investigating new therapeutic targets. In this context, the aim of this narrative review is to summarize the current treatment scenario and new potential therapeutic approaches in early stage PDAC, from both a preclinical and clinical point of view. Additionally, the review examines the role of target therapies in localized PDAC and the influence of neoadjuvant treatments on survival outcomes.
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Affiliation(s)
- Annalisa Pappalardo
- Medical Oncology Unit, Ospedale del Mare, Naples, Italy
- Division of Medical Oncology, Department of Precision Medicine, School of Medicine, University of study of Campania “L. Vanvitelli”, Naples, Italy
| | - Emilio Francesco Giunta
- Medical Oncology Unit, Ospedale del Mare, Naples, Italy
- Division of Medical Oncology, Department of Precision Medicine, School of Medicine, University of study of Campania “L. Vanvitelli”, Naples, Italy
| | - Giuseppe Tirino
- Division of Medical Oncology, Department of Precision Medicine, School of Medicine, University of study of Campania “L. Vanvitelli”, Naples, Italy
| | - Luca Pompella
- Division of Medical Oncology, Department of Precision Medicine, School of Medicine, University of study of Campania “L. Vanvitelli”, Naples, Italy
| | | | - Bruno Daniele
- Medical Oncology Unit, Ospedale del Mare, Naples, Italy
| | - Ferdinando De Vita
- Division of Medical Oncology, Department of Precision Medicine, School of Medicine, University of study of Campania “L. Vanvitelli”, Naples, Italy
| | - Angelica Petrillo
- Medical Oncology Unit, Ospedale del Mare, Naples, Italy
- Division of Medical Oncology, Department of Precision Medicine, School of Medicine, University of study of Campania “L. Vanvitelli”, Naples, Italy
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26
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Mavros MN, Moris D, Karanicolas PJ, Katz MHG, O'Reilly EM, Pawlik TM. Clinical Trials of Systemic Chemotherapy for Resectable Pancreatic Cancer: A Review. JAMA Surg 2021; 156:663-672. [PMID: 33787841 DOI: 10.1001/jamasurg.2021.0149] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Importance Adjuvant chemotherapy is the standard of care for resected pancreatic ductal adenocarcinoma (PDAC) based on level 1 evidence, but some studies suggest that a neoadjuvant approach (which is standard for borderline resectable PDAC) may be preferable for upfront resectable PDAC. An in-depth review was conducted of all randomized clinical trials that investigated neoadjuvant and adjuvant treatment of patients with resectable or resected PDAC, focusing on trial design, characteristics of enrolled population, and long-term outcomes. Observations The existing resectable PDAC trials have good internal validity but variable applicability because of their restrictive eligibility criteria. In these trials, overall survival is the criterion standard end point, but disease-free survival is more feasible, proximate, and specific to the assigned intervention (at the cost of subjective outcome assessment) and thus an acceptable end point in certain contexts. The prolonged survival in the PRODIGE 24 trial highlights both the success of mFOLFIRINOX (modified fluorouracil, leucovorin, irinotecan, and oxaliplatin) and the importance of patient selection. Neoadjuvant and perioperative trials have shown promising preliminary results; however, the number of patients who are not subsequently eligible for surgery reflects the limitations of this approach. Head-to-head comparisons of neoadjuvant and adjuvant treatments are limited to date in Western countries. Precision oncology with genomic and somatic testing for actionable mutations has promising preliminary results and may refine the management of PDAC, although the implications for early-stage disease and neoadjuvant therapy are unknown. Conclusions and Relevance This review found that adjuvant chemotherapy with mFOLFIRINOX is currently the standard of care in fit patients with resected PDAC; however, the role of neoadjuvant treatment is expanding. Precision oncology may help individualize the treatment regimen and sequence and improve outcomes. Enrollment of patients with resectable PDAC in clinical trials is strongly encouraged.
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Affiliation(s)
- Michail N Mavros
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Paul J Karanicolas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Eileen M O'Reilly
- Division of Gastrointestinal Medical Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus.,Deputy Editor, JAMA Surgery
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27
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Gaskill CE, Maxwell J, Ikoma N, Kim MP, Tzeng CW, Lee JE, Katz MHG. History of preoperative therapy for pancreatic cancer and the MD Anderson experience. J Surg Oncol 2021; 123:1414-1422. [PMID: 33831256 DOI: 10.1002/jso.26394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/18/2021] [Indexed: 12/11/2022]
Abstract
Systemic chemotherapy improves the survival of patients who undergo pancreatectomy, but whether chemotherapy should be delivered before or after surgery remains debated. At The University of Texas MD Anderson Cancer Center, localized pancreatic ductal adenocarcinoma (PDAC) has been preferentially treated with preoperative therapy-a practice supported by a robust history of institutional and national trials. In the following review, we discuss the historical use of perioperative therapy, our experience with it at MD Anderson Cancer Center and internationally, and the future of treatment and trials for PDAC.
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Affiliation(s)
- Cameron E Gaskill
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jessica Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ching-Wei Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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28
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Radiotherapy for Resectable and Borderline Resectable Pancreas Cancer: When and Why? J Gastrointest Surg 2021; 25:843-848. [PMID: 33205307 DOI: 10.1007/s11605-020-04838-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/17/2020] [Indexed: 01/31/2023]
Abstract
The role of (chemo) radiation in the perioperative management of patients with resectable and borderline resectable pancreatic ductal adenocarcinoma is controversial. Herein, we review and interpret existing data relating to the ability of (chemo) radiation to "downstage" pancreatic tumors, delay recurrence, and prolong patients' survival. In sum, the evidence suggests that while neoadjuvant (chemo) radiation may impact pathologic metrics favorably, it rarely converts anatomically unresectable tumors to resectable ones. And while data do support the ability of (chemo)radiation to delay cancer progression, its ability to prolong longevity has not been confirmed. It is possible that (chemo)radiation is effective in prolonging the survival of select patients, but to date, this cohort remains undefined due to heterogeneity in both the populations studied and the regimens used to treat them. Based on our interpretation of existing data, we currently administer neoadjuvant and adjuvant (chemo)radiation selectively to patients with localized pancreatic cancer who we consider at highest risk for local progression. We may also use it as an alternative to pancreatectomy in patients who are poor candidates for surgery. Ultimately, the role of (chemo)radiation in these settings is evolving. Better studies of patients most likely to benefit from its local effects are necessary to clearly define its place within the perioperative treatment algorithms used for patients with localized pancreatic cancer.
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29
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Rocha FG. Landmark Series: Immunotherapy and Targeted Therapy for Pancreatic Cancer. Ann Surg Oncol 2021; 28:1400-1406. [PMID: 33386541 DOI: 10.1245/s10434-020-09367-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/26/2020] [Indexed: 12/24/2022]
Abstract
Pancreatic cancer is one of the most aggressive gastrointestinal malignancies despite multimodality therapy. In the last several years, genomic studies have revealed that carcinogenesis is driven largely by key driver mutations that can be targeted for oncologic therapy. In addition, advances in cancer immunology have identified receptors and monoclonal antibodies that can be manipulated into harnessing the power of the host's immune system for antitumor treatment. These strategies have generated a paradigm shift in the management of several cancer types, including those in the gastrointestinal tract. However, there are several complicating factors when translating the results to pancreatic cancer, including the dense, fibrotic stroma unique to this disease that may shield the cancer cells from both cytotoxic and immunologic agents. Although the majority of trials have been performed in the metastatic setting, this review will focus on both the historic studies that have defined this field as well as the emerging data arising from ongoing efforts to exploit newly discovered mutations and their druggable targets.
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Affiliation(s)
- Flavio G Rocha
- Division of Surgical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR, USA.
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30
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Huguet F, Rivin Del Campo E, Labidi M, Ménard J, Sergent G, Durand B, Quéro L. Cancers gastriques et pancréatiques : la (chimio)radiothérapie néoadjuvante remplacera-t-elle la chimioradiothérapie adjuvante ? Cancer Radiother 2020; 24:493-500. [DOI: 10.1016/j.canrad.2020.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 05/24/2020] [Accepted: 05/28/2020] [Indexed: 12/24/2022]
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31
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Grossberg AJ, Chu LC, Deig CR, Fishman EK, Hwang WL, Maitra A, Marks DL, Mehta A, Nabavizadeh N, Simeone DM, Weekes CD, Thomas CR. Multidisciplinary standards of care and recent progress in pancreatic ductal adenocarcinoma. CA Cancer J Clin 2020; 70:375-403. [PMID: 32683683 PMCID: PMC7722002 DOI: 10.3322/caac.21626] [Citation(s) in RCA: 225] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 12/12/2022] Open
Abstract
Despite tremendous gains in the molecular understanding of exocrine pancreatic cancer, the prognosis for this disease remains very poor, largely because of delayed disease detection and limited effectiveness of systemic therapies. Both incidence rates and mortality rates for pancreatic cancer have increased during the past decade, in contrast to most other solid tumor types. Recent improvements in multimodality care have substantially improved overall survival, local control, and metastasis-free survival for patients who have localized tumors that are amenable to surgical resection. The widening gap in prognosis between patients with resectable and unresectable or metastatic disease reinforces the importance of detecting pancreatic cancer sooner to improve outcomes. Furthermore, the developing use of therapies that target tumor-specific molecular vulnerabilities may offer improved disease control for patients with advanced disease. Finally, the substantial morbidity associated with pancreatic cancer, including wasting, fatigue, and pain, remains an under-addressed component of this disease, which powerfully affects quality of life and limits tolerance to aggressive therapies. In this article, the authors review the current multidisciplinary standards of care in pancreatic cancer with a focus on emerging concepts in pancreatic cancer detection, precision therapy, and survivorship.
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Affiliation(s)
- Aaron J. Grossberg
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
- Brenden-Colson Center for Pancreatic Care, Oregon Health & Science University, Portland, OR
- Cancer Early Detection Advanced Research Center, Oregon Health & Science University, Portland, OR
| | - Linda C. Chu
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher R. Deig
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
| | - Eliot K. Fishman
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William L. Hwang
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
- Broad Institute of Harvard and MIT, Cambridge, MA
| | - Anirban Maitra
- Departments of Pathology and Translational Molecular Pathology, Sheikh Ahmed Pancreatic Cancer Research Center, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel L. Marks
- Brenden-Colson Center for Pancreatic Care, Oregon Health & Science University, Portland, OR
- Department of Pediatrics and Pape Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR
| | - Arnav Mehta
- Broad Institute of Harvard and MIT, Cambridge, MA
- Dana Farber Cancer Institute, Boston, MA
| | - Nima Nabavizadeh
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
| | - Diane M. Simeone
- Departments of Surgery and Pathology, Perlmutter Cancer Center, NYU Langone Health, New York, NY
| | - Colin D. Weekes
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Charles R. Thomas
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
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