PANCREATIC CANCER IN BRAZIL: MORTALITY TRENDS AND PROJECTIONS UNTIL 2029

Rising Mortality among Non-Hispanics due to Pancreatic Cancer in the United States. A CDC Database analysis

PURPOSE

To examine mortality trends among non-Hispanic (NH) adults with pancreatic cancer.

METHOD

CDC-WONDER database was used to extract death certificate data on pancreatic cancer-related mortality in NH adults aged ≥ 45 from 1999 to 2020. Age-adjusted mortality rates (AAMRs) per 100,000 persons and annual percent changes (APCs) were calculated and stratified by year, age, sex, race, and region.

RESULTS

From 1999 to 2020, 783,772 deaths occurred among middle-aged (45-64) and older (65-85 +) NH adults. Overall AAMR increased from 31.7 in 1999 to 33.8 in 2020 (APC: 0.35; 95% CI:0.28-0.41). NH older adults had higher AAMRs (67.9) than NH middle-aged adults (12.5). Men consistently had higher AAMRs (37.7) than women (28.4). NH African Americans had the highest AAMRs (40.8) compared to NH Whites (32.1), NH American Indians (23.9), and NH Asians (22.4). Metropolitan areas had a higher AAMR (32.7) than non-metropolitan areas (32.2). The Northeast region had the highest AAMR (34.0) followed by Midwest (33.2), South (32.2), and West (30.1). Delaware, District of Columbia, Louisiana, Michigan, and Mississippi had the highest AAMRs among states.

CONCLUSIONS

Pancreatic cancer-related mortality among NH adults has increased from 1999 to 2020. Highest AAMRs were reported in older men, NH African Americans, the Northeastern and metropolitan areas.

Incidence, risk factors and the prognostic role of thromboembolic events (TEEs) amongst patients with metastatic pancreatic adenocarcinoma (PAAD): a retrospective, single-center analysis

Background

Thromboembolic events (TEEs) are frequent among patients with pancreatic adenocarcinoma (PAAD). We set out to estimate the incidence and establish predictive risk factors for TEE and estimate the impact of TEEs on the overall survival (OS) of patients with metastatic PAAD.

Methods

This is a retrospective, single-center study. We included patients with a pathologically confirmed diagnosis of PAAD with distant metastases treated at AC Camargo Cancer Center from 2016 to 2021. We used the competitive risk survival models to estimate the cumulative incidence of TEE. Risk factors for the development of TEEs were evaluated using the competitive risk and logistic regression models. The impact of TEEs on OS was assessed using both landmark and time-dependent covariate Cox survival analyses.

Results

The study population consists of 199 patients. The cumulative incidence of TEEs in 1, 6 and 24 months were 10.1%, 19.3% and 30.2%, respectively. Log10(CA 19-9) was the only factor independently associated with increased risk of TEEs in the logistic regression (Odds ratio = 1.03; 95% confidence interval (95%CI), 1.00-1.06; p = 0.030) and competitive risk survival (Subdistribution hazard ratio = 1.14; 95%CI, 1.02-1.27; p = 0.019) models. In the landmark analysis, early TEEs (within 1 month of diagnosis) were not associated with inferior OS. In the time-dependent covariate Cox proportional hazard model, TEEs were not found to be statistically associated with inferior OS, although there was a trend towards it (Hazard ratio = 1.59; 95%CI, 0.99-2.54; p = 0.051).

Conclusion

TEEs occur in a large fraction of patients with metastatic PAAD. Statistical models with higher predictive performance are currently needed. For the time being, consideration for prophylactic anticoagulation should be done on an individual basis.

A narrative review on rare types of pancreatic cancer: should they be treated as pancreatic ductal adenocarcinomas?

Pancreatic cancer is one of the deadliest malignancies in humans and it is expected to play a bigger part in cancer burden in the years to come. Pancreatic ductal adenocarcinoma (PDAC) represents 85% of all primary pancreatic malignancies. Recently, much attention has been given to PDAC, with significant advances in the understanding of the mechanisms underpinning disease initiation and progression, along with noticeable improvements in overall survival in both localized and metastatic settings. However, given their rarity, rare histological subtypes of pancreatic cancer have been underappreciated and are frequently treated as PDAC, even though they might present non-overlapping molecular alterations and clinical behavior. While some of these rare histological subtypes are true variants of PDAC that should be treated likewise, others represent separate clinicopathological entities, warranting a different therapeutic approach. In this review, we highlight clinical, pathological, and molecular aspects of rare histological types of pancreatic cancer, along with the currently available data to guide treatment decisions.

Global long-term trends and spatial cluster analysis of pancreatic cancer incidence and mortality over a 30-year period using the global burden of disease study 2019 data

INTRODUCTION

Pancreatic cancer (PC) is one of the most fatal malignancies, and its incidence and mortality rates are growing annually throughout the world. In this research, we aimed to investigate the time trends and identify the spatial clusters of incidence and mortality on a global scale over the last 30 years, using the Global Burden of Disease (GBD) study 2019 data.

METHODS

Age-standardized incidence and mortality data due to PC were extracted from the GBD study, which was carried out from 1990 to 2019. A Joinpoint regression analysis was utilized to examine trends in the incidence and mortality of PC over the past three decades. As such, spatial analyses were undertaken to detect the spatial distribution and clustering of the metrics globally.

RESULTS

It was observed that both the incidence and mortality rates were higher in males than in females worldwide. The global mortality and incidence rates significantly increased by 0.8% per year over the time of follow-up period (p<0.05). By spatial cluster analysis for mortality, European and North African countries, as well as Greenland were explored as hot spots; while South African and Southeast Asian countries were explored as cold spots. Regarding incidence, hot spots were found in European countries, Southern America, and Greenland; whilst cold spots were determined in Southern Africa and Madagascar.

CONCLUSIONS

Collectively, the temporal trends disclosed a gradual rise in PC incidence and mortality rates over the period 1990-2019, reflecting the global health concern. We further found geographical variations in the patterns and identified high- and low-risk areas for incidence and mortality. These findings facilitate the design and implementation of more resource-efficient and geographically targeted treatments. Given the results of the current study, a practical approach to minimizing the future PC burden involves planned population-wide interventions, as well as primary prevention through healthier lifestyles.

PANCREATIC CANCER MORTALITY TRENDS AND CORRELATION WITH HUMAN DEVELOPMENT INDEX (HDI) IN BRAZIL OVER 40 YEARS

BACKGROUND

Pancreatic cancer mortality is greater in countries with a high Human Development Index (HDI). This study analyzed pancreatic cancer mortality rates trends, and their correlation with HDI in Brazil over 40 years.

METHODS

Data on pancreatic cancer mortality in Brazil between 1979 and 2019 were obtained from the Mortality Information System (SIM). Age-standardized mortality rates (ASMR) and Annual Average Percent Change (AAPC) were calculated. Pearson's correlation test was applied to compare mortality rates and HDI for three periods: 1986-1995 was correlated with HDI of 1991, 1996-2005 with HDI of 2000, and 2006-2015 with HDI of 2010; and to the correlation of AAPC versus the percentage change in HDI from 1991 to 2010.

RESULTS

A total of 209,425 deaths from pancreatic cancer were reported in Brazil, with an annual increase of 1.5% in men and 1.9% in women. There was an upward trend for mortality in most Brazilian states, with the highest trends observed in the North and Northeast states. A positive correlation between pancreatic mortality and HDI was observed over the three decades (r>0.80, P<0.05) and also between AAPC and HDI improvement by sex (r=0.75 for men and r=0.78 for women, P<0.05).

CONCLUSION

There was an upward trend in pancreatic cancer mortality in Brazil for both sexes, but rates among women were higher. Mortality trends were higher in states with a higher percentage improvement in HDI, such as the North and Northeast states.

Current Treatment of Potentially Resectable Pancreatic Ductal Adenocarcinoma: A Medical Oncologist's Perspective

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.

Short-term survival of patients with advanced pancreatic cancer admitted to intensive care unit: a retrospective cohort study

Background

Little is known about the outcomes of patients with advanced pancreatic cancer admitted to the intensive care unit (ICU) due to medical complications. We designed a study to evaluate their short-term (30-day) survival, predictors of short-term survival and chances of additional chemotherapy.

Methods

We reviewed all patients with advanced (stage III or IV) pancreatic adenocarcinoma admitted to an ICU in a dedicated Brazilian cancer centre from 2009 to 2018 due to medical reasons. We fitted multivariate regression models to identify predictors of 30-day survival and additional systemic chemotherapy.

Results

The study population consisted of 171 patients. Ninety-four patients (55.0%) had Eastern Cooperative Oncology Group (ECOG) performance status 2-4 and 146 (85.4%) had metastatic disease. Most patients (N = 75; 43.9%) were admitted to the ICU during first-line treatment. Median overall survival was 32 days (95% confidence interval (95% CI): 20-49). Survival rate at 30 days was 50.6%. ECOG performance status 2-4 was the only variable associated with lower probability of survival at 30 days in multivariate analysis (odds ratio: 0.28; 95% CI: 0.14-0.54; p < 0.001). Overall, 58 patients (33.9%) received additional chemotherapy and among all patients, 13.5% experienced clinical benefit from this treatment.

Conclusion

Patients with advanced pancreatic cancer admitted to the ICU for medical reasons have a dismal prognosis. Early palliative care and refined tools to establish those who would benefit from an ICU trial could help improve patients' care.

Burden of pancreatic cancer along with attributable risk factors in China from 1990 to 2019, and projections until 2030

OBJECTIVES

Understanding epidemiology trends and patterns of pancreatic cancer in China from 1990 to 2019 and predicting the burden to 2030 will provide foundations for future policies development.

METHODS

We collected incidence, mortality, and disability-adjusted life-years (DALYs) data of pancreatic cancer in China from 1990 to 2019 based on the Global Burden of Disease Study 2019. We calculated the estimated annual percentage change (EAPC) to depict the trends of pancreatic cancer burden and predicted the incidence and mortality in the next decade by using a Bayesian age-period-cohort analysis.

RESULTS

The number of incident cases sharply increased from 26.77 thousand in 1990 to 114.96 thousand in 2019, the age-standardized incidence rate (ASIR) nearly doubled from 3.17 per 100,000 in 1990 to 5.78 per 100,000 in 2019, with an EAPC of 2.32 (95% confidence interval [CI]: 2.12, 2.51). The mortality and DALYs presented a similar pattern with incidence. The dominant risk factor for pancreatic cancer was smoking, but the contribution of high body-mass index increased from 1990 to 2019. We projected that the incident cases and deaths of pancreatic cancer would increase to 218.79 thousand and 222.97 thousand, respectively, in 2030 with around 2 times growth.

CONCLUSIONS

During the past three decades, the incidence, mortality and DALYs of pancreatic cancer gradually increased in China, and the absolute number and rate of pancreatic cancer burden would continue to rise over the next decade. Comprehensive policies and strategies need to be implemented to reduce the incidence and mortality.

The increasing burden of pancreatic cancer in Brazil from 2000 to 2019: estimates from the Global Burden of Disease Study 2019

INTRODUCTION

Pancreatic cancer is increasing worldwide. The burden of pancreatic cancer in Brazil and its states was analyzed and compared with that from the USA and China.

METHODS

This is a descriptive study of the incidence and mortality estimates from the Global Burden of Disease 2019 study, from 2000 to 2019. The Brazilian states presenting the highest and lowest socio-demographic index (SDI) were selected from each of the five regions. The SDI consists of the per capita income, education, and fertility rate of each population.

RESULTS

A significant increase was found in age-standardized incidence and mortality of pancreatic cancer in all three countries, with differences in magnitude and annual increases. In Brazil, this incidence rose from 5.33 [95% Uncertainty Interval (UI): 5.06- 5.51] to 6.16 (95% UI: 5.68- 6.53) per 100,000 inhabitants. China and the Brazilian states with the lowest SDI, such as Pará and Maranhão, showed lower incidence and mortality rates, although presenting the highest annual increases. No difference was found between the sexes. A higher mortality rate was observed for those individuals of 70+ years, which was three to four times higher than those aged 50 to 69 years.

CONCLUSIONS

The increasing burden of pancreatic cancer in the studied countries, and the higher estimates for the elderly in a fast-aging country such as Brazil, indicates that more resources and health policies will be necessary. The greatest increase in the states with lower SDI reflects inequalities in the access to diagnosis and registries of this cancer.

Pancreatic cancer incidence and mortality trends: a population-based study

Objectives To analyze trends in pancreatic cancer incidence and mortality in Latin American countries. Methods An ecological study with incidence data from the International Agency for Research on Cancer and mortality data from the World Health Organization. The trend of incidence by Joinpoint regression, the variation of the annual average and the 95% confidence interval were analyzed. Results There were increasing trends in incidence in Brazil, in males, aged 40-59 years, and reduction in Costa Rica. In females, there was stability in all age groups. The mortality rates increased in the elderly in Brazil (AAPC: 1.09%; 95% CI: 0.76; 1.42), Peru (AAPC: 1.76%; 95% CI: 0.36; 3.17) and El Salvador (AAPC: 2.88%; 95% CI: 0.38; 5.43), while in Mexico, there was a reduction. In females, this rate increased in Brazil (AAPC: 1.38%; 95% CI: 1.07; 1.69), Peru (AAPC: 2.25%; 95% CI: 0.68; 3.85), Chile (AAPC: 3.62%; 95% CI:1.96; 5.31), Nicaragua (AAPC: 2.51%; 95% CI: 0.36; 4.71) and Paraguay (AAPC: 1.17%; 95% CI: 0.37; 1.98) and a downward trend was observed in Colombia and Ecuador. Conclusions Pancreatic cancer had a higher incidence in the elderly population of both sexes and an increase of the mortality trend in females was noted.

Comparative efficacy of modified FOLFIRINOX, gemcitabine plus capecitabine and gemcitabine plus nab-paclitaxel as adjuvant treatment for resected pancreatic cancer: a Bayesian network meta-analysis

Background

There are no head-to-head comparisons evaluating the efficacy of the main polychemotherapy regimens used for patients with pancreatic cancer in the adjuvant setting. We aimed to describe the relative efficacy of modified FOLFIRINOX (mFOLFIRINOX), gemcitabine plus capecitabine (GEM-CAP) and gemcitabine plus nab-paclitaxel (GEM-NAB) in this setting using a Bayesian network approach.

Methods

We collected data from the ESPAC-4, PRODIGE 24 and APACT trials. Disease-free survival (DFS), according to the investigators, and overall survival (OS) for the three polychemotherapy regimens were compared using gemcitabine as the reference arm. We ran Markov chain Monte Carlo simulations with a fixed-effect model to generate the posterior distribution of the hazard ratios (HRs) using non-informative priors. Relative efficacy was measured by HRs, surface under cumulative ranking and rankograms.

Results

mFOLFIRINOX was the chemotherapy regimen most likely to be the most effective in the adjuvant setting (98.9% and 89.6% probability for DFS and OS, respectively). GEM-NAB marginally improved DFS (HR = 0.97, 95% credible interval (95% CrI) = 0.77–1.21) and OS (HR = 0.98, 95% CrI = 0.76–1.25) when compared to GEM-CAP. However, GEM-NAB had the highest chances of being the second most active chemotherapy regimen (61.4% and 52.5% probability for DFS and OS, respectively), whereas GEM-CAP was less likely to represent the second most active regimen (37.7% and 40.1% probability for DFS and OS, respectively).

Conclusion

For patients eligible and fit enough to undergo adjuvant treatment with mFOLFIRINOX, this constitutes the treatment of choice. For those with contraindications to mFOLFIRINOX, while both GEM-NAB and GEM-CAP can be considered appropriate alternatives, GEM-NAB is likely the most effective regimen.

Burden of pancreatic cancer along with attributable risk factors in Europe between 1990 and 2019, and projections until 2039

Projecting the burden of pancreatic cancer over time provides essential information to effectively plan measures for its management and prevention. Here, we obtained data from the Global Burden of Disease (GBD) Study between 1990 and 2019, to model how pancreatic cancer will affect the 27 countries of the European Union (EU) plus the United Kingdom (the pre-Brexit EU-28) until 2039 by conducting the Bayesian age-period-cohort analysis. The number of new pancreatic cancer cases in the EU-28 was 59 000 in 1990, 109 000 in 2019 and projected to be 147 000 in 2039. This corresponded to 60 000, 109 000 and 155 000 for deaths, and a loss of 1.3 million, 2.0 million and 2.7 million for disability-adjusted life years (DALYs), respectively. The most pronounced increase of the crude incidence rate was observed and projected to be in the population older than 80 years. The age-standardized rate (ASR) of incidence, however, increased from 8.6 to 10.1 per 100 000 person-years during 1990-2019 but was projected to remain stable during 2019-2039. At the same time, our models only predicted a mild increase in the ASR of mortality until 2039. The fraction of pancreatic cancer mortality attributable to tobacco consumption decreased during 1990-2019, but we found upward trends for the attributable fractions for high fasting plasma glucose and high body mass index. In conclusion, a substantial increase in counts of incidence, mortality and DALYs lost of pancreatic cancer in the EU-28 is projected over the next two decades, which indicates the need for future health policies and interventions.

Disparities in access to health care system as determinant of survival for patients with pancreatic cancer in the State of São Paulo, Brazil

Little is known about the features and outcomes of Brazilian patients with pancreatic cancer. We sought to describe the socio-economic characteristics, patterns of health care access, and survival of patients diagnosed with malignant pancreatic tumors from 2000 to 2014 in São Paulo, Brazil. We included patients with malignant exocrine and non-classified pancreatic tumors according to the International Classifications of Disease (ICD)-O-2 and -O-3, diagnosed from 2000 to 2014, who were registered in the FOSP database. Prognostic factors for overall survival (OS) in the subgroup of patients with ductal or non-specified (adeno)carcinoma were evaluated using Cox proportional hazard model. The study population consists of 6855 patients. Median time from the first visit to diagnosis and treatment were 13 (Interquartile range [IQR] 4-30) and 24 (IQR 8-55) days, respectively. Both intervals were longer for patients treated in the public setting. Median OS was 4.9 months (95% confidence interval [95% CI] 4.7-5.2). Increasing age, male gender, lower educational level, treatment in the public setting, absence of treatment, advanced stage, and treatment from 2000 to 2004 were associated with inferior OS. From 2000-2004 to 2010-2014, no improvement in OS was seen for patients treated in the public setting. Survival of patients with malignant pancreatic tumors remains dismal. Socioeconomical variables, especially health care funding, are major determinants of survival. Further work is necessary to decrease inequalities in access to medical care for patients with pancreatic cancer in Brazil.