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Doshi S, Abad J, Wells A, Chawla A. Weight loss during neoadjuvant chemotherapy impacts perioperative outcomes in patients undergoing surgery for pancreatic cancer. Pancreatology 2023; 23:1020-1027. [PMID: 37926598 DOI: 10.1016/j.pan.2023.10.006] [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: 02/23/2023] [Revised: 09/22/2023] [Accepted: 10/05/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND While use of neoadjuvant chemotherapy (NAC) in pancreatic adenocarcinoma (PDAC) downstages cancers to be eligible for resection, weight loss during the neoadjuvant period due to cancer progression, gastric outlet obstruction, or neoadjuvant therapy itself is an area of concern. The goal of this study is to determine the effect of weight loss during NAC on perioperative outcomes of pancreatectomies. METHODS The NSQIP database 2014-2019 was utilized to study patients who received NAC for PDAC and underwent significant weight loss, defined as at least 10 % body weight loss in the six months prior to surgery. Univariate and multivariate analyses were conducted using Fisher's Exact Test, Pearson's Chi-squared Test, and logistic regression. RESULTS Of the 5590 PDAC patients who received NAC, 913 (16%) experienced significant weight loss. Patients who experienced significant weight loss were more likely to experience at least one complication compared to those who did not undergo weight loss (42.2% vs. 38.7%, p = 0.023). Those who had significant weight loss were more likely to undergo unplanned intubation postoperatively (3.8% vs 2.2 %, p = 0.004), have postoperative ventilator need >48 h (3.7% vs 1.8%, p < 0.001), have postoperative septic shock (3.9% vs 1.8 %, p < 0.001), and undergo reoperation (6.0% vs 4.3%, p = 0.027). However, there were no differences for pancreatic fistula (7.7% vs 9.3 %, p = 0.15), readmission rates (15% vs 15 %, p = 0.7), or 30-day mortality (1.5% vs 1.2%, p = 0.5). Utilizing logistic regression, BMI (OR: 1.05, p = 0.032), significant weight loss (OR = 1.18, p = 0.025), sex (OR = 1.26 with female baseline, p < 0.001), history of COPD (OR = 1.39, p = 0.012), hypertensive medication use (OR = 1.18, p = 0.004), and pancreatic radiotherapy (OR = 1.16, p = 0.010) were independent preoperative predictors of a post-operative complication. CONCLUSIONS Nutritional measures to stabilize weight during NAC should be considered to decrease post-pancreatectomy complications.
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Affiliation(s)
- Sahil Doshi
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - John Abad
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Surgical Oncology, Department of Surgery, Northwestern Medicine Regional Medical Group, Winfield, IL, USA
| | - Amy Wells
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Surgical Oncology, Department of Surgery, Northwestern Medicine Regional Medical Group, Winfield, IL, USA
| | - Akhil Chawla
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Surgical Oncology, Department of Surgery, Northwestern Medicine Regional Medical Group, Winfield, IL, USA; Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA.
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Kelly BN, Nicolais L, Mohamed A, Fitzgerald TL. Contemporary Treatment Paradigms are Associated with Improved Survival in Pancreatic Cancer. Am Surg 2023:31348231157897. [PMID: 36872555 DOI: 10.1177/00031348231157897] [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: 03/07/2023]
Abstract
INTRODUCTION Over the last decade, a paradigm shift has been made in treating pancreatic cancer. Starting in 2011, several trials demonstrated a survival advantage for multiagent chemotherapy (MAC). However, the implication for survival at the population level remains unclear. METHODS A retrospective study of the National Cancer Database from 2006 to 2019 was conducted. Patients treated from 2006 to 2010 were classified as "Era 1", and those treated from 2011 to 2019 as "Era 2." RESULTS A total of 316,393 patients with pancreatic adenocarcinoma were identified, with 87,742 treated in Era 1 and 228,651 in Era 2. Survival increased from Era 1 to Era 2 in all patients and sub-analyses; surgical (18.7 vs 24.6 months, HR .85, 95% CI 0.82-.88, P < .001), imminently resectable (Stage IA and IB, 12.2 vs 14.8 months, HR .90, 95% CI 0.86-.95, P < .001), high-risk (Stage IIA, IIB, and III, 9.6 vs 11.6 months, HR .82, 95% CI 0.79-.85, P < .001), and Stage IV (3.5 vs 3.9 months, HR .86, 95% CI 0.84-.89, P < .001). Survival was decreased for those who were African American (P = .031), on Medicaid (P < .001), or in the lowest quartile of annual income (P < .001). Surgery rates decreased from 20.5% in Era 1 to 19.8% in Era 2 (P < .001). DISCUSSION Adoption of MAC regimens at a population level correlates with improved pancreatic cancer survival. Unfortunately, socioeconomic factors are associated with an unequal benefit from new treatment regimens, and underuse of surgery for resectable neoplasms persists.
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Affiliation(s)
- Bridget N Kelly
- 115985University of New England College of Osteopathic Medicine, Biddeford, ME, USA
| | - Laura Nicolais
- Division of Surgical Oncology, 92602Maine Medical Center, Portland, ME, USA
| | - Abdimajid Mohamed
- Division of Surgical Oncology, 92602Maine Medical Center, Portland, ME, USA
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Ogobuiro I, Collier AL, Khan K, de Castro Silva I, Kwon D, Wilson GC, Schwartz PB, Parikh AA, Hammill C, Kim HJ, Kooby DA, Abbott D, Maithel SK, Snyder RA, Ahmad SA, Merchant NB, Datta J. Racial Disparity in Pathologic Response following Neoadjuvant Chemotherapy in Resected Pancreatic Cancer: A Multi-Institutional Analysis from the Central Pancreatic Consortium. Ann Surg Oncol 2023; 30:1485-1494. [PMID: 36316508 DOI: 10.1245/s10434-022-12741-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/10/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Major pathologic response (MPR) following neoadjuvant therapy (NAT) in pancreatic ductal adenocarcinoma (PDAC) patients undergoing resection is associated with improved survival. We sought to determine whether racial disparities exist in MPR rates following NAT in patients with PDAC undergoing resection. METHODS Patients with potentially operable PDAC receiving at least 2 cycles of neoadjuvant FOLFIRINOX or gemcitabine/nab-paclitaxel ± radiation followed by pancreatectomy (2010-2019) at 7 high-volume centers were reviewed. Self-reported race was dichotomized as Black and non-Black, and multivariable models evaluated the association between race and MPR (i.e., pathologic complete response [pCR] or near-pCR). Cox regression evaluated the association between race and disease-free (DFS) and overall survival (OS). RESULTS Results of 486 patients who underwent resection following NAT (mFOLFIRINOX 56%, gemcitabine/nab-paclitaxel 25%, radiation 29%), 67 (13.8%) patients were Black. Black patients had lower CA19-9 at diagnosis (median 67 vs. 204 U/mL; P = 0.003) and were more likely to undergo mild/moderate chemotherapy dose modification (40 vs. 20%; P = 0.005) versus non-Black patients. Black patients had significantly lower rates of MPR compared with non-Black patients (13.4 vs. 25.8%; P = 0.039). Black race was independently associated with worse MPR (OR 0.26, 95% confidence interval [CI] 0.10-0.69) while controlling for NAT duration, CA19-9 dynamics, and chemotherapy modifications. There was no significant difference in DFS or OS between Black and non-Black cohorts. CONCLUSIONS Black patients undergoing pancreatectomy appear less likely to experience MPR following NAT. The contribution of biologic and nonbiologic factors to reduced chemosensitivity in Black patients warrants further investigation.
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Affiliation(s)
- Ifeanyichukwu Ogobuiro
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA
| | - Amber L Collier
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA
| | - Khadeja Khan
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA
| | - Iago de Castro Silva
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA
| | - Deukwoo Kwon
- Department of Surgery, Icahn School of Medicine at Mount Sinai Department of Population Health Science and Policy, New York, NY, USA
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Patrick B Schwartz
- Department of Surgery, Carbone Cancer Center, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Alexander A Parikh
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Chet Hammill
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Hong J Kim
- Department of Surgery, Lineberger Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - David A Kooby
- Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA, USA
| | - Daniel Abbott
- Department of Surgery, Carbone Cancer Center, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Shishir K Maithel
- Department of Surgery, Emory University School of Medicine, Winship Cancer Institute, Atlanta, GA, USA
| | - Rebecca A Snyder
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Nipun B Merchant
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA
| | - Jashodeep Datta
- Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL, 33136, USA.
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Chase M, Friedman HS, Joo S, Navaratnam P. Adjuvant and neoadjuvant treatment patterns among resectable pancreatic cancer patients in the USA. Future Oncol 2022; 18:3929-3939. [PMID: 36520480 DOI: 10.2217/fon-2021-1583] [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: 12/23/2022] Open
Abstract
Aim: Chemotherapy is standard before and/or after pancreatic cancer resection, yet benefits of pre-resection chemotherapy are unclear. Real-world pre- and post-resection treatment patterns were evaluated retrospectively. Methods: Neoadjuvant (3-months pre-surgery) and adjuvant (6-months post-surgery) treatment claims from 1 January 2016 to 31 December 2019 in US adults with resectable pancreatic cancer were analyzed. Results: Of the 737 patients, 29% received no chemotherapy in either setting; 22% received chemotherapy in both settings. In the neoadjuvant and adjuvant settings, 69 and 33% of patients, respectively, received no treatment at all. FOLFIRINOX and gemcitabine monotherapy were the most common chemotherapies in the neoadjuvant and adjuvant settings, respectively. Adjuvant FOLFIRINOX increased post-2018, whereas gemcitabine-based regimens decreased. Conclusion: Several chemotherapy regimens were used in both settings. Treatment patterns differed between the two settings.
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