Neoadjuvant therapy versus upfront surgical strategies in resectable pancreatic cancer: A Markov decision analysis

BACKGROUND

Neoadjuvant therapy is gaining acceptance as a valid treatment option for borderline resectable pancreatic cancer; however, its value for clearly resectable pancreatic cancer remains controversial. The aim of this study was to use a Markov decision analysis model, in the absence of adequately powered randomized trials, to compare the life expectancy (LE) and quality-adjusted life expectancy (QALE) of neoadjuvant therapy to conventional upfront surgical strategies in resectable pancreatic cancer patients.

METHODS

A Markov decision model was created to compare two strategies: attempted pancreatic resection followed by adjuvant chemoradiotherapy and neoadjuvant chemoradiotherapy followed by restaging with, if appropriate, attempted pancreatic resection. Data obtained through a comprehensive systematic search in PUBMED of the literature from 2000 to 2015 were used to estimate the probabilities used in the model. Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

Of the 786 potentially eligible studies identified, 22 studies met the inclusion criteria and were used to extract the probabilities used in the model. Base case analyses of the model showed a higher LE (32.2 vs. 26.7 months) and QALE (25.5 vs. 20.8 quality-adjusted life months) for patients in the neoadjuvant therapy arm compared to upfront surgery. Probabilistic sensitivity analyses for LE and QALE revealed that neoadjuvant therapy is favorable in 59% and 60% of the cases respectively.

CONCLUSION(S)

Although conceptual, these data suggest that neoadjuvant therapy offers substantial benefit in LE and QALE for resectable pancreatic cancer patients. These findings highlight the value of further prospective randomized trials comparing neoadjuvant therapy to conventional upfront surgical strategies.

Evaluation of the SCA instrument for measuring patient satisfaction with cancer care administered via paper or via the Internet

Background: Patients’ perspectives provide valuable information on quality of care. This study evaluates the feasibility and validity of Internet administration of Service Satisfaction Scale for Cancer Care (SCA) to assess patient satisfaction with outcome, practitioner manner/skill, information, and waiting/access.

Patients and methods: Primary data collected from November 2007 to April 2008. Patients receiving cancer care within 1 year were recruited from oncology, surgery, and radiation clinics at a tertiary care hospital. An Internet-based version of the 16-item SCA was developed. Participants were randomised to Internet SCA followed by paper SCA 2 weeks later or vice versa. Seven-point Likert scale responses were converted to a 0–100 scale (minimum–maximum satisfaction). Response distribution, Cronbach’s alpha, and test–retest correlations were calculated.

Results: Among 122 consenting participants, 78 responded to initial SCA. Mean satisfaction scores for paper/Internet were 91/90 (outcome), 95/94 (practitioner manner/skill), 89/90 (information), and 86/86 (waiting/access). Response rate and item missingness were similar for Internet and paper. Except for practitioner manner/skill, test–retest correlations were robust r = 0.77 (outcome), 0.74 (information), and 0.75 (waiting/access) (all P < 0.001).

Conclusions: Internet SCA administration is a feasible and a valid measurement of cancer care satisfaction for a wide range of cancer diagnoses, treatment modalities, and clinic settings.

The quality-of-life impact of osteonecrosis of the jaw: Implications for bisphosphonate use in metastatic breast cancer

6620

Background: Osteonecrosis of the jaw (ONJ) has been linked to bisphosphonates used to prevent skeletal related events (SREs) in metastatic breast cancer (MBC). The primary aim of this decision-analysis study is to determine the preference threshold at which the quality of life (QOL) impact of ONJ may change bisphosphonate treatment decisions. Methods: We developed a Markov decision- analysis model of bisphosphonate use in MBC that includes the risk of ONJ. For the base case we estimated the QOL impact of ONJ by evaluating published ONJ reports with the Oral Health Impact Profile (OHIP). OHIP scores were transformed to EQ5D utilities and adjusted for MBC (published utility for MBC=0.63). We used published utility values for SRE: 0.46 for the month in which SRE occurs. Based on published data, we estimated that bisphosphonates reduce the incidence of SREs by 41% and that the incidence of SRE rises with increased bisphosphonate exposure: year 1=0.004/month; year 2=0.022/month; year 3=0.034/month. We inspected 2 treatment strategies: treat all patients with bisphosphonates (treat all) and treat no patient with bisphosphonates (treat none). Results: 18 published cases were adequate for evaluation. The mean OHIP score=27 (possible range 14–70), s.d.=1.8. We calculated that patients with MBC and ONJ have a utility=0.53 (s.d.=0.04) for the base-case. The model predicted a mean survival of 22 months for both strategies. In the treat all strategy each patient received a mean of 19 months of bisphosphonates and suffered 2.4 SREs. In the treat none strategy each patient suffered 4.0 SREs. In the base case, the treat all strategy maximized net quality-adjusted life, although by less than 1/2 month per patient. The treat all strategy was optimal for only 33% of patients. The treat all strategy does not maximize net quality-adjusted life if the risk of ONJ is 4.5 times higher than the base case or the ratio of the utility for ONJ to the utility for SRE is less than 0.4 (base-case ratio=1.152). Conclusions: The QOL impact of ONJ alters the decision to use bisphosphonates when 1) the incidence of ONJ is 4.5 times higher than published estimates; or 2) the long-term preference for ONJ is 60% lower than the short-term preference for SRE. Further QOL research may refine these estimates.

No significant financial relationships to disclose.

Analysis of hormonal receptor status in tissue from prostate cancer that developed 26 years after bilateral orchiectomy and following 41 years of estrogen therapy

14610

Background: The development of prostate cancer in the absence of normal male testosterone levels and in the presence of elevated estrogen levels is rare and poorly understood. Methods: The androgen, estrogen and progesterone receptors were evaluated in prostate cancer tissue from a 60-year-old, long-term transgender woman. Her serum hormone levels were assessed and the prostate specific antigen (PSA) level was followed during hormonal and radiation treatment. This patient began estrogen therapy at age 19 and underwent bilateral orchiectomy at age 34 during gender re-assignment surgery. Work-up for gross hematuria revealed a Gleason 8, locally advanced prostate cancer. Results: The tumor showed abundant staining for androgen receptors (AR), with a nuclear pattern consistent with hormone refractory prostate cancer. The tumor did not stain for estrogen receptors (ER) or progesterone receptors (PR). Compared to reference values for men, this transgender woman had low serum testosterone (44 ng/dl) and free testosterone (0.9 pg/mL) levels and elevated estradiol (53 pg/mL) and estrone (377 pg/mL) levels. Prior to the initiation of radiation, treatment with bicalutamide and dutasteride reduced her PSA from 240 ng/ml to 77 ng/ml at week 6 (see Table). After treatment with external beam radiation her PSA fell to 4.6 ng/mL. At week 24, her PSA was 0.8 ng/mL. Conclusions: This high-grade, locally advanced prostate cancer in a transgender woman represents the longest reported duration of a castrate state preceding the development of prostate cancer, exceeding prior reports by several decades. The AR positive and ER/PR negative status of this tumor in the setting of low testosterone and elevated estrogen levels challenge long-standing paradigms regarding the testosterone requirement for prostatic carcinogenesis. In addition, these findings raise questions about the role of estrogens in prostate cancer. [Table: see text]

[Table: see text]