Failure to Operate on Early Stage Pancreatic Cancer
Failure to Operate on Early Stage Pancreatic Cancer
Background: Despite studies demonstrating improved outcomes, pessimism persists regarding the effectiveness of surgery for pancreatic cancer. Our objective was to evaluate utilization of surgery in early stage disease and identify factors predicting failure to undergo surgery.
Methods: Using the National Cancer Data Base (1995-2004), 9559 patients were identified with potentially resectable tumors (pretreatment clinical Stage I: T1N0M0 and T2N0M0). Multivariate models were employed to identify factors predicting failure to undergo surgery and assess the impact of pancreatectomy on survival.
Results: Of clinical Stage I patients 71.4% (6823/9559) did not undergo surgery; 6.4% (616/9559) were excluded due to comorbidities; 4.2% (403/9559) refused surgery; 9.1% (869/9559) were excluded due to age; and 38.2% (3,644/9559) with potentially resectable cancers were classified as not offered surgery. Of the 28.6% (2736/9559) of patients who underwent surgery, 96.0% (2630/2736) underwent pancreatectomy, and 4.0% (458/2736) had unresectable tumors.
Patients were less likely to undergo surgery if they were older than 65 years, were black, were on Medicare or Medicaid, had pancreatic head lesions, earned lower annual incomes, or had less education (P < 0.0001). Patients were less likely to receive surgery at low-volume and community centers. Patients underwent surgery more frequently at National Cancer Institute/National Comprehensive Cancer Network-designated cancer centers (P < 0.0001). Patients who were not offered surgery had significantly better survival than those with Stage III or IV disease but worse survival than patients who underwent pancreatectomy for Stage I disease (P < 0.0001).
Conclusions: This is the first study to characterize the striking underuse of pancreatectomy in the United States. Of early stage pancreatic cancer patients without any identifiable contraindications, 38.2% failed to undergo surgery.
Pancreatic cancer is the fourth leading cause of cancer deaths in the United States. In 2007, the American Cancer Society estimates that over 37,000 patients will be diagnosed with pancreatic cancer, and more than 33,000 will die of the disease. Patients with pancreatic cancer have a particularly dismal prognosis due to multiple factors, including late presentation, aggressive tumor biology, complex surgical management, and the lack of effective systemic therapies. Overall survival rates have remained relatively unaffected with fewer than 5% of all patients surviving 5 years after diagnosis.
Surgery remains the only potentially curative treatment of localized pancreatic cancer. During the last 20 years, significant advances in preoperative evaluation, surgical techniques, and postoperative care have reduced the perioperative morbidity and mortality associated with pancreatic surgery. Mortality after pancreaticoduodenectomy has dropped from ~25% in the 1960s to less than 3% in some high-volume centers, and recent studies have suggested improvements in long-term survival rates after resection for localized disease that approach 30%.
Despite numerous studies and guidelines establishing pancreatectomy as the primary treatment modality for localized pancreatic adenocarcinoma, pessimistic attitudes toward all patients with pancreatic cancer have perhaps led to skepticism regarding the efficacy of resection. Clinicians have long recognized that a diagnosis of pancreatic cancer encompasses little variability in long-term outcomes; however, these views are outdated in light of recent evidence. Our hypothesis was that these attitudes affect utilization of surgery for early stage pancreatic cancer after controlling for age, comorbidities, and patient refusal to undergo surgery. The objectives of this study were 1) to evaluate and characterize the utilization of surgery for pancreatic adenocarcinoma, 2) to identify factors predicting failure to undergo surgery for localized disease, and 3) to evaluate the effect of surgery on survival.
Abstract and Introduction
Abstract
Background: Despite studies demonstrating improved outcomes, pessimism persists regarding the effectiveness of surgery for pancreatic cancer. Our objective was to evaluate utilization of surgery in early stage disease and identify factors predicting failure to undergo surgery.
Methods: Using the National Cancer Data Base (1995-2004), 9559 patients were identified with potentially resectable tumors (pretreatment clinical Stage I: T1N0M0 and T2N0M0). Multivariate models were employed to identify factors predicting failure to undergo surgery and assess the impact of pancreatectomy on survival.
Results: Of clinical Stage I patients 71.4% (6823/9559) did not undergo surgery; 6.4% (616/9559) were excluded due to comorbidities; 4.2% (403/9559) refused surgery; 9.1% (869/9559) were excluded due to age; and 38.2% (3,644/9559) with potentially resectable cancers were classified as not offered surgery. Of the 28.6% (2736/9559) of patients who underwent surgery, 96.0% (2630/2736) underwent pancreatectomy, and 4.0% (458/2736) had unresectable tumors.
Patients were less likely to undergo surgery if they were older than 65 years, were black, were on Medicare or Medicaid, had pancreatic head lesions, earned lower annual incomes, or had less education (P < 0.0001). Patients were less likely to receive surgery at low-volume and community centers. Patients underwent surgery more frequently at National Cancer Institute/National Comprehensive Cancer Network-designated cancer centers (P < 0.0001). Patients who were not offered surgery had significantly better survival than those with Stage III or IV disease but worse survival than patients who underwent pancreatectomy for Stage I disease (P < 0.0001).
Conclusions: This is the first study to characterize the striking underuse of pancreatectomy in the United States. Of early stage pancreatic cancer patients without any identifiable contraindications, 38.2% failed to undergo surgery.
Introduction
Pancreatic cancer is the fourth leading cause of cancer deaths in the United States. In 2007, the American Cancer Society estimates that over 37,000 patients will be diagnosed with pancreatic cancer, and more than 33,000 will die of the disease. Patients with pancreatic cancer have a particularly dismal prognosis due to multiple factors, including late presentation, aggressive tumor biology, complex surgical management, and the lack of effective systemic therapies. Overall survival rates have remained relatively unaffected with fewer than 5% of all patients surviving 5 years after diagnosis.
Surgery remains the only potentially curative treatment of localized pancreatic cancer. During the last 20 years, significant advances in preoperative evaluation, surgical techniques, and postoperative care have reduced the perioperative morbidity and mortality associated with pancreatic surgery. Mortality after pancreaticoduodenectomy has dropped from ~25% in the 1960s to less than 3% in some high-volume centers, and recent studies have suggested improvements in long-term survival rates after resection for localized disease that approach 30%.
Despite numerous studies and guidelines establishing pancreatectomy as the primary treatment modality for localized pancreatic adenocarcinoma, pessimistic attitudes toward all patients with pancreatic cancer have perhaps led to skepticism regarding the efficacy of resection. Clinicians have long recognized that a diagnosis of pancreatic cancer encompasses little variability in long-term outcomes; however, these views are outdated in light of recent evidence. Our hypothesis was that these attitudes affect utilization of surgery for early stage pancreatic cancer after controlling for age, comorbidities, and patient refusal to undergo surgery. The objectives of this study were 1) to evaluate and characterize the utilization of surgery for pancreatic adenocarcinoma, 2) to identify factors predicting failure to undergo surgery for localized disease, and 3) to evaluate the effect of surgery on survival.
