Selected Summaries 243
Early pancreatic cancer: Are we doing enough?
Bilimoria KL, Bentrem DJ, Ko CY, Stewart
AK, Winchester DP, Talamonti MS. (Departments of Surgery,
Feinberg School of Medicine, Northwestern University, Chicago,
IL; University of California, Los Angeles; VA Greater Los
Angeles Healthcare System; Evanston Northwestern Healthcare,
Evanston, IL; and the National Cancer Data Base, American
College of Surgeons, Chicago, USA.) National failure to
operate on early stage pancreatic cancer. Ann Surg
2007;246:173–80.
SUMMARY
Surgery remains the only modality with the potential to
cure pancreatic cancer, which has an overall dismal prognosis
due to late presentation, aggressive tumour biology, complex surgical
management, and the lack of effective systemic therapies.
Overall 5-year survival rates have remained at 5%, although it
is clear that resection of localized disease would enable
survival rates of up to 30% at 5 years. Further, improvements
in preoperative evaluation, surgical techniques and
perioperative care have brought mortality rates following
pancreaticoduodenectomy from around 25% in the 1960s to <3% in
high-volume centres.
Against this background, the authors of
this paper hypothesized that an air of therapeutic nihilism
still existed among clinicians treating pancreatic cancer and
sought to verify this by examining
- the utilization rate of surgery in pancreatic adenocarcinoma,
- the reasons for failing to apply surgery in localized
disease, and
- the effect of surgical resection on survival.
The source of data was the National Cancer Data Base (NCDB)
of the American College of Surgeons and the Commission on
Cancer, which accounted for over 75% of all cancers treated in
the USA with over 19 million patients from 1440 hospitals.
This database is unique because it requires both clinical and
pathological staging information in patients who undergo surgical resection.
Only those patients with pancreatic cancer who had complete
staging information and were clinically stage I (T1N0M0,
T2N0M0) were included in the analysis. Thus, out of 192 565
patients with pancreatic cancer, 9559 with pretreatment
clinical stage I disease who were potentially resectable were
selected for analysis. The study made some important
observations:
-
Over 60% of patients had Medicare or
private insurance.
-
About 70% of tumours were in the
pancreatic head.
-
Academic hospitals treated only around
45% of patients, and the remaining were treated at community
hospitals.
-
Overall, 2736 patients (28.6%)
underwent surgery, of which 96% had resectable tumours.
-
The reasons for not subjecting
patients to surgery included co-morbid conditions (6.4%),
patient refusal (4.2%), advanced age (9.1%), ‘not offered
surgery’ (38.2%) and unknown reasons (13.5%).
-
On comparing the data of operated
patients with those who were not, the following observations
were made:
-
Operated patients were younger (65.1
v. 71.7 years)
-
Failure to operate occurred more
among patients who had the following characteristics
-
Older
-
Black race
-
Lower annual incomes
-
Lower education
-
Medicare/Medicaid beneficiaries
-
Three-fold less likelihood in
head/body tumours as opposed to tumours of the
pancreatic tail
-
Low-volume centres
-
Community hospitals (the best
operation rate was at National Cancer Institute Cancer centres, followed by other academic centres, with
community hospitals having the least operation rates)
c. Refusal of surgery also occurred
more often in (i) older patients, (ii) blacks, (iii)
Medicaid beneficiaries, (iv) those with lesions of the
head/body of pancreas, (v) low-volume and community
hospitals. Surprisingly, annual income and level of
education did not affect patients’ refusal of surgery.
-
5-year survival rates for clinical
stage I disease among patients who underwent pancreatectomy
were better (19.3%) than those for patients with clinical
stage III/IV disease (0.8%). The corresponding median
survival was 19.1 and 4.2 months, respectively.
-
Stage I patients not offered surgery
had a median survival of only 8.4 months which was only
marginally better than that for stage IV patients.
-
Pancreatectomy was an independent
predictor of a greater than 2-fold increase in the
likelihood of survival.
-
During 1995–2004, the utilization of pancreatectomy in stage I patients increased from 21.8% to
35.7%.
COMMENT
This remarkable paper underlines the
importance of documen-tation. Despite the inherent
difficulties in achieving completeness of data entry into
registries, the paper has thrown up some serious issues.
First, this paper provides one more
evidence that surgical resection is the treatment of choice
for localized pancreatic cancer, a fact highlighted in
previous papers.1–3
The study did not include T3 and N1 tumours, both of which are
also benefited by surgery; had they been included, the power
of this study would have been enhanced.
Second, the paper underlines the fact that even in 2004,
only 35.7% of patients with stage I disease underwent surgical
resection. This indicates that 2 of every 3 patients who were
candidates for surgical therapy did not actually undergo
surgical resection. In over half these patients there was no
documented reason for not offering surgery, and in 38%, it
appeared that they were simply not offered surgery. This
reflects a persistent therapeutic nihilism that still ails
medical practice, with many physicians believing that
pancreatic cancer is untreatable, and that surgical treatment
has a high risk and doubtful benefit. Although not evaluated
in this study, it is clear that pancreatic resection currently
has a low operative mortality,4–6 and is
the only therapy that currently has the potential to cure.
Third, disparities in care were identified
in the analyses. The lower rates of surgery in the elderly is
understandable given that they may have greater co-morbid
illnesses; but racial disparity was difficult to explain, as
was the fact that malignancies of the pancreatic tail were
resected more often than those in the head. Cancer of the tail
of the pancreas is usually advanced at presentation, and stage
I cancers are few. The higher number of resections of
pancreatic tail tumours can only be explained on the basis
that distal pancreatectomy for tail cancer may be technically
easier than the Whipple operation; this reflects nihilism
among surgeons as well. The higher rate of surgery in academic
institutions reflects a greater willingness among surgeons in
such institutions to operate on pancreatic cancer. Further,
one may argue that patients not offered surgery might have had
co-morbid conditions which were not reported, but the data
showed that patients not operated had in fact a lower Charlson
score than those who were. It is possible that data entry was
more complete for those patients who were surgically treated
than those who were not; this is a limitation of data from
registries.
The stated weakness of the paper; namely,
that stage II patients were not included, is actually its
strength; if those had been included, the figures might have
been even more startling. The paper emphasizes 3 important
facts: (i) surgery is superior to non-operative treatment for
localized pancreatic cancer, (ii) surgery must be offered to
all patients with localized pancreatic cancer regardless of
age, race, hospital setting or tumour location, and (iii)
therapeutic nihilism must be eradicated from the minds of
physicians and surgeons treating pancreatic cancer.
This is only a first step, and I feel that
the principle must be carried forward to application of a
multimodality approach to localized pancreatic cancer, so that
survival can be improved further.
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Ferrone CR, Brennan MF, Gonen M, Coit DG,
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