Management of patients with pancreatic adenocarcinoma: national trends in patient selection, operative management, and use of adjuvant therapy

Abstract

Background: Surgical resection remains the only potentially curative option for patients with pancreatic adenocarcinoma (PAC). Advances in surgical technique and perioperative care have reduced perioperative mortality; however, temporal trends in perioperative morbidity and the use of adjuvant therapy on a population basis remain ill-defined.

Study design: Using Surveillance, Epidemiology, and End Results-Medicare data, 2,461 patients with resected PAC were identified from 1991 to 2005. We examined trends in preoperative comorbidity indices, adjuvant treatment, type of pancreatic resection, and changes in morbidity and mortality during 4 time intervals (ie, 1991-1996, 1997-2000, 2001-2003, and 2003-2005).

Results: The majority of patients underwent pancreaticoduodenectomy (n = 1,945; 79%). There was a temporal increase in mean patient age (p < 0.05) and the number of patients with multiple preoperative comorbidities (Elixhauser comorbidities ≥3: 1991-1996, 10% vs 2003-2005, 26%; p < 0.001). Perioperative morbidity (53%) did not, however, change over time (p = 0.97) and 30-day mortality decreased by half (1991-1996: 6% vs 2003-2005: 3%; p = 0.04). Overall, 51% (n = 1,243) of patients received adjuvant therapy, with the majority receiving chemoradiation (n = 817; 33%). Among patients who received adjuvant therapy, factors associated with receipt of adjuvant chemotherapy alone relative to chemoradiation included older patient age (odds ratio = 1.75; p < 0.001) and ≥3 medical comorbidities (odds ratio = 1.57; p = 0.007). Receipt of adjuvant chemotherapy alone also increased over time (2003-2005 vs 1991-1996, odds ratio = 2.21; p < 0.001).

Conclusions: Perioperative 30-day mortality associated with resection for PAC decreased by one-half from 1991 to 2005. Although patients undergoing resection for PAC were older and had more preoperative comorbidities, the incidence of perioperative complications remained stable. The relative use of adjuvant chemotherapy alone vs chemoradiation therapy for PAC has increased in the United States during the 15 years examined.

Figure 1

Flow diagram of patient selection out of the total 56,820 patients identified with pancreatic adenocarcinoma to arrive at those patients who had their cancer resected with curative intent within the Surveillance, Epidemiology, and End Results–Medicare database 1991–2005.

Figure 2

(A) Trends in Elixhauser medical comorbidities, postoperative complications, and 30-day postoperative mortality for patients with pancreatic adenocarcinoma (PAC) undergoing pancreatic resection. Star (★) indicates the overall test for trend across the 4 calendar-year quartiles. (B) Temporal trends in use of adjuvant therapy among patients with PAC. Star (★) indicates the overall test for trend across the 4 calendar-year quartiles.

Figure 3

Multivariable Cox overall survival from the time of the pancreatic resection stratified by receipt of adjuvant therapy. Patients who received any adjuvant therapy (chemoradiation or chemotherapy only) had a lower risk of death than patients who did not receive adjuvant treatment (both p < 0.05).