Optimal timing and treatment strategy for pancreatic cancer

• Type of Material: Article
• Authors: Adriana C. Gamboa, Emory University; Manali Rupji, Emory University; Jeffrey Switchenko, Emory University; Rachel M. Lee, Emory University; Michael K. Turgeon, Emory University; Benjamin I. Meyer, Emory University; Maria Russell, Emory University; Kenneth Cardona, Emory University; David Kooby, Emory University; Shishir Maithel, Emory University; Mihir Shah, Emory University
• Language: English
• Date: 2020-05-29
• Publisher: Wiley
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2020 John Wiley & Sons, Inc. All rights reserved.
• Final Published Version (URL): http://dx.doi.org/10.1002/jso.25976
• Title of Journal or Parent Work: Journal of Surgical Oncology
• Volume: 122
• Issue: 3
• Start Page: 457
• End Page: 468
• Grant/Funding Information: t was also supported in parts by the Katz Foundation.; The research reported in this publication was supported in part by the Biostatistics and Bioinformatics Shared Resource of Winship Cancer Institute of Emory University and NIH/NCI under award number P30CA138292.
• Keywords: Neoadjuvant chemoradiation; Rectal cancer; neoadjuvant therapy; pancreas cancer; Life Sciences & Biomedicine; treatment delay; Adenocarcinoma; Gemcitabine; Resection; Survival; time-to-treatment; Oncology; Time; Science & Technology; optimal treatments; Chemotherapy; Surgery; Chemoradiotherapy
• Research Categories: Health Sciences, Radiology; Health Sciences, Rehabilitation and Therapy; Health Sciences, Oncology; Health Sciences, Medicine and Surgery

Abstract

Background: For pancreatic adenocarcinoma (PDAC), no studies have established any association between earlier treatment initiation and long-term outcomes. In addition, an optimal type of initial treatment for the localized disease remains ill-defined. Methods: Patients in the National Cancer Database (2004-2015) with clinical stage I (CS-I) and II (CS-II) PDAC who underwent curative-intent resection were included. Optimal time from diagnosis-to-treatment including neoadjuvant chemotherapy, neoadjuvant chemoradiation, or upfront surgery was assessed. An optimal type of treatment was evaluated. The primary outcome was overall survival (OS). Results: Among 29 167 patients, starting any treatment within 0 to 6 weeks was associated with improved median OS compared with 7 to 12 weeks (21.0 vs 20.1 months; P = .004). This persisted when accounting for sex, race, and Charlson-Deyo score (hazard ratio [HR], 0.94; P = 0.02) and on subset analysis for CS-I (23.5 vs 21.8 months; P = .04) and CS-II (19.4 vs 18.3 months; P = .03). Neoadjuvant chemotherapy was associated with improved OS compared with neoadjuvant chemoradiation (25.6 vs 22.7 months; P <.0001) or US (25.6 vs 20.1 months; P <.0001) even when accounting for sex, race, and Charlson-Deyo score (neoadjuvant chemoradiation: HR, 0.86; P < .001; US: HR, 0.79; P < .001). This improvement persisted in subset analysis with NC compared with neoadjuvant chemoradiation (CS-I: 28.6 vs 25.0 months; CS-II: 25.0 vs 22.9 months; both P < .0001) and to US (CS-I: 28.6 vs 22.9 months; CS-II: 24.7 vs 18.4 months; both P < .0001). On multivariable analysis for each CS-I/CS-II, NC remained associated with 20% improved survival compared with neoadjuvant chemoradiation or upfront surgery. Conclusions: For PDAC, initiation of therapy within 6 weeks from diagnosis is associated with improved survival, with neoadjuvant chemotherapy associated with the best survival compared with neoadjuvant chemoradiation or upfront surgery.