Role of Surgery and Perioperative Therapy in Older Patients with Resectable Pancreatic Ductal Adenocarcinoma

Abstract

Background It is unclear whether results from recent trials of resectable pancreatic ductal adenocarcinoma (PDAC) are generalizable to older patients, who are underrepresented. We aimed to evaluate outcomes of surgery and of neoadjuvant and adjuvant therapy in older patients with resectable PDAC. Patients and Methods We included patients aged ≥65 years with upfront resectable PDAC from a prospectively maintained pancreatic cancer registry from 2007 to 2016. Patients were stratified into ages 65–75 and 75+ years. Overall survival (OS) was assessed in treatment comparisons: (A) surgery (n = 636) versus nonsurgical (n = 178), (B) neoadjuvant therapy (n = 139) versus upfront surgery (n = 497), and (C) adjuvant therapy (n = 379) versus surgery alone (n = 118). We compared neoadjuvant (n = 139) versus adjuvant therapy (n = 379) in an exploratory analysis. Results Nine hundred and three patients had a median age of 73.7 (range, 65–96.6) years. Median OS was 26.6 versus 11.9 months (adjusted hazard ratio [HRadj], 0.4; 95% confidence interval [CI], 0.31–0.52; p < .001) in Comparison A groups, 30.7 versus 25.8 months (HRadj, 0.69; 95% CI, 0.49–0.96; p = .03) in Comparison B groups, and 26.9 versus 17.4 months (HRadj, 0.62; 95% CI, 0.44–0.88; p = .008) in Comparison C groups, respectively. OS benefit in these treatment comparisons was present in age group 75+ with HRadj 0.24 (95% CI, 0.16–0.36; p < .001) in Comparison A and HRadj 0.52 (95% CI, 0.27–1; p = .049) in Comparison B, but not in Comparison C with HRadj 0.68 (95% CI, 0.43–1.08; p = .1). Statistically comparable median OS of patients who received neoadjuvant or adjuvant therapy stratified by age groups was observed. Conclusion Older patients with resectable PDAC who received surgery, neoadjuvant therapy, or adjuvant therapy appeared to have improved survival outcomes compared with those who did not receive such treatment. Implications for Practice Older patients with resectable pancreatic ductal adenocarcinoma (PDAC) in general are underrepresented in large clinical trials and less well studied in terms of the role of surgery, neoadjuvant therapy, and adjuvant therapy. This study collected data on older patients with resectable PDAC from a prospectively maintained single‐institutional pancreatic cancer registry of a tertiary referral center from 2007 to 2016. It was found that, with multidisciplinary evaluation, older patients with resectable PDAC who received surgery, neoadjuvant therapy, or adjuvant therapy appeared to have improved survival outcomes compared with those who did not receive such treatment. These results are of substantial importance to practitioners who treat older patients, who are traditionally underrepresented in most clinical trials.

Neoadjuvant therapy for resectable pancreatic cancer: a narrative review

“…In contrast, for patients between the ages of 65 and 75 years, NAT was associated with a similar mOS to adjuvant therapy (27.8 vs 26.8 months), and the survival benefit was very limited. [75] Cerullo et al [44] found that the estimates of OS at 1, 2, and 3 years were lower in patients who received NAT.…”

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC): Pancreatic Cancer

“…Treatment decisions are more complex because of the scarcity of data from large randomised studies in older patients and the heterogeneity of this population concerning functional status, comorbidity and polypharmacy. Not age, but comorbidity, life expectancy, and patient preferences should be decisive factors when offering treatment; evidence suggests that older patients who receive treatment have improved survival outcomes (see geriatric oncology section in the extended MDT) [60]. • Some studies indicate that people with low socioeconomic status (SES) are less likely to receive surgery, chemotherapy and radiotherapy, and have higher mortality rates that those with higher SES.…”

Feasibility, Safety, and Efficacy of Aggressive Multimodal Management of Elderly Patients with Pancreatic Ductal Adenocarcinoma

“…13,14 Several reports have confirmed the safety of pancreatic resection in elderly patients, with acceptable postoperative complication rates. [15][16][17] Similarly, administration of adjuvant chemotherapy is also considered feasible in high-performance status elderly patients. 18 That said, the safety and feasibility of delivering NAT, followed by surgical resection in the elderly remains unknown.…”

“…Thus, aggressive management of PDAC has become feasible and acceptable, including for elderly patients 13,14 . Several reports have confirmed the safety of pancreatic resection in elderly patients, with acceptable postoperative complication rates 15–17 . Similarly, administration of adjuvant chemotherapy is also considered feasible in high-performance status elderly patients 18 .…”