The risk of not receiving adjuvant chemotherapy after resection of pancreatic ductal adenocarcinoma: a nationwide analysis

Abstract

Background:The relation between type of postoperative complication and not receiving chemotherapy after resection of pancreatic ductal adenocarcinoma (PDAC) is unclear. The aim was to investigate which patient factors and postoperative complications were associated with not receiving adjuvant chemotherapy.Methods: Patients who underwent resection (2014)(2015)(2016)(2017) for PDAC were identified from the nationwide mandatory Dutch Pancreatic Cancer Audit. The association between patient-, tumor-, center-, treatment characteristics, and the risk of not receiving adjuvant chemotherapy was analyzed with multivariable logistic regression.Results: Overall, of 1306 patients, 24% (n = 312) developed postoperative Clavien Dindo 3 complications. In-hospital mortality was 3.5% (n = 46). Some 433 patients (33%) did not receive adjuvant chemotherapy. Independent predictors (all p < 0.050) for not receiving adjuvant chemotherapy were older age (odds ratio (OR) 0.96), higher ECOG performance status (OR 0.57), postoperative complications (OR 0.32), especially grade B/C pancreatic fistula (OR 0.51) and post-pancreatectomy hemorrhage (OR 0.36), poor tumor differentiation grade (OR 0.62), and annual center volume of <40 pancreatoduodenectomies (OR 0.51).Conclusions: This study demonstrated that a third of patients do not receive chemotherapy after resection of PDAC. Next to higher age, worse performance status and lower annual surgical volume, this is mostly related to surgical complications, especially postoperative pancreatic fistula and postpancreatectomy hemorrhage.This paper is not based on a previous communication to a society or meeting. * Shared senior authorship.

Neoadjuvant Treatment in Pancreatic Cancer

“…In the Prodige study, a RCT comparing a modified FOLFIRINOX regimen with gemcitabine in the adjuvant setting found an impressive median survival of 54 months with mFOLFIRINOX (29). Unfortunately, there is a significant fraction of patients who undergo upfront surgery but do not recover adequate functional status to receive adjuvant therapy and its treatment benefits (80).…”

How to Approach Para-Aortic Lymph Node Metastases During Exploration for Suspected Periampullary Carcinoma: Resection or Bypass?

“…The exact reason as to why a smaller proportion of patients in cohort A received adjuvant chemotherapy is unclear, however substantial variation of adjuvant chemotherapy rates for patients with pancreatic head carcinoma among different centers have been described. 20,21 In the present study, patients with PALN involvement who underwent resection had a median overall survival of 11 months, compared with 7 months in patients where resection was avoided (p = 0.049). In a smaller subgroup of patients with PALN involvement who received adjuvant chemotherapy, the median overall survival was 13 months after pancreatoduodenectomy, compared with 11 months after a palliative bypass procedure (p = 0.033).…”

Care after pancreatic resection according to an algorithm for early detection and minimally invasive management of pancreatic fistula versus current practice (PORSCH-trial): design and rationale of a nationwide stepped-wedge cluster randomized trial

“…Although these studies have led to an improved quality of care worldwide, pancreatic fistula still remains one of the most feared complications after pancreatic surgery. When not recognized early, pancreatic fistula may have major impact on the clinical course and is associated with an increased risk of in-hospital death, prolonged hospital stay, lower chance of receiving adjuvant chemotherapy and impaired long-term survival [3,5,42]. A recent study showed that the difference in clinical outcome in Dutch centers can be explained in difference in failure to rescue rate rather than incidence of major complications [11].…”

“…Pancreatic resection is, however, a major abdominal operation which is associated with a 50% risk of complications [2]. Complications are associated with postoperative death and reduced long-term survival because patients with a complicated postoperative course are often unfit to receive adjuvant chemotherapy [3][4][5].…”