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  • br Noor de Leede a Esther

    2020-07-27


    Noor de Leede a,1, Esther Bastiaannet a,b,1, Lydia van der Geest c, Kathleen Egan d, Cornelis van de Velde a, Lodovico Balducci e, Bert Bonsing a, Martine Extermann e,
    a Department of Surgical Oncology, Leiden University Medical Center, Leiden, the Netherlands
    b Department of Geriatrics and Gerontology, Leiden University Medical Center, Leiden, the Netherlands
    c Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands.
    d Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
    e Department of Senior Adult Oncology, Moffitt Cancer Center, Tampa, FL, USA
    Article history:
    Keywords:
    Pancreatic cancer
    Older
    International comparison 
    Objectives: A significant proportion of patients with pancreatic cancer are over the age of 70 years. The aim was to compare treatment and survival for older patients with pancreatic cancer treated throughout the Netherlands or Moffitt Cancer Center (Tampa, Florida).
    Methods: All age-eligible patients with pancreatic adenocarcinoma (2008–2012) were identified. Results were stratified by stage. Treatment (neoadjuvant, surgery, adjuvant and palliative treatment) and short-term survival were compared, and where appropriate adjusted (sex, age, grade, year) or stratified according to age or hospital (Netherlands- academic, teaching, non-teaching).
    Results: In total, 2728 patients were included. Neo-adjuvant chemoradiation was more often administered at Moffitt (non-metastatic stages), as was adjuvant chemoradiation and chemotherapy (p b .001). The proportion surgery was not significantly different. In patients with advanced disease, more patients at Moffitt underwent palliative chemotherapy (64.5% versus 17.4%; p b .001). Short-term survival was better among Moffitt patients (HR 0.30 (95%CI 0.11–0.82), HR 0.56 (0.41–0.72), HR 0.43 (0.36–0.52) for early, T3 or GW3965 positive and advanced). Differences were less pronounced comparing Dutch academic hospitals to Moffitt.
    Conclusion: In the present comparison, a treatment regimen as delivered at Moffitt was associated with prolonged short-term survival. Further detailed analyses of selection criteria for systemic treatment could lead to tailored treatment and improved outcomes.
    1. Introduction
    Due to the aging of Western populations, the number of older patients with cancer is expected to increase at an accelerating rate in coming years. For pancreatic cancer, more than half of patients is over the age of 70 years at diagnosis. Despite developments in treatment modalities, overall and cancer specific survival are however poor for most pancreatic cancer patients [1]. A multidisciplinary approach including radical surgical resection and systemic therapy is the only po-tentially curative option for selected patients [2]. This is however asso-ciated with a high risk of perioperative morbidity (ranging from 22 to
    All authors substantially contributed to the conception and design or analysis and interpretation of the data; drafting the article or revising secondary cell wall critically; and approved the final version to be published. Corresponding author at: Moffitt Cancer Center, Department of Senior Adult Oncology, 12902 Magnolia Drive, Tampa, FL 33612, USA E-mail address: [email protected] (M. Extermann).
    1 Both authors contributed equally
    50%) and mortality (ranging from 4 to 12%), especially in older patients [3,4]. Moreover, most patients present at an advanced stage, where sur-gery is not an option, thereby largely precluding long-term survival [5].
    Studies concerning the outcome of complex major surgery in older patients are most crucial as the proportion of older patients with cancer increases. Besides, there are concerns whether these surgical endeavors are justified [6]. Surgical treatment of pancreatic cancer presents distinctive challenges due to a high perioperative morbidity (51% com-plications) in patients with a dismal prognosis [6]. Previous studies have shown conflicting results with respect to pancreatoduodenectomy in older patients. Some studies show a comparable complication rate and survival as compared to younger patients [7–9]; others have shown that older patients present more often with postoperative cardiac events, stay longer in the intensive care unit, experience more nutri-tional and functional difficulties, and are more often readmitted than younger patients [10–12]. Therefore, two questions [13] are pertinent in the selection of older patients for surgery: is the older patient able to overcome the complex pancreatic surgery and secondly, will the
    older patient benefit from surgery considering the reduced life expec-tancy? A Dutch study [14] showed that over time resection rates increased in older patients in the Netherlands, and that despite higher short-term mortality, octogenarians who underwent pancreatic resec-tion showed long-term survival similar to younger patients.