title: Multimodality therapy for pancreatic cancer in the U.S. : utilization, outcomes, and the effect of hospital volume.
abstract: BACKGROUND
  Despite decreased perioperative morbidity and mortality and clinical trials suggesting improved outcomes with adjuvant therapy, national practice patterns in the management of pancreatic cancer remain poorly defined. The purpose of the current study was to evaluate multimodality therapy utilization and outcomes relative to hospital type and volume.
  
  
  METHODS
  Using the National Cancer Data Base, stage-specific treatment patterns were analyzed for 301,033 patients with pancreatic adenocarcinoma. Logistic regression was used to evaluate treatment utilization. Cox proportional hazards modeling was utilized to evaluate the effect of multimodality therapy on survival.
  
  
  RESULTS
  Stage at presentation did not differ from 1985-1994 to 1995-2003; however, the percentage of patients receiving cancer-directed treatment increased from 45.1% to 51.8% (P < .001). Pancreatectomy for localized disease (AJCC 6th edition stages I and II) increased from 36.9% to 49.3% (P < .001). After resection, the use of adjuvant chemotherapy alone increased from 4.1% to 5.7% (P < .001), but the use of adjuvant radiation alone decreased from 7.0% to 4.6% (P < .001). Adjuvant chemoradiation use increased from 26.8% to 38.7% (P < .001). The use of surgery alone decreased from 62.1% (5213 of 8400 cases) to 49.9% (10,807 of 21,679 cases) (P < .001). Patients with localized pancreatic cancer were more likely to receive pancreatectomy and adjuvant chemoradiation at academic and high-volume centers (P < .001). Survival for localized disease was better after surgery with adjuvant therapy (hazards ratio [HR], 0.44; 95% confidence interval [95% CI], 0.42-0.47) and surgical resection alone (HR, 0.54; 95% CI, 0.52-0.57) compared with no treatment.
  
  
  CONCLUSIONS
  To the authors' knowledge, the current study is the largest study regarding pancreatic cancer performed to date, and the first to investigate national practice patterns for multimodality therapy utilization. Multimodality therapy utilization has increased over time and appears to have a beneficial impact on survival.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Northwestern University, Chicago, Illinois, USA.
authors.forename: Karl Y
authors.initials: KY
authors.lastname: Bilimoria
authors.forename: David J
authors.initials: DJ
authors.lastname: Bentrem
authors.forename: Clifford Y
authors.initials: CY
authors.lastname: Ko
authors.forename: James S
authors.initials: JS
authors.lastname: Tomlinson
authors.forename: Andrew K
authors.initials: AK
authors.lastname: Stewart
authors.forename: David P
authors.initials: DP
authors.lastname: Winchester
authors.forename: Mark S
authors.initials: MS
authors.lastname: Talamonti
mesh_terms: D000046:Academic Medical Centers; D000230:Adenocarcinoma / Q000188:drug therapy / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery / Q000628:therapy*; D000368:Aged; D000369:Aged, 80 and over; D017024:Chemotherapy, Adjuvant / Q000706:statistics & numerical data; D005260:Female; D006742:Hospital Bed Capacity; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D016017:Odds Ratio; D010180:Pancreatectomy; D010190:Pancreatic Neoplasms / Q000188:drug therapy / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery / Q000628:therapy*; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D018714:Radiotherapy, Adjuvant / Q000706:statistics & numerical data; D012107:Research Design; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology