title: Sociodemographics and comorbidities influence decisions to undergo pancreatic resection for neoplastic lesions.
abstract: BACKGROUND
  Pancreatic resection is being performed with increasing frequency and safety. Technical outcomes and long-term survival for neoplastic lesions are well reported; however, reasons why patients do not undergo surgery for potentially resectable lesions are not well understood. The aim of this study was to determine the factors contributing to the decision not to operate for resectable pancreatic neoplasms.
  
  
  METHODS
  From 2004 to 2008, all patients with resectable pancreatic neoplasms at a single high-volume hepatopancreaticobiliary center were evaluated. The impact of patient factors, sociodemographics, medical comorbidities (Charlson combined comorbidity index (CCI) and ACCI), disease factors (tumor characteristics), and surgical factors (type of resection required) on the decision to undergo pancreatectomy were analyzed using univariate and multivariate binary logistic regression analysis.
  
  
  RESULTS
  Three hundred seventy-five patients with resectable pancreatic lesions were identified. The median age was 62 years (21-93); 203 out of 375 (54.1%) were males. Fifty-five (14.7%) did not undergo resection. On univariate analysis, age (odds ratio (OR) 1.116, p < 0.001), non-English speaking background (NESB; OR 4.276, p = 0.001), tumor type (p = 0.001 increased for cystic neoplasms including intraductal papillary mucinous neoplasm), CCI score (OR 1.239, p = 0.001), and ACCI score (OR 1.433, p < 0.001) were associated with an increased risk of not undergoing resection. Gender, age, marital status, and urban residence were not predictive. On multivariate analysis, NESB (p = 0.018) and the ACCI (p = 0.002) remained predictive of not undergoing resection. The majority of patients did not undergo surgery because the patient declined in 25 out of 55 (45.5%), and resection was not offered in 15 out of 55 (27.3%). In the remainder, medical contraindications precluded surgery. Advanced age, tumor type, comorbidities (27.3%), age (21.8%), surgical risk (29.1%), frailty (18.2%), and uncertain diagnosis (5.5%) were cited as reasons for not proceeding with surgery.
  
  
  CONCLUSIONS
  Patients with a higher ACCI and those from a NESB are less likely to undergo surgery for resectable neoplastic lesions of the pancreas. These factors must be taken into consideration in the decision-making process when considering surgery for patients with pancreatic neoplasms. Novel strategies should be employed to optimize access to surgery for patients with resectable pancreatic neoplasms.
authors.affiliation: Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: Charbel
authors.initials: C
authors.lastname: Sandroussi
authors.forename: Chantelle
authors.initials: C
authors.lastname: Brace
authors.forename: Erin D
authors.initials: ED
authors.lastname: Kennedy
authors.forename: Nancy N
authors.initials: NN
authors.lastname: Baxter
authors.forename: Steven
authors.initials: S
authors.lastname: Gallinger
authors.forename: Alice C
authors.initials: AC
authors.lastname: Wei
mesh_terms: D000368:Aged; D015897:Comorbidity; D003657:Decision Making; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000453:epidemiology* / Q000601:surgery; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors