Trajectory of care and use of multimodality therapy in older patients with pancreatic adenocarcinoma.
BACKGROUND
Multimodality therapy with chemotherapy and operative resection is recommended for patients with locoregional pancreatic cancer but is not received by many patients.


OBJECTIVE
To evaluate patterns in the use and timing of chemotherapy and resection and factors associated with receipt of multimodality therapy in older patients with locoregional pancreatic cancer.


METHODS
We used Surveillance, Epidemiology, and End Results-linked Medicare data (1992-2007) to identify patients with locoregional pancreatic adenocarcinoma. Multimodality therapy was defined as receipt of both chemotherapy and pancreatic resection. Logistic regression was used to determine factors independently associated with receipt of multimodality therapy. Log-rank tests were used to identify differences in survival for patients stratified by type and timing of treatment.


RESULTS
We identified 10,505 patients with pancreatic adenocarcinoma. 5,358 patients (51.0%) received either chemotherapy or surgery, with 1,166 patients (11.1%) receiving both modalities. Resection alone was performed in 1,138 patients (10.8%), and chemotherapy alone was given to 3,054 (29.1%) patients. In patients undergoing resection as the initial treatment modality, 49.4% never received chemotherapy; 97.4% of patients who underwent chemotherapy as the initial treatment modality never underwent resection. The use of multimodality therapy increased from 7.4% of patients in 1992-1995 to 13.8% of patients in 2004-2007 (P < .0001). The 2-year survival was 41.0% for patients receiving multimodality therapy, 25.1% with resection alone, and 12.5% with chemotherapy alone (P < .0001). Of the patients receiving multimodality therapy, chemotherapy was delivered in the adjuvant setting in 93.1% and in the neoadjuvant setting in 6.9%, with similar 2-year survival with either approach (neoadjuvant vs adjuvant, 46.9% vs 40.6%; P = .16). Year of diagnosis, white race, less comorbidity, and no vascular invasion were independently associated with receipt of multimodality therapy.


CONCLUSIONS
Only half of older patients with locoregional pancreatic cancer receive any treatment, and fewer than one quarter of treated patients receive multimodality therapy. Nearly all patients receiving chemotherapy as the initial treatment modality did not undergo resection, whereas half of those undergoing resection first received chemotherapy. When multimodality therapy is used, the vast majority of patients had chemotherapy in the adjuvant setting with a similar survival, regardless of approach.
Department of Surgery, University of Texas Medical Branch, Galveston, TX; Department of Surgery, the University of California, San Francisco-East Bay, Oakland, CA. Electronic address: abparmar@utmb.edu.
Abhishek D
AD
Parmar
Department of Surgery, University of Texas Medical Branch, Galveston, TX.
Gabriela M
GM
Vargas
Department of Surgery, University of Texas Medical Branch, Galveston, TX; Department of Surgery, the University of California, San Francisco-East Bay, Oakland, CA.
Nina P
NP
Tamirisa
Department of Surgery, University of Texas Medical Branch, Galveston, TX.
Kristin M
KM
Sheffield
Department of Surgery, University of Texas Medical Branch, Galveston, TX.
Taylor S
TS
Riall
D000230:Adenocarcinoma / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D024221:Antineoplastic Protocols; D017024:Chemotherapy, Adjuvant; D015331:Cohort Studies; D003131:Combined Modality Therapy / Q000706:statistics & numerical data / Q000639:trends; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D010190:Pancreatic Neoplasms / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D018714:Radiotherapy, Adjuvant; D018426:SEER Program