title: Pancreatectomy predicts improved survival for pancreatic adenocarcinoma: results of an instrumental variable analysis.
abstract: OBJECTIVE
  Pancreatic resection is the standard treatment option for patients with stage I/II pancreatic ductal adenocarcinoma (PDA), yet many studies demonstrate low rates of resection. The objective of this study was to evaluate whether increasing resection rates would result in an increase in average survival in patients with stage I/II PDA.
  
  
  METHODS
  SEER (Surveillance, Epidemiology, and End Results) data were analyzed for patients with stage I/II pancreatic head cancers treated from 2004 to 2009. Pancreatectomy rates were examined within Health Service Areas (HSAs) across 18 SEER regions. An instrumental variable analysis was performed, using HSA rates as an instrument, to determine the impact of increasing resection rates on survival.
  
  
  RESULTS
  Pancreatectomy was performed in 4322 of 8323 patients evaluated with stage I/II PDA (overall resection rate = 51.9%). The resection rate across HSAs ranged from an average of 38.6% (lowest quintile) to 67.3% (highest quintile). Median survival was improved in HSAs with higher resection rates. Instrumental variable analysis revealed that, for patients whose treatment choices were influenced by rates of resection in their geographic region, pancreatectomy was associated with a statistically significant increase in overall survival.
  
  
  CONCLUSIONS
  When controlling for confounders using instrumental variable analysis, pancreatectomy is associated with a statistically significant increase in survival for patients with resectable PDA. On the basis of these results, if resection rates were to increase in select patients, then average survival would also be expected to increase. It is important that this information be provided to physicians and patients so that they can properly weigh the risks and advantages of pancreatectomy as treatment of PDA.
authors: *Holden Comprehensive Cancer Center Departments of †Health Services Research ‡Biostatistics §Epidemiology ¶Surgery, The University of Iowa College of Public Health and University of Iowa Hospitals and Clinics, Iowa City, IA.
authors: Bradley D
authors: BD
authors: McDowell
authors: Cole G
authors: CG
authors: Chapman
authors: Brian J
authors: BJ
authors: Smith
authors: Anna M
authors: AM
authors: Button
authors: Elizabeth A
authors: EA
authors: Chrischilles
authors: James J
authors: JJ
authors: Mezhir
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D021441:Carcinoma, Pancreatic Ductal / Q000401:mortality* / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010180:Pancreatectomy / Q000706:statistics & numerical data*; D010190:Pancreatic Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D018714:Radiotherapy, Adjuvant / Q000706:statistics & numerical data; D018426:SEER Program; D015996:Survival Rate; D016896:Treatment Outcome