By Will Boggs MD
NEW YORK (Reuters Health) - Resection rates for pancreatic cancer remain low in Europe and the U.S., even for patients with early-stage tumors, according to data from seven population-based registries.
"The most interesting and surprising finding was the large variation of resection rates across countries,” Dr. Lina Jansen from German Cancer Research Center, Heidelberg, Germany, told Reuters Health by email. “These variations were not expected, as all investigated countries follow the U.S. National Comprehensive Cancer Network (NCCN) guidelines with respect to resectability in pancreatic cancer.”
Surgical resection is the only potential curative treatment for pancreatic cancer, but even most stage I-II pancreatic cancers are not curatively resectable and 5-year post-surgery survival remains low.
Dr. Jansen and colleagues used data from six European cancer registries (the Netherlands, Belgium, Norway, Denmark, Slovenia, and Estonia) and the U.S. Surveillance, Epidemiology, and End Results (SEER)-18 database to investigate variations in resection rates for pancreatic cancer. The findings were published online November 20 in Gut.
Stage I-II cancers represented only 18.8% (Slovenia) to 36.2% (U.S.) of cases. Most cancers were diagnosed with metastatic disease (54.5% in the U.S. to 72.8% in Slovenia).
Overall, resection rates ranged from 13.0% (Estonia) to 21.7% (Belgium). The U.S. resection rate, 16.2%, was only slightly higher than the 16.0% overall resection rate among more than 147,000 investigated patients.
Even for stage I-II cancers, which are mostly considered resectable, resection rates were only between 34.8% (Norway) and 68.7% (Denmark) and, most recently, only 44.0% in the U.S.
Most resected patients had stage I-II tumors (75.1% in Slovenia to 92.4% in Denmark). Neoadjuvant chemotherapy (0.3%-4.2%) and radiotherapy (0.1%-4.3%) were rarely administered, whereas adjuvant chemotherapy (12.0%-55.7%) and radiotherapy (0.1%-29.5%) generally were more common.
Overall resection rates increased between 2003 and 2014 in the U.S. (from 14.1% to 17.0%) and in the Netherlands (from 8.2% to 17.9%) and between 2011 and 2014 in Denmark (from 12.0% to 17.6%), whereas no significant trends were observed in other countries.
At the population level, patient age, performance status, tumor stage, location, and size were significantly associated with resection rates.
“From this purely observational study, we cannot decide whether there is an urgent need for more pancreatic cancer surgeries in stage I-II cancers,” Dr. Jansen said. “While resection offers the only chance to cure pancreatic cancer and can prolong survival, postsurgical morbidity is relatively high (30%-40%) and even after surgery and adjuvant chemotherapy the chance of long-term survival is low. For example, in the recently published CONKO-005 trial, patients with R0 resection and adjuvant treatment with gemcitabine had a median disease-free survival of 11.4 months and a median overall survival of 26.5 months.”
“Thus,” she said, “especially in pancreatic cancer, it is of utmost importance to inform the patient carefully about the potential benefits and harms of surgery. However, patients with resectable pancreatic cancer should generally be offered surgery by the treating physician.”
“We want to make physicians aware of these huge intra-country differences in resection rates that disclose the need for further standardization of pancreatic cancer treatment to improve patient care,” Dr. Jansen said. “Furthermore, we hope that these results point out the need for further studies exploring the reasons for these low resection rates to elucidate potentially modifiable areas in clinical practice and policymaking. For example, resectability might be largely influenced by surgeons’ capabilities and experience, surgical techniques, skills, procedures, and equipment, which might be improved by centralization of treatment, as it has been shown in the Netherlands.”
She added, “In the last years, investigations into novel therapeutics targeting specific molecular or immune pathways which contribute to personalized medicine are becoming increasingly popular. These new treatments are very expensive and often only contribute to a lengthened survival of few days/months. While the exploration of the new approaches should be encouraged, the potential benefit of standardization of effective classical treatments, which usually are associated with lower costs, should not be disregarded.”
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