National failure to operate on early stage pancreatic cancer

Abstract

Background: Despite studies demonstrating improved outcomes, pessimism persists regarding the effectiveness of surgery for pancreatic cancer. Our objective was to evaluate utilization of surgery in early stage disease and identify factors predicting failure to undergo surgery.

Methods: Using the National Cancer Data Base (1995-2004), 9559 patients were identified with potentially resectable tumors (pretreatment clinical Stage I: T1N0M0 and T2N0M0). Multivariate models were employed to identify factors predicting failure to undergo surgery and assess the impact of pancreatectomy on survival.

Results: Of clinical Stage I patients 71.4% (6823/9559) did not undergo surgery; 6.4% (616/9559) were excluded due to comorbidities; 4.2% (403/9559) refused surgery; 9.1% (869/9559) were excluded due to age; and 38.2% (3,644/9559) with potentially resectable cancers were classified as "not offered surgery." Of the 28.6% (2736/9559) of patients who underwent surgery, 96.0% (2630/2736) underwent pancreatectomy, and 4.0% (458/2736) had unresectable tumors. Patients were less likely to undergo surgery if they were older than 65 years, were black, were on Medicare or Medicaid, had pancreatic head lesions, earned lower annual incomes, or had less education (P < 0.0001). Patients were less likely to receive surgery at low-volume and community centers. Patients underwent surgery more frequently at National Cancer Institute/National Comprehensive Cancer Network-designated cancer centers (P < 0.0001). Patients who were not offered surgery had significantly better survival than those with Stage III or IV disease but worse survival than patients who underwent pancreatectomy for Stage I disease (P < 0.0001).

Conclusions: This is the first study to characterize the striking underuse of pancreatectomy in the United States. Of early stage pancreatic cancer patients without any identifiable contraindications, 38.2% failed to undergo surgery.

FIGURE 1. Treatment trends for Stage I pancreatic adenocarcinoma comparing utilization of pancreatectomy, nonsurgical treatment, and no treatment.

FIGURE 2. Management of 9559 patients with pretreatment, clinical Stage I pancreatic adenocarcinoma from 1995 to 2004.

FIGURE 3. Reasons why patients did not undergo surgery for clinical Stage I pancreatic cancer over time compared with those undergoing surgery.

FIGURE 4. Five-year survival for pancreatic adenocarcinoma comparing patients who underwent pancreatectomy for clinical Stage I (n = 2736), were not offered surgery despite being clinical Stage I (n = 3644), and those with Stage III or IV who did not undergo surgery (n = 68,521).