Treatment and survival rates of stage IV pancreatic cancer at VA hospitals: a nation-wide study

Abstract

Background: Metastatic pancreatic cancer (MPC) is associated with an extremely high mortality. Current NCCN guidelines recommend systemic therapy, as it is superior to best supportive care. Undertreatment of MPC continues to be an issue. Recent treatment and survival data of MPC in Veterans' Affairs' (VA) hospitals have not been published. The relationship between MPC treatment and survival and the American College of Surgeons' (ACS) Committee on Cancer (CoC) accreditation in VA hospitals has not been studied.

Methods: Nationwide data from the National Veterans Affairs Cancer Cube Registry was analyzed. In total, 6,775 patients were diagnosed with MPC between 2000 and 2014. CoC accreditation of each VA hospital was obtained using the ACS website.

Results: MPC constitutes 52.31% of all pancreatic cancer diagnosed (6,775/12,951 cases). The near totality was men (97.44%). The above 70 years age group and the 60-70 years age group were the most common ages at diagnosis with 39.39% and 38.02% respectively. The proportion of early-onset pancreatic cancer (EOPC) was 2.84%. When compared to all stages of pancreatic cancer, stage IV pancreatic cancer had a lower proportion of cancer originating from the head of the pancreas (39.33% versus 50.63%) and more originating from the tail (17.99% versus 13.39%). Tumors originating from head of the pancreas are more likely to cause biliary symptoms and thus are more likely to be caught at an earlier stage. Overall, treatment rate in the VA at the national level with first-line chemotherapy was 37.61%. The rate of treatment over the years has increased in a linear fashion from 33.01% in 2000 to 41.95% in 2014. This has corresponded with an increase of 1-5 years survival of 9.29% in 2000 to 22.99% in 2014 and 5-10 years survival from 0.96% in 2000 to 6.00% in 2012. Treatment rates in CoC-accredited and non-CoC accredited VA hospitals were similar (38.94% and 38.12%, respectively). Survival rates in CoC-accredited and non-COC accredited VAs were similar with a 1-5 years survival rate of 8.89% and 8.57%, respectively.

Conclusions: Treatment and survival of MPC have risen significantly in the past decade at VA hospitals. CoC accreditation is not associated with a change in treatment or survival rates.

Keywords: Pancreatic neoplasms; pancreatic neoplasms/classification; pancreatic neoplasms/epidemiology; pancreatic neoplasms/therapy.

Figure 1

Age distribution of stage IV pancreatic cancer. Patients affected by MPC are older with 39.39% over the age of 70 and 38.02% between 60 and 69 years .

Figure 2

Anatomic distribution of metastatic pancreatic cancer (MPC) and pancreatic cancer. Tail of pancreas constitutes a higher fraction of MPC at presentation.

Figure 3

ECOG-PS distribution of pancreatic cancer. Stage IV cancer presents with a worse performance status with increasing numbers of ECOG 2, 3 and 4 (22.17%, 14.39% and 3.19% respectively).

Figure 4

Survival of metastatic pancreatic cancer (MPC). Stage IV cancer has a dismal prognosis with 85.18% surviving less than 1 year.

Figure 5

Timeline showing increase in treatment (A) and survival (B) of metastatic pancreatic cancer (MPC). (A) Linear trend (r²=0.73 and slope =0.85) shows increase in treatment of stage IV pancreatic cancer over time; (B) the increase in survival is more significant than the increase treatment rate, as shown by the trendline.

Figure S1

Italicized hospitals are CoC-accredited, while underlined are not. CoC-accredited VA hospitals are italicized and CoC-non-accredited hospitals are underlined. Accreditation status obtained in September 2017.