Cancer Care 2017 Public Reporting of Outcomes
Pancreatic cancer is a leading cause of cancer related death worldwide. Screening efforts and treatment outcomes have been historically poor. In recent years, surgical morbidity and mortality rates have declined dramatically, unfortunately with little long term benefits. Cancer recurrence remains the most common outcome even after a successful operation. For this reason, adjuvant chemotherapy is almost universally recommended following a “successful” surgical resection regardless of margins and lymph node status.
Historical nihilism has lead toward a generalized omission of treatment, surgery and chemotherapy, for all stages of pancreatic cancer. Many patients are never referred for a surgical oncology opinion; many resected patients are never referred for adjuvant chemotherapy. Efforts are now underway to reverse this “under treatment” problem. Nationally recognized guidelines such as the NCCN (National Comprehensive Cancer Network) recommend that all pancreatic cancer patients who are in good health and resectable be offered both surgery and chemotherapy. There currently is no consensus or data with regard to timing of chemotherapy and surgery. Postoperative complications causing prolonged delays or omission of chemotherapy are often cited as a rationale for using a chemotherapy first approach. We decided to examine delivery of postoperative chemotherapy as a quality measure in our patient population. We performed an analysis of the time to initiation of adjuvant chemotherapy following a pancreaticoduodenectomy and compared our data with national guidelines in this Pancreatic Cancer Quality Report.
We performed a retrospective review of all patients receiving surgical treatment for invasive adenocarcinoma at Kalispell Regional Medical Center (KRMC) performed February 2013 through January 2017.
Defined inclusion criteria: pancreatic head resection for adenocarcinoma; exclusion criteria pancreatic resections for dysplasia, neuroendocrine, cholangiocarcinoma or pancreatitis. We specifically selected patients undergoing a pancreaticoduodenectomy (commonly referred to as Whipple procedure), as these patients have the highest chances of not receiving postoperative chemotherapy. We examined initiation of chemotherapy after surgery and rationale for not receiving standard treatment.
We identified 38 cases, of which 34 would qualify for adjuvant postoperative chemotherapy. Four, or 10 percent, received preoperative chemotherapy for a variety of reasons and were examined separately. Eighty-five percent of patients received the recommended adjuvant chemotherapy following a pancreaticoduodenectomy. The great majority of patients initiated chemotherapy in the early postoperative period with 85 percent starting treatment in less than 12 weeks (Figure 1). Some of our patients did not receive chemotherapy. Ten percent (three cases) refused chemotherapy despite recommendations. Six percent (two cases) failed to receive postoperative chemotherapy due to either postoperative complications or comorbidities.
Postoperative starting of chemotherapy with 85 percent (red line) starting treatment by week 12. Very few cases failed to start treatment due to complication or comorbitidites (6 percent).
Nationally patients seldom receive the recommended postoperative chemotherapy despite published national guidelines. In a recent report looking at more than 13,000 pancreatic cancer patients, 32 percent did not receive standard adjuvant chemotherapy following a pancreaticoduodenectomy. In more than 80 percent of those not receiving the standard treatment, the cited reason was “not recommended,” which may imply a combination of items: poor health following surgery to nihilistic attitude toward the disease. Ten percent refused treatment and less than 5 percent could not receive treatment due to complications or comorbidities. These findings highlight the gap between recommendations and goals and real world treatment shortcomings and stand in direct contrast to nationally published and universally accepted guidelines (Berquist, Annals of Surgical Oncology, 2017). In a second report looking at the timing of chemotherapy following surgery, the authors reported that 60 percent of patients never received any chemotherapy, but those that did receive chemotherapy typically did so within 12 weeks of surgery (Mirkin, Cancer, 2016). What do these studies tell us? Patients in the United States fail to receive the recommended adjuvant chemotherapy following surgery. Unfortunately the reasons for this failure nationally are not clearly defined from these publications.
We wanted to know if our results mirrored or refuted these national findings. At KRMC, 85 percent of patients received the recommended combination of surgery and chemotherapy, and most receive the treatment within the early postoperative phase (less than 12 weeks). Efforts to reach a goal of 100 percent, although desirable, may not ever be achieved, as 10 percent of our patients refused treatment and 6 percent did not receive treatment due to complication or comorbidities. At present, patients treated at KRMC begin adjuvant chemotherapy following a pancreaticoduodenectomy at a rate far higher than patients treated elsewhere in the United States. KRMC adherence to guideline recommendations was 85 percent compared to national rates between 40 percent and 60 percent.