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Does the Use of Neoadjuvant Therapy for Pancreatic Adenocarcinoma Increase Postoperative Morbidity and Mortality Rates?
Amanda Cooper*1, Abhishek Parmar2, Bruce L. Hall3, Matthew H. Katz1, Jason B. Fleming1, Thomas Aloia1, Taylor S. Riall2, Henry Pitt4
1Surgical Oncology, MD Anderson, Houston, TX; 2Department of Surgery, University of Texas Medical Branch at Galveston, Galveston, TX; 3Division of General Surgery, Washington University School of Medicine, St. Louis, MO; 4Temple University Health System, Philadelphia, PA
Introduction: The effects of neoadjuvant therapy on postoperative complications following pancreatectomy for pancreatic cancer have not been well studied. Using prospectively collected data from the NSQIP Pancreatectomy Demonstration Project, we compared postoperative outcomes for patients with pancreatic adenocarcinoma treated with a surgery-first vs. neoadjuvant therapy-first approach.
Methods: We included all patients with pancreatic adenocarcinoma captured within the NSQIP Pancreatectomy Demonstration Project from November 2011 to December 2012. Patients were classified according to neoadjuvant therapy status (chemotherapy and/or radiation). Patients receiving neoadjuvant therapy were then further classified as having received chemotherapy alone or radiation with or without chemotherapy. The groups were compared using the Fisher's exact test with significance set at p<0.05.
Results: Of the 1,567 patients with pancreatic cancer identified, 199 patients received neoadjuvant therapy—99 patients (6.3%) received neoadjuvant chemotherapy alone and 100 (6.4%) received neoadjuvant (chemo)radiation. Demographic data were not notably different between the surgery-first and the neoadjuvant therapy groups. Patients treated with neoadjuvant therapy were more likely to need a vascular resection than patients treated with surgery first (41.5% vs. 17.3%, p<0.0001). Patients treated with any neoadjuvant therapy were also more like to undergo biliary stenting (58.9% vs. 44.5%, p=0.0006) and were less likely to have a laparoscopic resection (6.0% vs. 8.6%, p=0.05) than patients treated with surgery first. The 30-day mortality rate did not differ for patients in the neoadjuvant therapy compared to the surgery-first groups (2.0% vs. 1.5%, p=0.56). Overall postoperative morbidity also did not differ between the two groups (56.3% vs. 52.9%, p=0.34). Postoperative mortality and the incidence of most 30-day complications did not differ significantly based on use of neoadjuvant therapy; however, patients treated with neoadjuvant therapy were significantly less likely to have a deep organ space infection (3.0% vs. 11.5%, p=0.0004) and patients treated with neoadjuvant radiation were less like to develop a pancreatic fistula (7.3% vs. 15.5%, p=0.03).
Conclusions: Only 12.7% of patients with pancreatic adenocarcinoma captured in the Pancreatectomy Demonstration Project were treated with neoadjuvant therapy. Our data suggest that patients receiving neoadjuvant therapy in this dataset had more extensive disease (more frequently requiring vascular resection). Despite this, neoadjuvant therapy was associated with lower rates of deep organ-space infections and neoadjuvant radiation was associated with lower rates of pancreatic fistula. Concern over increasing rates of postoperative complications should not deter the use of neoadjuvant therapy for pancreatic cancer.
Demographic Characteristics by Treatment Strategy
| Characteristics | No Neoadjuvant Therapy | Neoadjuvant Chemotherapy | Neoadjuvant Radiation | | Race | | | | | Caucasian | 116 (88.1%) | 86 (86.9%) | 89 (89.9%) | | African American | 96 (7.3%) | 5 (5.1%) | 4 (4.0%) | | Other | 61 (4.6%) | 8 (8.1%) | 6 (6.1%) | | Gender | | | | | Female | 635 (46.4%) | 42 (42.4%) | 48 (48.0%) | | Male | 733 (53.6%) | 57 (57.6%) | 52 (52.0%) | | ASA Class | | | | | Class I | 10 (0.7%) | 0 (0%) | 1 (1.0%) | | Class II | 359 (26.3%) | 24 (24.2%) | 27 (27.0%) | | Class III | 937 (68.8%) | 69 (69.7%) | 63 (63.0%) | | Class IV | 57 (4.2%) | 6 (6.1%) | 9 (9.0%) | | BMI Category | | | | | Underweight | 26 (1.9%) | 1 (0.6%) | 3 (3.0%) | | Normal | 512 (37.5%) | 44 (44.9%) | 50 (50.0%) | | Obese | 350 (25.6%) | 16 (16.3%) | 14 (14.0%) | | Overweight | 478 (35.0%) | 37 (37.8%) | 33 (33.0%) |
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