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A Tale of Two Cities: Reconsidering Adjuvant Radiation in Pancreatic Cancer Care
Susanna W. Degeus*1, 2, Lindsay a. Bliss1, Mariam F. Eskander1, Alexander Vahrmeijer2, Tara S. Kent1, a. James Moser1, Mark P. Callery1, Bert a. Bonsing2, Jennifer F. Tseng1
1BIDMC, Boston, MA; 2Leiden University Medical Centre, Leiden, Netherlands
Background. Pancreatic ductal adenocarcinoma has a dismal prognosis. Although pancreatic cancer care has become more concentrated at high-volume centres and increasingly standardized there are still considerable differences in care between centres. The role of adjuvant radiation in the treatment of resectable pancreatic cancer is controversial. It is the standard of care in most high-volume the United States (US) centres, but is not generally utilized in Europe (EU). This study compares treatment characteristics and survival outcomes between two representative high-volume pancreatic cancer centres in the US and EU.
Methods. Medical records of patients with pancreatic ductal adenocarcinoma (PDAC) who underwent surgical resection from January 2003 through December 2013 at ternary centres in Boston (US) and Leiden (EU) were reviewed for clinical pathological characteristics, operative techniques, postoperative outcomes, adjuvant treatment and overall survival. Patient and treatment characteristics were compared by chi-square. Survival curves for both treatment groups were compared using the log-rank test. Multivariate Cox regression was performed to identify independent predictors for overall survival in resected PDAC patients.
Results. 410 total patients were identified, 233 (54%) and 187 (46%) were treated in the US and EU respectively. The majority of patients had stage II disease at presentation (83%), which was similar (p = 0.842) in both treatment groups. Negative resection margins were comparable (57% US vs. 66% EU; p = 0.102). 82% of the patients in this US population proceeded to adjuvant treatment after surgery compared to 51% of the patients in EU (p < 0.001). 65% of the US patients received adjuvant radiation therapy while EU patients were solely treated with adjuvant chemotherapy. The perioperative morbidity was comparable (1.4% US vs. 2.7% EU; p = 0.345), but unadjusted median overall survival was significantly (p = 0.011) lower in the EU (16 months vs. 22 months). However, after adjustment for factors including adjuvant treatment, centre location was no longer predictive for overall survival. Predictive factors for overall survival were resection margin status (p = 0.019), pT stage (p = 0.012), adjuvant chemotherapy (p = 0.039) and adjuvant radiation (p = 0.030).
Conclusion. The academic high-volume pancreatic cancer centres in the US and EU investigated in this study offer comparable standards of pancreatic cancer care, with the notable lack of adjuvant radiation treatment in the EU population. This study, while nonrandomized, suggest that adjuvant radiation may be associated with a survival benefit for resectable pancreatic cancer patients. Adjuvant treatment, including consideration of radiation therapy, should be of paramount importance in the care of early-stage pancreatic adenocarcinoma.
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