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Practice Patterns and Impact of Imaging Surveillance After Resection for Pancreatic Ductal Adenocarcinoma
June Peng*, Colin O'Rourke, Gareth Morris-Stiff, R Matthew Walsh, Sricharan Chalikonda
Cleveland Clinic, Cleveland, OH
Background
Current strategy for surveillance after surgical resection of pancreatic ductal adenocarcinoma (PDAC) varies widely with no evidence basis to guide practice. The current NCCN recommendation is to perform a history and physical, computed tomography (CT), and obtain CA 19-9 levels every 3-6 months for two years and annually thereafter. We examined the practice pattern at our institution to determine the yield and impact of diagnostic imaging on treatment decisions.
Methods
Patients who underwent resection for PDAC at our tertiary care institution between 1/1/2010 and 12/31/2012 were screened. A total of 59 patients were included in the final analysis who had complete radiologic and clinical data to allow correlation between symptoms and imaging results. Patients were excluded due to incomplete records for care at outside institutions (70), concurrent malignancy (7), or lack of oncologic follow-up by choice or medical decline (13). Patient demographics, clinical symptoms, pathology, cross sectional imaging, and treatment regimens were extracted from a prospectively collected electronic medical record. The impact of imaging was determined based on documentation of clinical encounters. Further intervention was defined as initiation of therapeutic anticoagulation, and any procedure or surgery. A change in treatment plan was defined as a change in the chemoradiation regimen or enrollment in hospice or palliative care.
Results
Thirty-three of 59 patients were male (56%) and the median age was 68 years (range 35-83 years). In total, 430 imaging studies were acquired, with a median number of 6 studies per patient (range 1-27) and median time between studies of 81 days (range 0-490 days). At the time of each study, patients were asymptomatic at the time of 252 of the 430 studies (59%) and symptomatic for 178 (41%) with new symptoms reported at the time of 106 studies. Imaging completed in the presence of any symptom was more likely to prompt further intervention (25.2% vs 12.3%) and alter the treatment plan (18.0% vs 9.9%).
Conclusion
Our institutional experience demonstrates that the majority of patients are asymptomatic at the time of surveillance imaging for follow-up after resection for PDAC. Although the presence of symptoms increased the likelihood of a result that would require further intervention or change in treatment plan, imaging studies impacted decision making in a minority of the cases both for symptomatic and asymptomatic patients.
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