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Survival Analysis for Locally Extending Pancreatic Cancer Patients
Motokazu Sugimoto*, Joshua Barton, Louis W. Traverso
Center for Pancreatic and Liver Disease, St. Luke's Health System, Boise, ID
Introduction: The treatment of pancreatic cancer is in evolution. What can we learn from the clinical outcomes using NCCN Guidelines for pancreatic cancer?
Methods: Between Jun/2010 and Dec/2013 there were 226 pancreatic cancer patients seen at St. Luke's Health System. All had histological confirmation. Cases were categorized by tumor extension on the initial imaging studies: locally confined, locally extending, or metastatic disease. Treatments were chosen using NCCN guidelines and the overall survival (OS) was compared.
Results: Median OS was 9.7 mo for all cases (n = 226) - 16.1 mo for locally confined (n = 21), 11.6 mo for locally extending (n = 125), and 5.0 mo for metastatic disease (n = 80). Not unexpectedly independent predictors for shorter OS included ECOG ≥ 2, metastasis, and resection. To observe the true effect of non-operative protocols with minimal selection bias we excluded those with ECOG ≥ 2 (n = 47), metastasis (n = 80), and resection (n = 33). In 71 cases receiving anti-cancer therapy, independent predictors for better OS was use of FOLFIRINOX (leucovorin + fluorouracil + irinotecan + oxaliplatin) (P = 0.047), concurrent chemoradiation after induction chemotherapy (P = 0.007), and no progression of tumor ≥ 6 mo (P < 0.001). Parameters related to no tumor progression ≥ 6 mo were age ≥ 68 yr (P = 0.046) and the initial use of FOLFIRINOX (P = 0.026). Within this group median OS for the cases with initial use of FOLFIRINOX vs. gemcitabine-based was 17.9 mo vs. 12.2 mo (P = 0.026). Rates of patients with ECOG 0 among those with initial treatment of FOLFIRINOX vs. gemcitabine-based regimens were 74% vs. 40% (P = 0.010).
Conclusions: After excluding those with ECOG ≥ 2, metastasis, and resection we attempted to determine the true outcome of non-operative treatment protocols in locally-extending pancreatic cancer. Survival was better if FOLFIRINOX was used or if the tumor did not progress ≥ 6 months after beginning any chemotherapy treatment. The former result should be used with caution as it appeared that the oncologist reserved the initial use of FOLFIRINOX for ECOG 0 cases as allowed by NCCN guidelines. The 6 month no progression period is probably reliable as the tumor can best be vetted under treatment if no progression is noted for ≥ 6 months. We speculate that no progression after 6 months of treatment in a patient with a locally extending pancreatic cancer should be selection criteria for potential resection.
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