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ALTHOUGH U.S. PATIENTS HAVE COMPARABLE ACCESS TO CARE, EARLIER RESECTION DOES NOT IMPROVE SURVIVAL IN PANCREATIC CANCER
Katelin Mirkin*, Christopher S. Hollenbeak, Joyce Wong
Surgery, Penn State, Hershey, PA
Background:
Because cancer care is quite heterogeneous in the U.S., we sought to identify whether disparities of access to surgical care for pancreatic cancer exist and to determine if time from diagnosis to surgery was associated with survival.
Methods:
The U.S. National Cancer Data Base (2003-2011) was reviewed for patients with clinical stages 1 and 2 resected pancreatic adenocarcinoma. Patients who received neoadjuvant therapy were excluded, as were patients who underwent surgery greater than 12 weeks from diagnosis. Univariate and multivariate timing and survival analyses were performed. Landmark analyses were performed to estimate overall survival.
Results:
14,807 patients with clinical stages I-II resected adenocarcinoma were included: 37.8% (N=5,599) were diagnosed at the time of surgery, 13.7% (N=2,025) underwent resection 1-2 weeks after diagnosis, 25.4% (N=3,760) at 2-4 weeks, 19.5% (N=2,881) 4-8 weeks, and 3.7% (N=542) 8-12 weeks following diagnosis. The majority of patients were white, male, covered by Medicare, with a median age of 67. The majority of patients lived between 20-50 miles of the hospital, received their treatment at an academic center, and underwent a pancreaticoduodenectomy. The bimodal distribution of treatment initiation at diagnosis and 2-4 weeks after diagnosis was observed across every patient and facility demographic including age, sex, race, insurance coverage, income strata, education level, distance from hospitals, facility type and location, comorbidities, clinical stage and type of surgical resection.
Multivariate analyses showed Hispanic and other minority patients received earlier treatment (-1.15 days, p=0.013, -2.18 days, p=0.009, respectively), relative to Caucasian patients. Greater distance to treatment center (11-20mi: +2.13, p<0.001, 21-50mi: +1.81, p<0.001, 51-100mi: +2.50, p<0.001, >100mi: +2.16, p<0.001), and treatment at an academic center (+2.57, p<0.001) were associated with a delay in care. The highest level of income strata (-1.77, p=0.003), and treatment outside the Northeast was associated with earlier treatment.
12 month landmark analyses found similar median survivals between cohorts: patients treated within 1 week: 25.6 months, 1-2 weeks: 24.4 months, 2-4 weeks; 24.7 months, 4-8 weeks: 25.0 months, 8-12 weeks: 24.5 months.
Conclusions:
For patients with clinical stage I-II pancreatic adenocarcinoma, there do not appear to be large disparities in access to surgical care. Nearly one third of patients are diagnosed at the time of surgery. However, there appears to be no survival benefit to earlier initiation of surgical resection within 12 weeks from diagnosis. This suggests that allowing time for tissue confirmation and performing other adjunct tests in preparation for surgery may not negatively impact survival.
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