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OCTOGENARIANS UNDERGOING PANCREATICODUODENECTOMY VERSUS DEFINITIVE RADIOTHERAPY FOR LOCOREGIONAL THERAPY OF PANCREATIC DUCTAL ADENOCARCINOMA
Muhammad Muntazir Mehdi Khan
*, Edward A. Joseph, Sricharan Chalikonda, David Bartlett, Casey Allen
Surgical Oncology, Allegheny Health Network, Pittsburgh, PA
Background: Pancreaticoduodenectomy (PD) remains the standard for locoregional therapy of pancreatic ductal adenocarcinoma (PDAC) in the head of the pancreas. However, octogenarians have reduced life expectancy, potentially negating the benefit of aggressive intervention. Radiotherapy provides an alternative for definitive locoregional therapy, but comparative data on these treatment modalities among octogenarians are limited. We compared survival outcomes of PD versus radiotherapy in octogenarians with non-metastatic PDAC.
Methods: We queried the National Cancer Database to identify patients aged 80 and above diagnosed with resectable or borderline-resectable PDAC in the head of the pancreas between 2004 and 2019. Patients with stage IV disease were excluded. Patients were categorized based on the treatment received: PD or radiotherapy. The primary outcome was overall survival from the time of diagnosis.
Results: A total of 7,910 patients diagnosed with PDAC were included in the analysis. The mean age was 83.1 ± 2.6 years, with 44.8% male (n=3,564), 85.9% non-Hispanic White (n=6,795), 10.7% (n=850) having a Charlson-Deyo score ?2, and 14.8% (n=751) having stage III disease at presentation. The median survival of the overall cohort was 11.5 (5.9-21.8) months. Overall, 55.3% (n=4,373) of patients underwent PD alone, while 44.7% (n=3,537) underwent definitive radiotherapy. Patients in the PD cohort were more likely to be younger (82.8 ± 2.4 vs 83.6 ± 2.7 years), non-Hispanic White (86.8% vs 84.8%), have a Charlson-Deyo score of 1 (26.0% vs 23.0%), and were less likely to have received chemotherapy (38.6% vs 69.9%); all p<0.050. Patients who underwent PD had better overall survival (14.0 [6.0-30.7] vs 9.9 [5.8-15.9] months, p<0.001) compared to patients who underwent definitive radiotherapy (Figure). On multivariable Cox proportional hazards analysis, after controlling for covariables, radiotherapy (HR 1.73, 95% CI 1.61-1.87, p<0.001) and advanced stage of disease (stage III: HR 1.35, 95% CI 1.22-3.85, p<0.001) were predictors of long-term mortality. Furthermore, upon stratification by disease stage, patients with early-stage disease had worse survival when undergoing radiotherapy (Stage I-II: HR 1.83, 95% CI 1.69-1.97, p<0.001). However, stage III patients had no difference in survival among the two cohorts (Stage III: HR 0.92, 95% CI 0.72-1.18, p=0.523).
Conclusion: Octogenarians with non-metastatic PDAC have a poor long-term prognosis. Although surgery offers a survival benefit in patients with early stage PDAC, it does not provide a significant long-term survival advantage in octogenarians with advanced-stage disease in comparison with definitive radiotherapy. As PD in the elderly population may pose quality-of-life impairments, these findings highlight the need for individualized treatment strategies for octogenarians with PDAC.
Figure: Kaplan-Meier Survival Analysis Among Octogenarians Undergoing PD vs. Definitive Radiotherapy for Pancreatic Ductal Adenocarcinoma
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