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POST-PANCREATODUODENECTOMY COMPLICATIONS DELAY AND LIMIT THE RECEIPT OF ADJUVANT CHEMOTHERAPY IN RESECTABLE PANCREATIC CANCER: A CONTEMPORARY, POPULATION-LEVEL ANALYSIS
Dillon C. Cheung
*, Yu-Hui Chang, Lena K. Egbert, John A. Jenkins, Richard Bold, Chee-Chee Stucky, Nabil Wasif, Zhi Ven Fong
Surgery, Mayo Clinic Arizona, Scottsdale, AZ
Introduction: While a neoadjuvant approach is increasingly utilized for resectable pancreatic ductal adenocarcinoma (PDAC), upfront resection remains the most prevalent treatment. Prior studies in the era of single agent adjuvant chemotherapy (AC) showed that up to 57% of patients undergoing upfront resection did not receive AC secondary to postoperative complications. This study aims to investigate the influence that postoperative complications have on the rate of receipt of AC, delay in receiving AC, type of AC regimen (multi-agent versus single agent), and duration of AC in a contemporary cohort of patients with PDAC.
Methods:Using the Medicare-linked Surveillance, Epidemiology, and End Results (SEER) database, we identified patients who underwent upfront pancreatoduodenectomy for stage I to III PDAC from 2009 to 2019. Kaplan Meier analyses and multilevel cox proportional hazard models were used to evaluate the association of postoperative complications (within 30 days after surgery) on the receipt of AC as a function of time to incorporate delays in the receipt of AC (>12 weeks from surgery). Landmark analysis was performed for survival analyses to adjust for immortal time bias.
Results:A total of 3,221 patients who underwent upfront surgery for PDAC were included in the study, of whom 1,789 (55.5%) received AC. The rates of AC for patients with complications vs. those without complications were not statistically different (52.8% vs. 56%,
p=0.22). Both groups of patients were also as likely to receive multi-agent AC (21.4% vs. 24.2%,
p=0.36). However, patients with a complication were more likely to have a delay in receiving AC compared to those without complications (46.2% vs. 26.2%,
p<0.0001). They also received a shorter median duration of AC (155 days vs 175 days,
p=0.006). On multivariable analysis, postoperative complications were associated with a lower likelihood of receiving AC (HR 0.68, 95% CI: 0.50-0.92,
p=0.01). On survival analysis, the receipt of AC demonstrated a survival benefit (HR 0.60, 95% CI 0.54-0.66,
p<0.001, Figure), whereas the delay of AC was associated with worse overall survival when compared to timely receipt of AC (HR 1.19, 95% CI 1.06-1.35,
p=0.004, Figure).
Conclusion:In a contemporary cohort of patients with PDAC undergoing upfront surgery, postoperative complications did not decrease the likelihood of receipt of AC, likely secondary to improved perioperative management and patient selection. However, a neoadjuvant approach is still preferable since postoperative complications were associated with receiving a shorter median duration of AC and delays in the receipt of AC, which was associated with poorer overall survival compared to timely receipt of AC.
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