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REDEFINING TOTAL NEOADJUVANT THERAPY (TNT) IN PANCREATIC DUCTAL ADENOCARCINOMA (PDAC): DURATION VERSUS MODALITY
Jennifer Hwang
*, Emily Papai, James Sun, Jordan D. Fredette, Leonard Miller, Joseph Krempa, Hal Rives, Anthony Villano, Sanjay S. Reddy
Fox Chase Cancer Center, Philadelphia, PA
Introduction: PDAC is among the top five causes of cancer-related deaths worldwide. Neoadjuvant therapy (NAT) allows for treatment of micrometastatic disease that may be present at the time of diagnosis, thereby improving outcomes. NAT has been administered as a single modality consisting of chemotherapy only (NACT). The addition of radiation (CRT) to NAT has shown improvement in outcomes. TNT is currently defined as including both NACT and CRT irrespective of duration, but the optimal treatment regimen is unknown. Lymph node ratio (LNR, positive LN/total LN) has shown prognostic significance in overall survival (OS). The objective is to determine if TNT is best defined by modality or duration based on their impact on LNR.
Methods: The National Cancer Database (NCDB) was used to identify PDAC patients receiving NAT from 2004-2020. Patients must have received treatment with curative intent and with OS exceeding the maximum NAT duration of interest (7 months). The modality arm compared NACT with traditional TNT, while temporal trends were compared between <3.5 months and 3.5-7 months of chemotherapy. Ordinary least squares and logistic regression were used to assess the association of duration of neoadjuvant chemotherapy and modality of therapy with nodes ratio and unplanned readmission. Overall survival was also analyzed with modality and chemo duration as predictors in a Cox Proportional Hazards Regression Model.
Results: Of 682 PDAC patients, 394 (57.8%) received NACT and 288 (42.2%) received NACT plus CRT. Most patients (53.7%) received <3.5 months of NAT. Most patients were Caucasian (82.1%) males (57.9%) with a median age of 61 with few comorbidities (Charlson score 0-1, 93.7%). Patients receiving longer duration of NAT had lower odds of having a LNR >0, although not statistically significant (OR=0.742; p=0.085). Similarly, patients receiving both NACT and CRT had statistically significant lower odds of having LNR >0 when compared to NACT alone (OR=0.64; p=0.025). Risk of death was neither associated with longer duration of therapy [hazard ratio (HR)=1.172; p=0.305] nor receiving TNT versus NACT alone (HR=0.907; p=0.502).
Conclusion: Treatment with traditionally defined TNT is associated with having lower LNR. Modality of NAT has a stronger impact on LNR than duration of treatment, but no association was found with overall survival.
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