HPB
Marco Dal Molin, MD
Resident
University of Maryland
Baltimore, Maryland, United States
Disclosure: Disclosure information not submitted.
Routine use of neoadjuvant chemotherapy (NAC) in resectable pancreatic adenocarcinoma (PDAC) is controversial. Some centers use NAC routinely, while others use it selectively or not at all. This study provides a real-world view of current utilization and examines the effect of varying degrees of hospital adoption of NAC on outcomes.
Methods:
We analyzed 5450 patients with clinical stage I PDAC who were treated in 154 high-volume centers in the National Cancer Database, 2015-2017. Hospitals were classified based on their utilization of NAC in stage I PDAC into no, low (1sttertile), medium (2nd tertile), and high (3rd tertile) adopters. Logistic regression was used to assess the impact of institutional adoption of NAC on short term outcomes (margin status, readmission, 30- and 90-day mortality). Cox regression models were used to examine the effect of NAC adoption on overall survival (OS).
Results:
Utilization of NAC in stage I PDAC increased by 41.5% over the study period. There were 22 no adoption (n = 443 patients), 44 low (n = 1596), 41 medium (n = 1726), and 47 high (n = 1685) adoption hospitals. High adopters utilized NAC for between 24-69% of their stage I PDAC patients. There was a decrease in margin positive resection (21.8%, 19.7%, 17.4%, 11.9%, p< 0.001), no difference in 30-day readmission rate (7%, 6.6%, 6.3%, 5.3%, p=0.357), decrease in 30-day mortality (2.8%, 2.1%, 0.7%, 1.6%, p=0.012), and decrease in 90-day mortality (7%, 3.7%, 2.7%, 2.7%, p=0.001) comparing no, low, medium, and high adopters of NAC, respectively. On multivariable analysis, NAC adoption was an independent predictor of OS, with higher adoption associated with improved OS in Stage I PDAC (Figure 1. Low HR 0.8, 95% CI 0.64-1.01; Medium HR 0.7, 95% CI 0.55-0.88; High HR 0.7, 95% CI 0.55-0.88). These estimates were largely unchanged after controlling for receipt of NAC.
Conclusions:
Hospitals that utilize a NAC treatment strategy more frequently have better OS and no detriment in short term outcomes. This effect persists even after controlling for receipt of NAC, which suggests there are other characteristics of centers with higher adoption of NAC that are associated with improved OS in stage I PDAC.