Underuse of pancreatectomy in the United States

More than half of eligible patients with operable, early-stage pancreatic cancer don't undergo potentially life-extending surgery, suggests a study published online in the Annals of Surgery, published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

"The only opportunity for cure in early-stage patients is surgical resection, but nihilistic attitudes toward pancreatic cancer likely contribute to this striking underuse of curative resection for pancreatic adenocarcinoma," according to the new report. The lead author was Dr. Karl Y. Bilimoria of Northwestern University, Chicago.

The researchers analyzed data on more than 9,500 patients with early-stage cancers of the pancreas treated between 1995 and 2004. All patients had "potentially resectable" cancers that had not yet spread to the lymph nodes or elsewhere. Data for the study came from the American College of Surgeons National Cancer Data Base (NCDB).

The study looked at how many patients underwent surgery, called pancreatectomy, to remove the cancer. If surgery was not performed, the researchers evaluated the reasons why.

Overall, 71 percent of the patients did not undergo pancreatectomy. In about 19 percent of cases, there was a clear reason—some patients were considered too old or too ill for surgery, while others refused the operation.

However, about 38 percent of patients were simply listed in the database as "not offered surgery." For another 14 percent, no reason was given why the patients did not undergo surgery. Thus approximately 52 percent of patients with early-stage, potentially operable pancreatic cancer "did not have a documented or identifiable reason for why they did not undergo surgery," the researchers write.

The remaining 29 percent of patients did undergo pancreatectomy. In all but four percent of this group, the cancer was successfully resected.

Certain groups were less likely to undergo pancreatectomy, including patients over age 65, African-Americans, patients on Medicare or Medicaid, and patients with lower incomes and less education. Patients treated at designated cancer centers were more likely to undergo surgery.

Survival was significantly better for patients who had the operation: median survival time was 19 months, compared to about eight months for patients listed as "not offered surgery." By comparison, median survival time for patients with advanced, inoperable pancreatic cancer was four months.

Pancreatectomy is well-established as the primary treatment for early-stage pancreatic cancer. The results of surgery have improved steadily over the years, including a chance of long-term survival—in the new study, 19 percent of patients undergoing pancreatectomy were alive after five years. Despite these advances, however, many doctors and surgeons continue to have pessimistic attitudes toward all patients with pancreatic cancer.

"This is the first study to characterize the striking underuse of pancreatectomy in the United States," the researchers write. Despite a demonstrated survival benefit, more than half of patients with operable cancer fail to receive surgery.

"There is an opportunity to improve the care of pancreatic cancer patients in the United States by offering surgery to all appropriate patients with respectable disease," Dr. Bilimoria and colleagues conclude. They call for nationwide quality improvement measures—similar to those used to promote research-proven treatments for advanced colon cancer—to find out why patients with early-stage disease are not being offered surgery and to increase the appropriate use of pancreatectomy.

This article, titled "National Failure to Operate on Early-Stage Pancreatic Cancer," is currently available online to Annals of Surgery subscribers in the Publish Ahead of Print pre-print format. The full article will be available in an issue of Annals of Surgery towards the end of the year.