Geographic variation in attitudes regarding locally advanced pancreatic cancer management

Abstract

Presenter: Bradley Reames MD, MS | University of Nebraska Medical Center Background: Evidence to guide management of locally advanced pancreas cancer (LAPC) is limited to retrospective reports. Numerous studies suggest attitudes regarding LAPC management are inconsistent between surgeons and across institutions. We sought to examine the influence of geographic practice location on surgeon attitudes regarding management of LAPC. Methods: An extensive electronic survey was distributed by email to an international cohort of pancreas surgeons. Data collected included practice characteristics, preferences for staging and management, and 6 clinical vignettes (with detailed videos of post-neoadjuvant arterial and venous CT imaging) to assess attitudes regarding eligibility for surgical exploration. Descriptive and comparative statistics were used to examine differences in attitudes across geographic locations of practice. Results: A total of 153 eligible responses (estimated response rate: 10.6%) were received from 4 continents: North and South America (NSA, combined N=94, 61.4%), Europe (EUR, N=25, 16.3%), and Asia (N=34, 22.2%). Median duration of practice was 12 years (IQR 6-20) and most particpants are considered high volume surgeons (>10 pancreatectomies/year, 86.3%) working at high volume hospitals (>25/year, 88.9%). Examination of attitudes regarding LAPC management revealed numerous significant differences across practice locations. Participants from Asia more frequently prefer MRI (67.6%) and PET/CT (44.1%) for initial staging, versus NSA (23.4% and 8.5%) and EUR (32% and 16%, P < 0.001 for both). Neoadjuvant chemotherapy is "always" recommended by a majority of participants in NSA (81.9%) and EUR (68.0%), but a minority of those in Asia (47.1%, P=0.001). The preferred duration of neoadjuvant systemic therapy varied: participants from Asia commonly prefer 2 months (61.8%), while NSA participants prefer 4 months (52.1%), and responses from EUR were mixed (P=0.006). Participants from EUR were less likely to recommend neoadjuvant radiation (32% never recommend), compared to those from NSA (3.2% never recommend) and Asia (17.6% never recommend, P < 0.001). Participants offering minimally-invasive surgery from NSA and EUR were more likely to use a robotic approach (48% and 75%, respectively) than those from Asia (33.3%, P=0.01). Participants from Asia were less likely to consider isolated liver (67.6%) or lung (61.8%) metastases contraindications to exploration, versus those from NSA (90.4% and 88.3%) and EUR (72% and 72%, P < 0.005 for both), and this corresponded to a greater propensity to consider exploration in a vignette of olgiometastatic disease (56.7%, vs. 25.6% for NSA and 43.5% for EUR, P=0.007). For all three groups, concern regarding arterial involvement was the most common reason to avoid exploration in 6 vignettes. Participants from Asia commonly recommended continuing current chemotherapy as an alternative to exploration, while those from NSA frequently recommended clinical trial options, and responses from EUR were mixed. Conclusion: In an international survey of high volume pancreas surgeons, attitudes regarding LAPC management varied across geographic locations of practice. Better evidence is needed define the optimal management approach to LAPC.