Impact of Timing of Chemotherapy for Pancreatic Cancer in the Elderly: A National Cancer Database Study

Abstract

Background: Recent data favor neoadjuvant chemotherapy for pancreatic adenocarcinoma (PDAC). The aim of this study is to evaluate the effect of timing of chemotherapy on overall survival of elderly patients undergoing pancreatic surgery for PDAC. Methods: The NCDB was reviewed from 2004 to 2016. The effect of chemotherapy in elderly patients (≥75) was studied. Three major groups were analysed: adjuvant (ADJ), neoadjuvant (NEO) and neoadjuvant with adjuvant (BOTH). Results: A total of 380,524 patients were diagnosed with PDAC. Of these, 130,039 were ≥75 years of age, and 18,291 patients (7.1%) underwent surgery. Chemotherapy was provided as follows: 5,640 underwent ADJ, 888 NEO and 345 BOTH. A majority being diagnosed at stage II patients in NEO (48%) and BOTH (53%) . The 3 year survival was 31.9% in BOTH (95% CI: 26.4 - 38.6), 24.7% in NEO (95% CI: 21.6 - 28.3) and 25.0% in ADJ (95% CI: 23.8-26.3). Univariate Cox regression shows a significantly improved survival in BOTH in comparison to ADJ (p=0.0081) and a trend in improvement in comparison to NEO (p=0.079). There was a tendency to improved survival when elderly patients that received only neoadjuvant vs those receiving adjuvant chemotherapy (p=0.23). On multivariate analysis comorbidities were identified as an independent factor negatively impacting survival. Chemotherapy given as BOTH was independently associated with improved survival (figure 1). Conclusion: Elderly surgical patients undergoing BOTH neoadjuvant and adjuvant chemotherapy had improved survival. Therefore, BOTH should be given elderly patients if tolerated.