Surgical Management of Non-metastatic Pancreatic Cancer in the United Kingdom: Results of a Nationwide Survey on Current Practice

Abstract

Background: Advancements in surgical technique and systemic treatment have evolved the concept of resectability in pancreatic adenocarcinoma (PDAC). It is presently unclear what clinical pathways are followed for patients with non-metastatic PDAC in specialised centres for pancreatic surgery across the United Kingdom (UK). Methods: Between August 2019 and August 2020 a nationwide electronic survey was conducted aiming at a national cohort of pancreatic surgeons in the UK. Participants replied to a list of standardised questions and clinical vignettes, and data were collected and analysed focusing on management preferences, resectability criteria, and contraindications to surgery. Results: Within the study period, 65 responders completed the survey, accounting approximately for 58% of all pancreatic surgeons from 27 specialist centres (96%) in the UK. A stratification in standard, high, and very-high volume institutions was performed for data analysis. Multidisciplinary team meetings are utilised universally for the management of patients with PDAC, however, different staging systems for resectability classification are being applied. In resectable PDAC, upfront surgical resection was the treatment of choice and neoadjuvant treatment (NAT) was considered in patients with CA19-9 >1000U/ml. In borderline resectable PDAC, most surgeons were keen to proceed with surgical exploration post NAT, but differences were noted in preferred chemotherapy regimens. Surgeons from standard volume institutions performed fewer vein resections annually and were more likely to deem patients with locally advanced PDAC as unresectable compared to their colleagues from high and very-high volume centres. Intra-institutional variability in patient management was also present and ranging between 20-80%. Conclusion: Significant variability in the surgical management of non-metastatic PDAC was identified both on inter- and intra-institutional level. These results demonstrate the necessity of establishing national audit mechanisms for outcome surveillance and optimisation of clinical pathways. Surgeon responses on five clinical vignettes based on real patients with different PDAC diagnoses