Understanding Surgical Attrition for “Resectable” Pancreatic Cancer

Abstract

ObjectivesWe used a novel combined analysis to evaluate various factors associated with failure to undergo surgery in non-metastatic pancreatic cancer. MethodsWe identified rates of surgery and reasons for surgical attrition from clinical trials, which studied neoadjuvant therapy in resectable pancreatic cancer. Next, we queried the National Cancer Database (NCDB) for Stage I-III, T1-3 pancreatic adenocarcinoma patients. We investigated the rates and factors associated with the receipt of surgery. Finally, we evaluated variable importance predicting the receipt of surgery. ResultsIn clinical trials, 25-30% of patients did not undergo surgery, mostly due to disease progression. In the NCDB, the overall surgical rate was only 49%, but increased to 67% in a curated cohort meant to mirror clinical trial patients. Patients treated at and low-volume institutions (OR=0.64, 95% CI: 0.61-0.67) and who were uninsured (OR=0.56, 95% CI: 0.52-0.62) and Medicaid-insured (OR=0.67, 95% CI: 0.64-0.71) were less likely to receive potentially curative surgery. ConclusionWe have identified a realistic target surgery rate of 70%-75% in potentially-resectable pancreatic cancer. While attrition to pancreatic cancer surgery is mostly due to tumor biology, our study identified the most important non-medical barriers, such as facility volume and insurance, affecting pancreatic cancer surgery.