Comparative Effectiveness of Neoadjuvant Therapy and Upfront Resection for Patients with Resectable Pancreatic Adenocarc
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ORIGINAL ARTICLE – PANCREATIC TUMORS
Comparative Effectiveness of Neoadjuvant Therapy and Upfront Resection for Patients with Resectable Pancreatic Adenocarcinoma: An Instrumental Variable Analysis Wilson Luiz da Costa Jr., MD, MPH, PhD1 , Hop S. Tran Cao, MD2, Kyle H. Sheetz, MD, MSc3, Xiangjun Gu, PhD1, Edward C. Norton, PhD4,5, and Nader N. Massarweh, MD, MPH6,7 1
Department of Medicine, Epidemiology, and Population Sciences, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX; 2Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; 3Department of Surgery, University of Michigan, Ann Arbor, MI; 4Department of Health Management and Policy, University of Michigan, Ann Arbor, MI; 5Department of Economics, University of Michigan, Ann Arbor, MI; 6Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX; 7Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
ABSTRACT Background. Neoadjuvant therapy (NAT) is increasingly being used in the management of patients with resectable pancreatic ductal adenocarcinoma (PDAC); however, there is a lack of evidence regarding the benefit among these patients. Objective. The aim of this study was to evaluate overall survival (OS) in PDAC patients with resectable disease treated with NAT or upfront resection through instrumental variable (IV) analysis. Design. A national cohort study of resectable PDAC patients in the National Cancer Data Base (2007–2015) treated with either upfront surgery or resection after NAT. Using multivariable modeling and IV methods, OS was compared between those treated with NAT and upfront resection. The IV was hospital-level NAT utilization in the most recent year prior to treatment. Results. The cohort included 16,666 patients (14,012 upfront resection; 2654 NAT) treated at 779 hospitals. Among those treated with upfront resection, 59.9% received any adjuvant therapy. NAT patients had higher median (27.9 months, 95% confidence interval [CI]
Ó Society of Surgical Oncology 2020 First Received: 1 July 2020 Accepted: 17 October 2020 W. L. da Costa Jr., MD, MPH, PhD e-mail: [email protected]
26.2–29.1) and 5-year OS (24.1%, 95% CI 21.9–26.3%) compared with those treated with upfront surgery (median 21.2 months, 95% CI 20.7–21.6; 5-year survival 20.9%, 95% CI 20.1–21.7%). After multivariable modeling, NAT was associated with an approximately 20% decrease in the risk of death (hazard ratio [HR] 0.78, 95% CI 0.73–0.84), and this effect was magnified in the IV analysis (HR 0.61, 95% CI 0.47–0.79). Conclusions. In patients with resectable PDAC, NAT is associated with improved survival relative to upfront resection. Given the benefits of multimodality therapy and the challenges in receiving adjuvant therapy, consideration should be given to treating all PDAC patients with NAT.
Worldwide, pancreatic ductal adenocarcinoma (PDAC) is a leading cause of cancer-related mortality.1 Curativeintent treatme
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