Miura John T, Krepline Ashley N, George Ben, Ritch Paul S, Erickson Beth A, Johnston Fabian M, Oshima Kiyoko, Christians Kathleen K, Evans Douglas B, Tsai Susan
Department of Surgery, Pancreatic Cancer Program, The Medical College of Wisconsin, Milwaukee, WI.
Department of Medicine, Pancreatic Cancer Program, The Medical College of Wisconsin, Milwaukee, WI.
Surgery. 2015 Dec;158(6):1545-55. doi: 10.1016/j.surg.2015.06.017. Epub 2015 Aug 1.
Treatment sequencing in older patients is difficult because of concomitant comorbidities and often decreasing performance status. The present study sought to examine the effect of neoadjuvant therapy and pancreatic surgery in older patients with resectable or borderline-resectable (BLR pancreatic cancer (PC).
Patients with resectable or BLR PC treated with neoadjuvant therapy were classified as older (≥ 75 years) or younger (<75 years).
Neoadjuvant therapy was initiated in 246 patients; 210 (85%) younger than 75 years and 36 (15%) older. Older patients had a greater median Charlson comorbidity index (CCI): 6 vs 4 (P < .01). Completion of all intended therapy (neoadjuvant therapy and surgery) occurred in 177 (72%) of the 246 patients; 153 (73%) of the 210 younger and 24 (67%) of the 36 older patients (P = .43). Failure to complete all therapy was associated with BLR clinical stage (odds ratio [OR] 0.26, P = .001), increased posttreatment/preoperative serum levels of CA19-9 (OR 0.27, 95% confidence interval 0.14-0.53), and CCI ≥ 6 (OR 0.44, 95% confidence interval 0.22-0.86). Median overall survival for all study patients was 26.1 and 19.7 months (P = .13) for younger and older patients, respectively. Of the 177 patients who completed all therapy, the difference in survival between younger and older patients was not statistically significant (36.5 months vs 27.2 months, P = .47).
Failure to complete neoadjuvant therapy and eventual pancreatic resection is associated with BLR stage, increased posttreatment/preoperative CA19-9, and CCI ≥ 6, but not older age. Older patients who completed neoadjuvant therapy and underwent resection experienced a survival benefit compared with those who did not complete all intended therapy. Balancing the toxicity of sequential therapies with their cumulative effect on tolerance and risk for pancreatic surgery will be the key to developing optimal treatment sequencing in older patients with PC.
由于合并症以及身体机能状态往往不断下降，老年患者的治疗顺序安排较为困难。本研究旨在探讨新辅助治疗和胰腺手术对可切除或边界可切除（BLR）胰腺癌（PC）老年患者的影响。
接受新辅助治疗的可切除或BLR PC患者被分为老年组（≥75岁）和年轻组（<75岁）。
246例患者开始接受新辅助治疗；其中75岁以下的患者210例（85%），75岁及以上的患者36例（15%）。老年患者的Charlson合并症指数（CCI）中位数更高：分别为6和4（P <.01）。246例患者中有177例（72%）完成了所有预定治疗（新辅助治疗和手术）；210例年轻患者中有153例（73%），36例老年患者中有24例（67%）（P =.43）。未完成所有治疗与BLR临床分期相关（比值比[OR] 0.26，P =.001），治疗后/术前CA19-9血清水平升高（OR 0.27，95%置信区间0.14 - 0.53），以及CCI≥6（OR 0.44，95%置信区间0.22 - 0.86）。所有研究患者的总生存期中位数分别为26.1个月和19.7个月（P =.13），年轻患者和老年患者分别为26.1个月和19.7个月。在完成所有治疗的177例患者中，年轻患者和老年患者的生存差异无统计学意义（36.5个月对27.2个月，P =.47）。
未能完成新辅助治疗及最终的胰腺切除术与BLR分期、治疗后/术前CA19-9升高以及CCI≥有关，但与年龄无关。完成新辅助治疗并接受手术切除的老年患者与未完成所有预定治疗的患者相比，生存期有所改善。平衡序贯治疗的毒性及其对胰腺手术耐受性和风险的累积影响，将是为老年PC患者制定最佳治疗顺序的关键。
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