Department of Surgery, Division of Surgical Oncology, Stanford University, Stanford, Palo Alto, California, USA.
Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA.
Cancer Med. 2021 Sep;10(17):5925-5935. doi: 10.1002/cam4.4144. Epub 2021 Jul 21.
Although surgical resection is necessary, it is not sufficient for long-term survival in pancreatic ductal adenocarcinoma (PDAC). We sought to evaluate survival after up-front surgery (UFS) in anatomically resectable PDAC in the context of three critical factors: (A) margin status; (B) CA19-9; and (C) receipt of adjuvant chemotherapy.
The National Cancer Data Base (2010-2015) was reviewed for clinically resectable (stage 0/I/II) PDAC patients. Surgical margins, pre-operative CA19-9, and receipt of adjuvant chemotherapy were evaluated. Patient overall survival was stratified based on these factors and their respective combinations. Outcomes after UFS were compared to equivalently staged patients after neoadjuvant chemotherapy on an intention-to-treat (ITT) basis.
Twelve thousand and eighty-nine patients were included (n = 9197 UFS, n = 2892 ITT neoadjuvant). In the UFS cohort, only 20.4% had all three factors (median OS = 31.2 months). Nearly 1/3rd (32.7%) of UFS patients had none or only one factor with concomitant worst survival (median OS = 14.7 months). Survival after UFS decreased with each failing factor (two factors: 23 months, one factor: 15.5 months, no factors: 7.9 months) and this persisted after adjustment. Overall survival was superior in the ITT-neoadjuvant cohort (27.9 vs. 22 months) to UFS.
Despite the perceived benefit of UFS, only 1-in-5 UFS patients actually realize maximal survival when known factors highly associated with outcomes are assessed. Patients are proportionally more likely to do worst, rather than best after UFS treatment. Similarly staged patients undergoing ITT-neoadjuvant therapy achieve survival superior to the majority of UFS patients. Patients and providers should be aware of the false perception of 'optimal' survival benefit with UFS in anatomically resectable PDAC.
尽管手术切除是必要的，但对于胰腺导管腺癌 (PDAC) 患者的长期生存来说并不充分。我们试图评估在三种关键因素的背景下，对于解剖上可切除的 PDAC 患者，进行初始手术（UFS）后的生存情况：（A）切缘状态；（B）CA19-9；以及（C）接受辅助化疗。
回顾了 2010 年至 2015 年国家癌症数据库中临床可切除（0/Ⅰ/Ⅱ 期）PDAC 患者的数据。评估了手术切缘、术前 CA19-9 和接受辅助化疗的情况。根据这些因素及其各自的组合对患者的总体生存情况进行分层。基于意向治疗（ITT）原则，将 UFS 后的结果与接受新辅助化疗的相同分期患者进行比较。
共纳入 12089 例患者（UFS 组 n=9197，ITT 新辅助化疗组 n=2892）。在 UFS 队列中，仅有 20.4%的患者同时满足这三个因素（中位 OS=31.2 个月）。近 1/3（32.7%）的 UFS 患者无一个或仅一个因素，且这些因素同时预示着最差的生存情况（中位 OS=14.7 个月）。UFS 后随着失败因素的增加，生存率逐渐下降（两个因素：23 个月；一个因素：15.5 个月；无因素：7.9 个月），调整后仍如此。ITT 新辅助化疗组的总体生存率优于 UFS 组（27.9 比 22 个月）。
尽管初始手术治疗被认为有益，但当评估与预后高度相关的已知因素时，只有 1/5 的 UFS 患者实际实现了最大生存获益。与 UFS 治疗后最差的生存情况相比，UFS 后更可能出现比例更高的患者预后更差的情况。接受 ITT 新辅助治疗的相同分期患者的生存情况优于大多数 UFS 患者。患者和医生应意识到，在解剖上可切除的 PDAC 中，初始手术治疗具有“最佳”生存获益的这种错误认知。
