The Impact of Hospital Neoadjuvant Therapy Utilization on Survival Outcomes for Pancreatic Cancer
Many surgeons advocate the use of neoadjuvant treatment for resectable pancreatic cancer, however little is known about variation in the utilization of neoadjuvant therapy (NAT) at the hospital level.
The National Cancer Data Base was used to identify patients undergoing resection for pancreatic cancer between 2006 and 2014 at high-volume centers. Hospitals were grouped by NAT utilization using standard deviations (SD) from the mean as follows: high neoadjuvant utilizers (> 2 SDs above the mean, > 40% of patients receiving NAT); medium–high (1–2 SDs, 27–40%), medium (0–1 SD, 14–26%); or low (− 1.1 to 0 SDs, < 14%). Overall survival (OS) was compared across NAT utilization groups.
Among 107 high-volume centers, 20,119 patients underwent resection. The proportion of patients receiving NAT varied widely among hospitals, ranging from 0 to 74%, with only five centers using NAT in > 40% of patients. These five hospitals had the longest median OS at 28.9 months, compared with 21.1 months for low neoadjuvant utilizers (p < 0.001). On multivariable analysis, high and medium–high NAT utilization predicted improved OS, with a hazard ratio (HR) of 0.68 (95% confidence interval [CI] 0.56–0.83, p < 0.001) and 0.80 (95% CI 0.68–0.95, p = 0.010), respectively, compared with low utilizers. After excluding patients who underwent NAT, there remained an association of improved OS with high NAT utilization (HR 0.74, 95% CI 0.60–0.93, p = 0.009).
High-volume hospitals that more commonly utilize NAT demonstrated longer survival for all patients treated at those centers. In addition to altering patient selection for surgery, high neoadjuvant utilization may be a marker of institutional factors that contribute to improved outcomes.
AVF’s position as a research fellow is supported by a National Institutes of Health Surgical Oncology Training Grant (T32 CA090217). SMW and DEA are supported by the resources and use of facilities at the William S. Middleton Memorial Veterans Hospital, Madison, WI, USA.
Alexander V. Fisher, Daniel E. Abbott, Manasa Venkatesh, Glen E. Leverson, Stephanie A. Campbell-Flohr, Sean M. Ronnekleiv-Kelly, Caprice C. Greenberg, Emily R. Winslow, and Sharon M. Weber declare no conflicts of interest or financial disclosures.
- 9.National Comprehensive Cancer Network. NCCN Guidelines Version 2.2017 Pancreatic Adenocarcinmoa. https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf (2017). Accessed 13 Jun 2017.
- 18.Fong Y, Gonen M, Rubin D, Radzyner M, Brennan MF. Long-term survival is superior after resection for cancer in high-volume centers. Ann Surg. 2005;242:540-4-7.Google Scholar
- 21.StataCorp LP. STATA multilevel mixed-effects reference manual. Release 13. College Station, TX. StataCorp. LLC. https://www.stata.com/manuals13/me.pdf. Accessed 8 Jan 2018.
- 22.Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC cancer staging manual. 7th ed. New York, NY: Springer; 2010.Google Scholar