Elsevier

Radiotherapy and Oncology

Volume 143, February 2020, Pages 101-107
Radiotherapy and Oncology

Original Article
Neoadjuvant treatment strategies for resectable pancreas cancer: A propensity-matched analysis of the National Cancer Database

https://doi.org/10.1016/j.radonc.2020.01.007Get rights and content

Highlights

  • •

    The optimal neoadjuvant treatment in resectable pancreas cancer is unclear.

  • •

    Chemotherapy alone, with conventional RT, or with SBRT were compared.

  • •

    Neoadjuvant SBRT was associated with favorable survival and pathological outcomes.

  • •

    Combination of full-dose chemotherapy and SBRT warrants prospective study.

Abstract

Background and purpose

The optimal neoadjuvant approach in patients with resectable pancreas cancer is unclear. We investigated outcomes after preoperative chemotherapy alone, chemotherapy with conventionally-fractionated radiation (CFRT), or chemotherapy with stereotactic body radiotherapy (SBRT).

Materials and methods

The NCDB was queried for patients with resectable pancreatic adenocarcinoma (pretreatment stage T1-3, N0-1, M0) who received preoperative, multiagent chemotherapy and definitive surgery from 2010 to 2015. CFRT was 40–60 Gy in 20–35 fractions. SBRT was 20–25 Gy in 1 fraction or 30–50 Gy using at least 5 Gy per fraction. Multivariable regression and propensity score matching were used to adjust for potential confounders, including age, comorbidity score, and pretreatment extent of disease. The primary outcome was overall survival measured from surgery.

Results

In total, 1355 patients received preoperative chemotherapy alone, 552 patients received preoperative chemotherapy with CFRT, and 175 patients received preoperative chemotherapy with SBRT. Receipt of SBRT was associated with significantly improved overall survival compared to chemotherapy alone (median 30 vs 21 months, p = 0.02; adjusted hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.47–0.90, p = 0.01). Similarly, SBRT was associated with significantly improved overall survival compared to CFRT (median 29 vs 16 months, p = 0.002; adjusted HR 0.53, 95% CI 0.37–0.76, p = 0.001). Additionally, SBRT was associated with significantly increased rates of pathological complete response and margin-negative resection. Rates of postoperative readmissions and mortality were comparable.

Conclusions

Neoadjuvant chemotherapy with SBRT is associated with favorable survival and pathological outcomes, warranting consideration for prospective validation.

Section snippets

Data source and cohort identification

The National Cancer Database (NCDB) is a registry sponsored by the American College of Surgeons and the American Cancer Society that captures 70% of cancers in the United States. Reporting facilities are Commission on Cancer-accredited and required to have at least 90% patient follow-up over 5 years [9]. All data were de-identified. This study was deemed exempt by the university institutional review board. Our results have not been verified by the NCDB, and the NCDB is not responsible for the

Results

In total, 1355 patients received preoperative combination chemotherapy alone; 552 patients received preoperative chemotherapy with CFRT; and 175 patients received preoperative chemotherapy with SBRT (Fig. 1). Patient characteristics for each cohort are listed in Table 1. Median follow-up was 34 months from surgery (39 months from diagnosis).

The absolute number of patients increased over time for all neoadjuvant strategies (Supplemental Figs. 1–3). However, the relative proportion of patients

Discussion

Our findings suggest that neoadjuvant combination chemotherapy plus SBRT may be associated with a survival benefit, alongside favorable pathological and perioperative outcomes, compared to other neoadjuvant strategies (chemotherapy alone or chemotherapy with CFRT) among patients with operable pancreas cancer who undergo surgical resection. These results reflect patterns of care and outcomes in the modern era, coincident with the increased use of more effective, multiagent systemic therapy

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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