Many Patients With Operable Pancreatic Cancer are Not Offered Surgical Treatment
Analysis of data from the largest cancer database in the country has shown that a significant proportion of patients with operable pancreatic cancer are not being offered surgical treatment, even though an operation is the only potential cure for this type of cancer. Researchers from the National Cancer Database (NCDB) released their comments today on this groundbreaking study that found that 38.2 percent of patients with early-stage pancreatic cancer were not offered a surgical procedure as a treatment.
"As surgeons, the message we have been sending for many years is that surgical treatment for early-stage pancreatic cancer can have a positive impact on survival and quality of life. This study suggests, however, that the percentage of patients who should have an operation but don't get it, is alarmingly high," according to Mark S. Talamonti, MD, FACStermterm, chief of the division of surgical oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, and co-researcher of the study.
Dr. Talamonti believes patients are not being offered an operation because of nihilism and skepticism on the part of medical professionals, including some surgeons, who question whether patients with pancreatic cancer can benefit from any treatment at all.
"For physicians who trained before the 1980s and 1990s when studies started to show some improvement in survival and quality of life from treatment for pancreatic cancer, the general idea was that there was no effective treatment for the disease. While this is a very formidable disease with considerable medical challenges, the reality is that not everybody has to die. Many patients do benefit by having the appropriate operation by sufficiently experienced surgeons in high-volume medical centers," Dr. Talamonti said.
"The pessimistic attitude toward pancreatic cancer and pancreatic cancer surgery is based on outdated data," explained Karl Bilimoria, MD, a research fellow at the American College of Surgeons (ACS) and Department of Surgery, Feinberg School of Medicine, Northwestern University, focusing on surgical oncologic outcomes and lead author of the study. "Pancreatic cancer had terrible outcomes in the 1960s. The mortality and complications associated with surgical procedures for pancreatic cancer and the lack of effective systemic therapies made the short-term and long-term outlook for patients rather dismal. But there have been improvements over the last 30 to 40 years, to the point where postoperative mortality is less than 3 percent in many hospitals, and long-term survival rates are now about 30 percent after surgical resection for Stage I disease," Dr. Bilimoria added.
"We need to get the message out to the gatekeepers -- the primary care and internal medicine physicians, gastroenterologists, and medical oncologists who see these patients before they are referred to surgeons -- that it's better to operate than not to operate," Dr. Talamonti said.
Data for the study were obtained from the National Cancer Data Base (NCDB), which is maintained by the American College of Surgeons Commission on Cancer (CoC). The NCDB accounts for more than 75 percent of all cancers treated in the United States each year. The database includes information on more than 20 million patients with cancer who have been cared for at 1,440 hospitals in this country.
NCDB researchers examined data on 292,565 patients with pancreatic cancer. From 1995 to 2004, they studied 9,559 patients with Stage I disease who were potential candidates for an operation. Stage I pancreatic cancer is confined to the pancreas itself, and it typically occurs in 10 percent to 15 percent of patients initially diagnosed with pancreatic cancer, according to Dr. Bilimoria.
Although overall utilization of surgical procedures for pancreatic cancer increased during the period of the study by 14 percent, only 28.6 percent of patients actually underwent an operation. Of the remaining patients who did not have an operation, 51.7 percent did not have a documented or identifiable reason why they did not have the procedure. A total of 38.2 percent of patients were not offered an operation, and 13.5 percent did not undergo a procedure for unknown reasons.
Although the study could not fully explore why patients with operable cancer did not have a surgical procedure, it did at least identify some common underlying factors -- advanced age, race, socioeconomic status, and insurance status. Patients who were not offered an operation tended to be about 6 years older than those who had one -- 71.7 years versus 65.1 years on average. Patients also were less likely to have an operation if they were African American, had lower annual incomes or less education, and were covered by Medicare or Medicaid.
A surgical procedure also was not offered to many patients whose tumor was located in the head or the body of the pancreas. "This finding goes back to a previous perception that the Whipple procedure [also known as pancreatoduodenectomy, during which surgeons remove the head of the pancreas, the first portion of the small intestine (duodenum), part of the bile duct, and sometimes a portion of the stomach] was worse than the disease. But over the last 10 to 15 years, there have been unequivocal data that the operation is associated with improvement in quality of life and survival when done by experienced surgeons. The thought may still exist that the operation is a bad thing to subject patients to, even though the data show that is just not true," said Dr. Talamonti.
The American College of Surgeons is beginning to explore how it may respond to findings from this study. "ACS is looking at not just the Whipple procedure but cancer surgery in general to make sure segments of our population are not underserved and that the information that is disseminated about surgical treatment for pancreatic cancer is accurate," Dr. Talamonti, said. "It is imperative to get the information out that patients who need and qualify for this surgical approach are offered the operation."
"Pancreatic cancer surgeons should continue to give lectures about the efficacy of this type of surgery and treatment for pancreatic cancer to improve the medical community's opinion of what surgeons can do for patients with pancreatic cancer in 2007," Dr. Bilimoria, said.
Pancreatic cancer is the fourth leading cause of death due to cancer in this country. The American Cancer Society estimates that in 2007 more than 37,000 individuals will be diagnosed with pancreatic cancer and more than 33,000 will die from the disease.
A complete report of these research findings entitled "National Failure to Operate on Early-Stage Pancreatic Cancer" will appear in an upcoming issue of Annals of Surgery. Other authors of the study include David J. Bentrem, MD, FACS (Northwestern University, Chicago, IL); Clifford Y. Ko, MD, FACS (University of California, Los Angeles, and VA Greater Los Angeles); Andrew K. Stewart, MA (American College of Surgeons Commission on Cancer); and David P. Winchester, MD, FACS (American College of Surgeons).
The study was supported by the American College of Surgeons Clinical Scholars in Residence program and a research grant from the Northwestern University Department of Surgery.
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and to improve the care of the surgical patient. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 71,000 members and is the largest organization of surgeons in the world. For more information, visit http://www.facs.org/.