Background: Pancreatic adenocarcinoma is an aggressive malignancy, with most patients diagnosed with advanced or metastatic disease. Palliative therapies comprise an important, but underutilized, aspect of care. This aim of this study was to characterize the trends, factors, and outcomes associated with utilization of palliative therapies.
Methods: Patients with stage IV pancreatic adenocarcinoma from the 2003–2011 U.S. National Cancer Database were identified and stratified by receipt of palliative therapy. Linear regression, multivariable logistic regression, and survival analyses using multivariate proportional hazards models were performed.
Results: Sixty-eight thousand and seventy-five patients with stage IV disease were identified, of which only 11,449 (16.8%) underwent designated palliative therapy. The majority received systemic chemotherapy (37.2%), followed by surgery (19.0%), pain management alone (15.3%), radiation (8.1%), referral alone (11.7%), or a combination thereof (8.7%). Utilization of palliative therapies increased from 12.9% in 2003 to 19.2% in 2011 (P<0.001). Patients were less likely to undergo palliation when older than 60 (OR 0.89, P<0.001), or of black or Hispanic race (OR 0.83, P<0.001; OR 0.80, P<0.001, respectively, vs. Caucasians). Presence of comorbidities increased the use of palliative therapy (OR 1.16 per comorbidity, P<0.001). Survival was improved in those receiving palliative systemic chemotherapy (HR 0.55, P<0.001) and palliative surgery (HR 0.94, P<0.001), although this may be due to selection bias.
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Conclusions: Despite the continued dismal prognosis of pancreatic cancer, palliation of symptoms remains underutilized in this country, particularly in non-Caucasian, older patients. Increased awareness of palliative options may help increase its utilization.
Keywords: Palliative therapy; pancreatic adenocarcinoma; National Cancer Database
Submitted Mar 08, 2017. Accepted for publication May 04, 2017.
doi: 10.21037/jgo.2017.06.01
INTRODUCTION
With approximately 50% of cases presenting with metastatic disease, pancreatic adenocarcinoma continues to carry a dismal prognosis (1,2). Its gravity is twofold: the lack of effective screening protocols leads many patients to be diagnosed with unresectable disease, and current limitations with surgical and medical therapies typically preclude effective treatment once diagnosed. Unlike diseases such as metastatic colorectal cancer, patients with metastatic pancreatic cancer are currently not candidates for curative resection. Until the effectiveness of available therapies can surpass the aggressive biology of the disease, palliation of symptoms will remain a mainstay of treatment, with a focus on alleviating symptoms rather than treating the disease. While not all patients present with symptoms requiring intervention, they frequently develop with disease progression (2,3).
Because of the location of the pancreas within the retroperitoneum, its proximity to vital structures, aggressive behavior, and potential for metastatic spread, pancreatic adenocarcinoma can cause a variety of symptoms that can impair a patient’s quality of life. Pain is a presenting symptom in approximately half of patients, and develops in a majority of patients at some point during the disease process (2,4,5). Furthermore, it has been estimated that approximately 80% of patients with pancreatic head adenocarcinoma will seek intervention for symptoms of biliary obstruction (2). Gastric outlet obstruction, often requiring intervention, occurs in 20% of patients, and may develop in another 20–40% during the course of their disease (2). The challenge with palliation is minimizing symptoms of disease while limiting morbidity due to therapy. Benefits of palliation extend beyond alleviating pain; by shifting the clinical focus to palliative strategies, several studies have noted lower overall costs of care (6,7). Understanding the current status of palliative care among patients with pancreatic cancer is important for addressing existing barriers to its implementation. This study focused on the cohort of patients who presented with metastatic pancreatic adenocarcinoma at diagnosis, and aimed to evaluate trends and patterns of palliative care utilization in the United States.
