Role of Surgery and Perioperative Therapy in Older Patients with Resectable Pancreatic Ductal Adenocarcinoma

Abstract

BACKGROUND: It is unclear whether results from recent trials of resectable pancreatic ductal adenocarcinoma (PDAC) are generalizable to older patients who are underrepresented. We aimed to evaluate outcomes of surgery, neoadjuvant, and adjuvant therapy in older patients with resectable PDAC. PATIENTS AND METHODS: We included patients age≥65 with upfront resectable PDAC from a prospectively maintained pancreatic cancer registry from 2007 to 2016. Patients were stratified into 65-75 and 75+ years. Overall survival (OS) was assessed in treatment comparisons: (A) surgery (n=636) vs. non-surgical (n=178), (B) neoadjuvant therapy (n=139) vs. upfront surgery (n=497), (C) adjuvant therapy (n=379) vs. surgery alone (n=118). We compared neoadjuvant (n=139) vs. adjuvant therapy (n=379) in an exploratory analysis. RESULTS: 903 patients had a median age of 73.7 (range: 65-96.6) years. Median OS was 26.6 vs. 11.9 months (HR(adj) = 0.4, 95%CI 0.31-0.52, p<0.001) in Comparison A groups, 30.7 vs. 25.8 months (HR(adj) = 0.69, 95%CI 0.49-0.96, p=0.03) in Comparison B groups, and 26.9 vs. 17.4 months (HR(adj) = 0.62, 95%CI 0.44-0.88, p=0.008) in Comparison C groups, respectively. OS benefit in these treatment comparisons was present in age group 75+ with HR(adj) 0.24 (95%CI 0.16-0.36, p<0.001) in Comparison A, HR(adj) 0.52 (95%CI 0.27-1, p=0.049) in Comparison B, but not in Comparison C with HR(adj) 0.68 (95%CI 0.43-1.08, p=0.1). Statistically comparable median OS of patients who received neoadjuvant or adjuvant therapy stratified by age groups was observed. CONCLUSION: Older patients with resectable PDAC who received surgery, neoadjuvant, or adjuvant therapy appeared to have improved survival outcomes compared to those who did not receive such treatment. IMPLICATIONS FOR PRACTICE: Older patients with resectable pancreatic ductal adenocarcinoma (PDAC) in general are underrepresented in large clinical trials and less well studied in terms of the role of surgery, neoadjuvant, and adjuvant therapy. We studied older patients with resectable PDAC from a prospectively maintained single-institutional pancreatic cancer registry of a tertiary referral center from 2007 to 2016. We found that with multidisciplinary evaluation, older patients with resectable PDAC who received surgery, neoadjuvant, or adjuvant therapy appeared to have improved survival outcomes compared with those who did not receive such treatment. These results are of substantial importance to practitioners who treat older patients traditionally underrepresented in most clinical trials.