Chemotherapy ‘Legitimate Alternative’ To Surgery For Select Stage I–II Pancreatic Cancer Patients

Key patient characteristics may negate survival benefit of surgery over chemotherapy in patients with potentially resectable pancreatic cancer

medwireNews: Researchers challenge the use of surgery versus chemotherapy alone for elderly patients with potentially resectable pancreatic adenocarcinoma, finding the magnitude of survival benefit to be small in those aged 80 years or older.

Patients with positive lymph nodes and those who are unsuitable for postoperative chemotherapy may also derive relatively small benefit from a surgical approach, the team suggests in Cancer.

“The old adage that ‘surgery is the only chance for cure’ may be misleading and not completely realistic for many elderly patients with adenocarcinoma of the pancreas”, comment Todd Tuttle, from the University of Minnesota in Minneapolis, USA, and co-authors.

The team reviewed the outcome of 2629 patients with pancreatic cancer entered into the US Surveillance, Epidemiology, and End Results–Medicare database between 2000 and 2010, all of whom had stage I or II disease and a Charlson Comorbidity index of 2 or less.

In all, 1735 patients underwent pancreatectomy – 41% of whom also received postoperative chemotherapy – while 494 patients received only chemotherapy.

Initial analysis showed that patients were less likely to undergo surgery if they were aged 80 years or older, had a tumour size of 2 cm or larger, or had unknown tumour size.

The median overall survival (OS) rate was 15 months for patients who underwent surgery versus 10 months for those who received chemotherapy, with 5-year rates of 2.2% versus 1.4%. For surgery patients who did and did not receive postoperative chemotherapy, the median OS was 16 versus 13 months.

But further analysis showed that the absolute OS benefit with surgery attenuated with increasing age, so that for patients aged 80 years and older, the median OS rates with surgery and chemotherapy were 13 and 10 months, respectively.

In the surgery group, patients with positive lymph nodes also had poorer median OS than those without (1v vs 19 months).

Multivariate analysis confirmed that surgery was associated with a significant decrease in 5-year mortality (hazard ratio [HR]=0.61), whereas stage II versus stage I disease (HR=1.18) and tumour size of at least 2 cm (HR=1.25) were significant predictors of poor survival.

There was also a trend towards poorer survival with increasing age, with HRs of 1.06–1.15 for those in age groups of up to 85 years or older versus patients aged 66–69 years, although the differences did not reach statistical significance.

Citing a high morbidity rate and long recovery time for pancreatectomy, the researchers suggest that chemotherapy may be a “better strategy” than surgery for these select patient groups and “should be considered a legitimate therapeutic alternative”.

“At the very least, physicians should consider the use of neoadjuvant chemotherapy for these patients and reserve surgery for those who do not develop radiographic evidence of metastatic disease and maintain a good performance status”, Todd Tuttle and team recommend.


Marmor S, Burke EE, Virnig BA, et al. A comparative analysis of survival outcomes between pancreatectomy and chemotherapy for elderly patients with adenocarcinoma of the pancreas. Cancer 2016; Advance online publication 15 July. DOI: 10.1002/cncr.30199

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