Management of Locally Advanced Pancreatic Cancer

Results of an International Survey of Current Practice

Bradley N Reames, Alex B. Blair, Robert W. Krell, Vincent P. Groot, Georgios Gemenetzis, James C. Padussis, Sarah P Thayer, Massimo Falconi, Christopher L. Wolfgang, Matthew J. Weiss, Chandrakanth Are, Jin He

Research output: Contribution to journalArticle

Abstract

Objective: The aim of this study was to investigate surgeon preferences for the management of patients with locally advanced pancreatic cancer (LAPC). Background: Select patients with LAPC may become candidates for curative resection following neoadjuvant therapy, and recent reports of survival are encouraging. Yet the optimal management approach remains unclear. Methods: An extensive electronic survey was systematically distributed by email to an international cohort of pancreas surgeons. Data collected included practice characteristics, management preferences, attitudes regarding contraindications to surgery, and 6 clinical vignettes of patients that ultimately received a margin negative resection (with detailed videos of post-neoadjuvant imaging) to assess propensity for surgical exploration if resection status is not known. Results: A total of 153 eligible responses were received from 4 continents. Median duration of practice is 12 years (interquartile range 6-20) and 77% work in a university setting. Most surgeons (86%) are considered high volume (>10 resections/yr), 33% offer a minimally-invasive approach, and 50% offer arterial resections in select patients. Most (72%) always recommend neoadjuvant chemotherapy, and 65% prefer FOLFIRINOX. Preferences for the duration of chemotherapy varied widely: 39% prefer ≥2 months, 43% prefer ≥4 months, and 11% prefer ≥ 6 months. Forty-one percent frequently recommend neoadjuvant radiotherapy, and 53% prefer 5 to 6 weeks of chemoradiation. The proportion of surgeons favoring exploration following neoadjuvant varied extensively across 5 vignettes of LAPC, from 14% to 53%. In a vignette of oligometastatic liver metastases, 31% would offer exploration if a favorable therapy response is observed. Conclusions: In an international cohort of pancreas surgeons, there is substantial variation in management preferences, perceived contraindications to surgery, and the propensity to consider exploration in LAPC. These results emphasize the importance of a robust and nuanced multidisciplinary discussion for each patient, and suggest an evolving concept of "resectability."

Original languageEnglish (US)
JournalAnnals of surgery
DOIs
StateAccepted/In press - Jan 1 2019

Fingerprint

Pancreatic Neoplasms
Pancreas
Drug Therapy
Neoadjuvant Therapy
Patient Preference
Practice Management
Radiotherapy
Surveys and Questionnaires
Surgeons
Neoplasm Metastasis
Survival
Liver
Therapeutics

Keywords

  • locally advanced pancreas cancer
  • multidisciplinary management
  • pancreas cancer
  • pancreas surgery
  • survey research

ASJC Scopus subject areas

  • Surgery

Cite this

Management of Locally Advanced Pancreatic Cancer : Results of an International Survey of Current Practice. / Reames, Bradley N; Blair, Alex B.; Krell, Robert W.; Groot, Vincent P.; Gemenetzis, Georgios; Padussis, James C.; Thayer, Sarah P; Falconi, Massimo; Wolfgang, Christopher L.; Weiss, Matthew J.; Are, Chandrakanth; He, Jin.

In: Annals of surgery, 01.01.2019.

Research output: Contribution to journalArticle

Reames, Bradley N ; Blair, Alex B. ; Krell, Robert W. ; Groot, Vincent P. ; Gemenetzis, Georgios ; Padussis, James C. ; Thayer, Sarah P ; Falconi, Massimo ; Wolfgang, Christopher L. ; Weiss, Matthew J. ; Are, Chandrakanth ; He, Jin. / Management of Locally Advanced Pancreatic Cancer : Results of an International Survey of Current Practice. In: Annals of surgery. 2019.
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abstract = "Objective: The aim of this study was to investigate surgeon preferences for the management of patients with locally advanced pancreatic cancer (LAPC). Background: Select patients with LAPC may become candidates for curative resection following neoadjuvant therapy, and recent reports of survival are encouraging. Yet the optimal management approach remains unclear. Methods: An extensive electronic survey was systematically distributed by email to an international cohort of pancreas surgeons. Data collected included practice characteristics, management preferences, attitudes regarding contraindications to surgery, and 6 clinical vignettes of patients that ultimately received a margin negative resection (with detailed videos of post-neoadjuvant imaging) to assess propensity for surgical exploration if resection status is not known. Results: A total of 153 eligible responses were received from 4 continents. Median duration of practice is 12 years (interquartile range 6-20) and 77{\%} work in a university setting. Most surgeons (86{\%}) are considered high volume (>10 resections/yr), 33{\%} offer a minimally-invasive approach, and 50{\%} offer arterial resections in select patients. Most (72{\%}) always recommend neoadjuvant chemotherapy, and 65{\%} prefer FOLFIRINOX. Preferences for the duration of chemotherapy varied widely: 39{\%} prefer ≥2 months, 43{\%} prefer ≥4 months, and 11{\%} prefer ≥ 6 months. Forty-one percent frequently recommend neoadjuvant radiotherapy, and 53{\%} prefer 5 to 6 weeks of chemoradiation. The proportion of surgeons favoring exploration following neoadjuvant varied extensively across 5 vignettes of LAPC, from 14{\%} to 53{\%}. In a vignette of oligometastatic liver metastases, 31{\%} would offer exploration if a favorable therapy response is observed. Conclusions: In an international cohort of pancreas surgeons, there is substantial variation in management preferences, perceived contraindications to surgery, and the propensity to consider exploration in LAPC. These results emphasize the importance of a robust and nuanced multidisciplinary discussion for each patient, and suggest an evolving concept of {"}resectability.{"}",
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AU - Reames, Bradley N

AU - Blair, Alex B.

AU - Krell, Robert W.

AU - Groot, Vincent P.

AU - Gemenetzis, Georgios

AU - Padussis, James C.

AU - Thayer, Sarah P

AU - Falconi, Massimo

AU - Wolfgang, Christopher L.

AU - Weiss, Matthew J.

AU - Are, Chandrakanth

AU - He, Jin

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N2 - Objective: The aim of this study was to investigate surgeon preferences for the management of patients with locally advanced pancreatic cancer (LAPC). Background: Select patients with LAPC may become candidates for curative resection following neoadjuvant therapy, and recent reports of survival are encouraging. Yet the optimal management approach remains unclear. Methods: An extensive electronic survey was systematically distributed by email to an international cohort of pancreas surgeons. Data collected included practice characteristics, management preferences, attitudes regarding contraindications to surgery, and 6 clinical vignettes of patients that ultimately received a margin negative resection (with detailed videos of post-neoadjuvant imaging) to assess propensity for surgical exploration if resection status is not known. Results: A total of 153 eligible responses were received from 4 continents. Median duration of practice is 12 years (interquartile range 6-20) and 77% work in a university setting. Most surgeons (86%) are considered high volume (>10 resections/yr), 33% offer a minimally-invasive approach, and 50% offer arterial resections in select patients. Most (72%) always recommend neoadjuvant chemotherapy, and 65% prefer FOLFIRINOX. Preferences for the duration of chemotherapy varied widely: 39% prefer ≥2 months, 43% prefer ≥4 months, and 11% prefer ≥ 6 months. Forty-one percent frequently recommend neoadjuvant radiotherapy, and 53% prefer 5 to 6 weeks of chemoradiation. The proportion of surgeons favoring exploration following neoadjuvant varied extensively across 5 vignettes of LAPC, from 14% to 53%. In a vignette of oligometastatic liver metastases, 31% would offer exploration if a favorable therapy response is observed. Conclusions: In an international cohort of pancreas surgeons, there is substantial variation in management preferences, perceived contraindications to surgery, and the propensity to consider exploration in LAPC. These results emphasize the importance of a robust and nuanced multidisciplinary discussion for each patient, and suggest an evolving concept of "resectability."

AB - Objective: The aim of this study was to investigate surgeon preferences for the management of patients with locally advanced pancreatic cancer (LAPC). Background: Select patients with LAPC may become candidates for curative resection following neoadjuvant therapy, and recent reports of survival are encouraging. Yet the optimal management approach remains unclear. Methods: An extensive electronic survey was systematically distributed by email to an international cohort of pancreas surgeons. Data collected included practice characteristics, management preferences, attitudes regarding contraindications to surgery, and 6 clinical vignettes of patients that ultimately received a margin negative resection (with detailed videos of post-neoadjuvant imaging) to assess propensity for surgical exploration if resection status is not known. Results: A total of 153 eligible responses were received from 4 continents. Median duration of practice is 12 years (interquartile range 6-20) and 77% work in a university setting. Most surgeons (86%) are considered high volume (>10 resections/yr), 33% offer a minimally-invasive approach, and 50% offer arterial resections in select patients. Most (72%) always recommend neoadjuvant chemotherapy, and 65% prefer FOLFIRINOX. Preferences for the duration of chemotherapy varied widely: 39% prefer ≥2 months, 43% prefer ≥4 months, and 11% prefer ≥ 6 months. Forty-one percent frequently recommend neoadjuvant radiotherapy, and 53% prefer 5 to 6 weeks of chemoradiation. The proportion of surgeons favoring exploration following neoadjuvant varied extensively across 5 vignettes of LAPC, from 14% to 53%. In a vignette of oligometastatic liver metastases, 31% would offer exploration if a favorable therapy response is observed. Conclusions: In an international cohort of pancreas surgeons, there is substantial variation in management preferences, perceived contraindications to surgery, and the propensity to consider exploration in LAPC. These results emphasize the importance of a robust and nuanced multidisciplinary discussion for each patient, and suggest an evolving concept of "resectability."

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