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

2 Citations (Scopus)

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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