Feasibility, Safety, and Efficacy of Aggressive Multimodal Management of Elderly Patients with Pancreatic Ductal Adenocarcinoma
Author:
Qiao Guoliang1, Fong Zhi Ven1, Bolm Louisa2, Fernandez del-Castillo Carlos1, Ferrone Cristina R1, Servin-Rojas Maximiliano1, Pathak Priyadarshini3, Lau-Min Kelsey3, Allen Jill N3, Blaszkowsky Lawrence S3, Clark Jeffrey W3, Parikh Aparna R3, Ryan David P3, Weekes Colin D3, Roberts Hannah M4, Wo Jennifer Y4, Hong Theodore S4, Lillemoe Keith D1, Qadan Motaz1
Affiliation:
1. Department of Surgery, Massachusetts General Hospital, Boston, MA 2. Department of Surgery, University Medical Center Schleswig-Holstein, Lubeck, Germany 3. Department of Medicine, Massachusetts General Hospital, Boston, MA 4. Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
Abstract
Objective:
We aimed to evaluate the safety and efficacy of NAT followed by surgical resection in patients with PDAC aged ≥75 years.
Summary Background Data:
Whether administration of neoadjuvant therapy (NAT) followed by surgical resection in elderly patients with pancreatic ductal adenocarcinoma (PDAC) is safe and effective is unknown.
Methods:
The present study is a three-part comparison of older (≥ 75 years) versus younger (< 75 years) patients in different settings throughout the continuum of PDAC care. The first analysis was a comparison of older versus younger consecutive patients with non-metastatic PDAC who were initiated on FOLFIRINOX. The second was a comparison of older vs. younger patients who underwent NAT followed by surgical resection, and the third and final analysis was a comparison of older patients who underwent either NAT followed by surgical resection vs. upfront surgical resection. Postoperative complications, overall survival (OS), and time to recurrence (TTR), were compared. Propensity-score matching (PSM) analysis was performed to adjust for potential confounders.
Results:
In the first analysis, a lower proportion of older patients (n=40) were able to complete the intended neoadjuvant FOLFIRINOX (8) cycles compared to younger patients (n=214) (65.0% vs. 81.4%, P=0.021). However, older patients were just as likely to undergo surgical exploration as younger patients (77.5% vs 78.5%, P=0.89) as well as surgical resection (57.5% vs 55.6%, P=0.70). In the second analysis, PSM was conducted to compare older (n=54) vs. younger patients (n=54) who underwent NAT followed by surgical resection. There were no significant differences in postoperative complications between the matched groups. While there was a significant difference in overall survival (OS) between older and younger patients (median OS: 16.43 months vs. 30.83 months, P=0.002), importantly, there was no significant difference in time to recurrence (TTR, median: 7.65 months vs. 11.83 months, P=0.215). In the third analysis, older patients who underwent NAT followed by surgical resection (n=48) were compared with similar older patients who underwent upfront surgical resection (n=48). After PSM, there was a significant difference in OS (median OS: 15.78 months vs. 11.51 months, P=0.037) as well as TTR (median TTR: 8.81 months vs. 7.10 months, P=0.046) representing an association with improved outcomes that favored the neoadjuvant approach among older patients alone.
Conclusions:
This comprehensive three-part study showed that administration of NAT followed by surgical resection appears to be safe and effective among patients ≥ 75 years of age. An aggressive approach should be offered to older adults undergoing multimodal treatment of PDAC.
Publisher
Ovid Technologies (Wolters Kluwer Health)
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