Competing Risks for Mortality in Patients With Asymptomatic Pancreatic Cystic Neoplasms: Implications for Clinical Management. (August 2017)

• Record Type: Journal Article
• Authors: Kwok, Karl; Chang, Jonathan; Duan, Lewei; Huang, Brian Z; Wu, Bechien U
• Is Part Of: American journal of gastroenterology. Volume 112:Number 8(2017)
• Publication Date: 2017-08
• Subjects: Stomach -- Diseases -- Periodicals; Intestines -- Diseases -- Periodicals; Gastroenterology -- Periodicals; Gastrointestinal Diseases -- Periodicals; Electronic journals; Periodicals; 616.33
• DOI: 10.1038/ajg.2017.141
• Languages: English
• ISSNs: 0002-9270

Abstract

Abstract : Objectives: Pancreatic cystic neoplasms (PCNs) are being detected with increased frequency. Current clinical practice guidelines emphasize management based on cyst‐related features. We aimed to evaluate the impact of comorbidity on mortality in PCN patients via competing risk analysis. Methods: We analyzed a retrospective cohort of patients diagnosed between 2005–2010, with follow‐up through 2015, for overall and cause‐specific mortality. Comorbidities were classified by the Charlson comorbidity index. We used Cox proportional hazards regression to evaluate the independent effect of cyst features, age, gender, and comorbidities on cause‐specific mortality. Subgroup analysis was performed to determine the cause‐specific mortality based on four a priori clinical profiles—healthy patients with low‐ or high‐risk cysts, and high‐comorbidity patients with low‐ or high‐risk cysts. Results: A total of 1, 800 patients with PCNs comprised the study cohort (median follow‐up 5.7 years). A total of 402 deaths (22.3%) occurred during the study period: 43 pancreatic cancer and 359 non‐pancreatic cancer deaths. Compared to healthy patients without any high‐risk cyst features (reference group), patients with high comorbidity as well as high‐risk cyst features had an increased risk of overall mortality (Cox hazard ratio 6.30, 95% confidence interval (CI) 4.71, 8.42, P <0.01), pancreatic cancer mortality (subdistribution hazard ratio (SHR) 51.13, 95% CI 6.35, 411.29, P <0.01), as well as non‐pancreatic cancer mortality (SHR 5.24, 95% CI 3.85, 7.12, P <0.01). Meanwhile, low‐risk patients with a high‐risk cyst were more likely to experience pancreatic cancer mortality (SHR 68.14, 95% CI 9.27, 501.01, P <0.01) rather than non‐pancreatic cancer mortality (SHR 1.22, 95% CI 0.88, 1.71, P =0.23), compared to the reference group. Similarly, compared to the reference group, high‐risk patients with a low‐risk cyst were more likely to experience non‐pancreatic cancer mortality (SHR 3.96, 95% CI 2.98, 5.26, P <0.01) rather than pancreatic cancer mortality (SHR 2.35, 95% CI 0.14, 38.82, P =0.55). Conclusions: Most of the deaths in the study were unrelated to pancreatic cancer. This has implications for clinical management. By applying patient‐related factors in conjunction with cyst features, we defined commonly encountered patient profiles to help guide PCN clinical management.