Management of Locally Advanced Pancreatic Cancer: Results of an International Survey of Current Practice. Issue 6 (June 2021)

• Record Type: Journal Article
• Authors: 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
• Is Part Of: Annals of surgery. Volume 273:Issue 6(2021)
• Publication Date: 2021-06
• Subjects: locally advanced pancreas cancer -- multidisciplinary management -- pancreas cancer -- pancreas surgery -- survey research; Surgery -- Periodicals; 617.005
• DOI: 10.1097/SLA.0000000000003568
• Languages: English
• ISSNs: 0003-4932

Abstract

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." Abstract : Supplemental Digital Content is available in the text