New developments in the treatment of pancreatic cancer

The incidence of pancreatic cancer is increasing due to the ageing population among other things, while 5-year survival has improved in the past two decades from 3 to 7%.- In case of biliary obstruction due to pancreatic cancer, biliary drainage before surgery or ablative therapy using a covered metal stent instead of plastic reduces the rate of complications.- In patients with metastasized pancreatic cancer a combination of folinic acid, fluorouracil, irinotecan and oxaliplatin (FOLFIRINOX) results in improved survival. Approximately 20% of patients with locally, unresectable pancreatic cancer can undergo surgical resection following treatment with FOLFIRINOX.- The effectiveness of radiofrequency ablation, irreversible electroporation and stereotactic radiotherapy for locally, unresectable pancreatic cancer is currently investigated in multicenter trials.- The effectiveness of neo-adjuvant chemoradiation and minimal invasive surgery in patients with resectable pancreatic cancer is currently investigated in randomized multicenter trials.

The use of adjuvant chemotherapy for pancreatic cancer varies widely between hospitals: a nationwide population-based analysis

Adjuvant chemotherapy after pancreatoduodenectomy for pancreatic cancer is currently considered standard of care. In this nationwide study, we investigated which characteristics determine the likelihood of receiving adjuvant chemotherapy and its effect on overall survival. The data were obtained from the Netherlands Cancer Registry. All patients alive 90 days after pancreatoduodenectomy for M0 -pancreatic cancer between 2008 and 2013 in the Netherlands were included in this study. The likelihood to receive adjuvant chemotherapy was analyzed by multilevel logistic regression analysis and differences in time-to-first-chemotherapy were tested for significance by Mann-Whitney U test. Overall survival was assessed by Kaplan-Meier method and Cox regression analysis. Of the 1195 patients undergoing a pancreatoduodenectomy for pancreatic cancer, 642 (54%) patients received adjuvant chemotherapy. Proportions differed significantly between the 19 pancreatic centers, ranging from 26% to 74% (P < 0.001). Median time-to-first-chemotherapy was 6.7 weeks and did not differ between centers. Patients with a higher tumor stage, younger age, and diagnosed more recently were more likely to receive adjuvant treatment. The 5-year overall survival was significantly prolonged in patients treated with adjuvant chemotherapy-23% versus 17%, log-rank = 0.01. In Cox regression analysis, treatment with adjuvant chemotherapy significantly prolonged survival compared with treatment without adjuvant chemotherapy. The finding that elderly patients and patients with a low tumor stage are less likely to undergo treatment needs further attention, especially since adjuvant treatment is known to prolong survival in most of these patients.

Impact of a Nationwide Training Program in Minimally Invasive Distal Pancreatectomy (LAELAPS)

OBJECTIVE:

To study the feasibility and impact of a nationwide training program in minimally invasive distal pancreatectomy (MIDP).

SUMMARY OF BACKGROUND DATA:

Superior outcomes of MIDP compared with open distal pancreatectomy have been reported. In the Netherlands (2005 to 2013) only 10% of distal pancreatectomies were in a minimally invasive fashion and 85% of surgeons welcomed MIDP training. The feasibility and impact of a nationwide training program is unknown.

METHODS:

From 2014 to 2015, 32 pancreatic surgeons from 17 centers participated in a nationwide training program in MIDP, including detailed technique description, video training, and proctoring on-site. Outcomes of MIDP before training (2005-2013) were compared with outcomes after training (2014-2015).

RESULTS:

In total, 201 patients were included; 71 underwent MIDP in 9 years before training versus 130 in 22 months after training (7-fold increase, P < 0.001). The conversion rate (38% [n = 27] vs 8% [n = 11], P < 0.001) and blood loss were lower after training and more pancreatic adenocarcinomas were resected (7 [10%] vs 28 [22%], P = 0.03), with comparable R0-resection rates (4/7 [57%] vs 19/28 [68%], P = 0.67). Clavien-Dindo score ≥III complications (15 [21%] vs 19 [15%], P = 0.24) and pancreatic fistulas (20 [28%] vs 41 [32%], P = 0.62) were not significantly different. Length of hospital stay was shorter after training (9 [7-12] vs 7 [5-8] days, P < 0.001). Thirty-day mortality was 3% vs 0% (P = 0.12).

CONCLUSION:

A nationwide MIDP training program was feasible and followed by a steep increase in the use of MIDP, also in patients with pancreatic cancer, and decreased conversion rates. Future studies should determine whether such a training program is applicable in other settings.