Population-based outcomes in pancreatic cancer: Improvements in survival, underutilization of surgical resection for early stage disease, and regionalization of care

Abstract

Pancreatic cancer is the 4th leading cause of cancer deaths in both men and women in the United States. Currently, surgical resection remains the only hope for long-term survival in patients with this aggressive cancer. The work defined in this thesis provides population-based data on patients with pancreatic cancer that can be used to improve outcomes and set policy on a national level. \r\n It is unclear if the improvements in survival seen in major centers over the last decade have been translated to the general population of patients with pancreatic cancer. An analysis of the Surveillance, Epidemiology, and End Results (SEER) population-based tumor registry, demonstrated that survival in patients with pancreatic cancer has improved over the last decade. The improvement in survival can be, in part, attributed to the increased resection rates seen over the same time period. \r\n While clear evidence supports the use of surgical resection in patients with locoregional pancreatic cancer, fewer than one third of patients undergo surgical resection. The reasons for underutilization of surgical resection were further evaluated. In the SEER-Medicare population, only 75% of patients with locoregional pancreatic cancer were evaluated by a surgeon was only 75%. Worse, only 42% of patients received the minimal appropriate care necessary to make an informed decision regarding surgical resection. Advanced age, comorbidities, and minority race/ethnicity were predictive of no surgical resection. \r\n A strong volume-outcome relationship has been demonstrated for pancreatic resection. Despite this recommendation for regionalization of care based on those data, we demonstrated that 35% of patients undergoing resection in Texas are still being resected at centers doing fewer than ten per year. In addition, a volume cutoff, while useful, it not the best criteria for regionalization as outcomes following surgical resection varied significantly among high-volume centers. \r\n In summary, we need to work toward maximizing appropriate evaluation including evaluation by a surgeon, and surgical resection in patients with locoregional disease. In addition, we need to define standards for hospitals and surgeons to achieve referral center status for the care of pancreatic cancer patients and work to achieve 100% regionalization of care to these centers to improve outcomes. \r\n