Surgery Alone for Resectable Pancreatic Adenocarcinoma: Should We Operate if Multimodal Treatment is Off the Table?

Abstract

Background: Operative intervention with multimodal therapy, including systemic therapy and/or radiation, is routinely used in the curative-intent treatment of patients with pancreatic ductal adenocarcinoma (PDAC). Occasionally, patients are unable to undergo multimodal therapy. However, contemporary data on the benefit of surgery-alone for patients with resectable PDAC are limited.

Study design: The National Cancer Database (NCDB) was queried for patients diagnosed with resectable (clinical stage ≤II) PDAC between 2010-2016. Patients who underwent upfront resection without additional treatment were compared to those who refused surgery, to determine the comparative role of isolated surgical intervention for PDAC. Propensity score matching was used to account for selection bias.

Results: A total of 2,391 (6.1%) underwent upfront curative-intent resection without further treatment and 485 (1.2%) refused recommended surgery. Propensity matching resulted in 471 well-balanced pairs. In the surgery group, 30-day and 90-day mortality was 7% (n=33) and 17% (n=81), respectively. Median overall survival (OS) was 14.09 months (95% CI: 12.39, 16.72) compared to 6.34 months (95% CI: 5.72, 6.9) in the no treatment group (log rank test p < 0.001). Estimated 1-year OS rates were 56% (95% CI: 51.7, 60.8) vs. 26% (95% CI: 22.3, 30.6), respectively. For patients who underwent surgery with R0 resection, median OS was 17.87 months (95% CI: 14.7, 21.3) compared to 7.56 months (95% CI: 6.5, 11.5) for non-R0 resection (log rank test p<0.001).

Conclusions: This national study of patients with early stage PDAC affirms that surgical resection, in the absence of multimodal therapy, is associated with improved outcomes compared with no resection. However, the association with improved survival is clinically annulled in the absence of a negative-margin resection.