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

Abstract

Operative intervention with multimodal therapy, including systemic therapy and 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 operation alone for patients with resectable PDAC are limited. The National Cancer Database was queried for patients diagnosed with resectable (clinical stage II or less) PDAC between 2010 and 2016. Patients who underwent upfront resection without additional treatment were compared with those who refused operation, to determine the comparative role of isolated surgical intervention for PDAC. Propensity score matching was used to account for selection bias. A total of 2,391 (6.1%) underwent upfront curative-intent resection without further treatment and 485 (1.2%) refused recommended operation. Propensity matching resulted in 471 well-balanced pairs. In the surgery group, 30- and 90-day mortality was 7% (33) and 17% (81), respectively. Median overall survival (OS) was 14.09 months (95% CI 12.39 to 16.72) compared with 6.34 months (95% CI 5.72 to 6.9) in the no-treatment group (log rank test p < 0.001). Estimated 1-year OS rates were 56% (95% CI 51.7 to 60.8) vs 26% (95% CI 22.3 to 30.6), respectively. For patients who underwent operation with R0 resection, median OS was 17.87 months (95% CI 14.7 to 21.3) compared with 7.56 months (95% CI 6.5 to 11.5) for non-R0 resection (log rank test p < 0.001). 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.