Top

Published in:

01-01-2008 | Hepatobiliary and Pancreatic Tumors

Variations in Surgical Treatment and Outcomes of Patients With Pancreatic Cancer: A Population-Based Study

Authors: Anand Govindarajan, MD, MSc, Jensen C. C. Tan, MD, Nancy N. Baxter, MD, PhD, Natalie G. Coburn, MD, MPH, Calvin H. L. Law, MD, MPH

Published in: Annals of Surgical Oncology | Issue 1/2008

Abstract

Background

There is ongoing debate on how variations in surgical technique affect outcomes in pancreatic cancer. This population-based study examines current surgical practice and outcomes for cancer of the pancreatic head.

Methods

All patients 18 to 85 years old diagnosed with nonmetastatic adenocarcinoma of the pancreatic head from 1998 through 2003 were identified from the Surveillance, Epidemiology and End Results (SEER) Program registry. Multivariable regression was used to elucidate factors associated with the type of pancreaticoduodenectomy performed, extent of lymph node (LN) assessment, early mortality, and late survival.

Results

Overall, 2111 patients were included in the study, with 83.7% treated with a standard Whipple pancreaticoduodenectomy (PD). However, there was marked regional variation in the use of pylorus-preserving pancreaticoduodenectomy (PPPD; range, .03%–32.0%; P < .0001) and total pancreatectomy (TP; range, .04%–19.5%; P < .0001). TP was associated with significantly higher early mortality (odds ratio, 2.6; 95% confidence interval, 1.6 to 4.1; P < .0001), but late survival did not differ significantly between TP, PPPD, and PD (P = .69). Significant variation was also seen in the number of LN assessed (range across SEER regions, 7.3–13.5; P < .0001). Decreased LN assessment reduced the odds of diagnosing a patient as node positive and was associated with worse late survival.

Conclusions

In this population-based study, we found marked clinically important variability in the surgical treatment of adenocarcinoma of the pancreatic head, with respect to the use of TP, PPPD, or PD, and the extent of LN assessment. Further research is warranted to elucidate the underlying reasons, and to clarify the role of adequate lymphadenectomy.

Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2006. CA Cancer J Clin 2006;56:106–30PubMedCrossRef

Stojadinovic A, Brooks A, Hoos A, Jaques DP, Conlon KC, Brennan MF. An evidence-based approach to the surgical management of resectable pancreatic adenocarcinoma. J Am Coll Surg 2003;196:954–64PubMedCrossRef

Kausch W. Das carcinom der papilla duodeni und seine radikale entfernung. Beitr Klin Chir 1912;78:439–51

Whipple AO. Present-day surgery of the pancreas. N Engl J Med 1942;226:515–8CrossRef

Watson K. Carcinoma of the ampulla of Vater. Successful radical resection. Br J Surg 1944;31:368–73CrossRef

Bell RH Jr. Pancreaticoduodenectomy with or without pylorus preservation have similar outcomes. Cancer Treat Rev 2005;31:328–31PubMedCrossRef

Hunt DR, McLean R. Pylorus-preserving pancreatectomy: functional results. Br J Surg 1989;76:173–6PubMedCrossRef

Lin PW, Lin YJ. Prospective randomized comparison between pylorus-preserving and standard pancreaticoduodenectomy. Br J Surg 1999;86:603–7PubMedCrossRef

Lin PW, Shan YS, Lin YJ, Hung CJ. Pancreaticoduodenectomy for pancreatic head cancer: PPPD versus Whipple procedure. Hepatogastroenterology 2005;52:1601–4PubMed

10.

Nguyen TC, Sohn TA, Cameron JL, et al. Standard vs radical pancreaticoduodenectomy for periampullary adenocarcinoma: a prospective, randomized trial evaluating quality of life in pancreaticoduodenectomy survivors. J Gastrointest Surg 2003;7:1–9PubMedCrossRef

11.

Riall TS, Cameron JL, Lillemoe KD, et al. Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma—part 3: update on 5-year survival. J Gastrointest Surg 2005;9:1191–204PubMedCrossRef

12.

Seiler CA, Wagner M, Bachmann T, et al. Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical Whipple resection-long term results. Br J Surg 2005;92:547–56PubMedCrossRef

13.

Seiler CA, Wagner M, Sadowski C, Kulli C, Buchler MW. Randomized prospective trial of pylorus-preserving vs classic duodenopancreatectomy (Whipple procedure): initial clinical results. J Gastrointest Surg 2000;4:443–52PubMedCrossRef

14.

Shan YS, Sy ED, Lin PW. Role of somatostatin in the prevention of pancreatic stump-related morbidity following elective pancreaticoduodenectomy in high-risk patients and elimination of surgeon-related factors: prospective, randomized, controlled trial. World J Surg 2003;27:709–14PubMedCrossRef

15.

van Berge Henegouwen MI, Moojen TM, van Gulik TM, Rauws EA, Obertop H, Gouma DJ. Postoperative weight gain after standard Whipple’s procedure versus pylorus-preserving pancreatoduodenectomy: the influence of tumour status. Br J Surg 1998;85:922–6PubMedCrossRef

16.

van Berge Henegouwen MI, van Gulik TM, DeWit LT, et al. Delayed gastric emptying after standard pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: an analysis of 200 consecutive patients. J Am Coll Surg 1997;185:373–9PubMed

17.

Wagner M, Redaelli C, Lietz M, Seiler CA, Friess H, Buchler MW. Curative resection is the single most important factor determining outcome in patients with pancreatic adenocarcinoma. Br J Surg 2004;91:586–94PubMedCrossRef

18.

Yeo CJ, Cameron JL, Lillemoe KD, et al. Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality. Ann Surg 2002;236:355–66PubMedCrossRef

19.

Yeo CJ, Cameron JL, Sohn TA, et al. Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short-term outcome. Ann Surg 1999;229:613–22PubMedCrossRef

20.

Tran KT, Smeenk HG, van Eijck CH, et al. Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors. Ann Surg 2004;240:738–45PubMedCrossRef

21.

Farnell MB, Pearson RK, Sarr MG, et al. A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma. Surgery 2005;138:618–28PubMedCrossRef

22.

Pedrazzoli S, DiCarlo V, Dionigi R, et al. Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy Study Group. Ann Surg 1998;228:508–17

23.

Hirata K, Sato T, Mukaiya M, et al. Results of 1001 pancreatic resections for invasive ductal adenocarcinoma of the pancreas. Arch Surg 1997;132:771–6PubMed

24.

Satake K, Nishiwaki H, Yokomatsu H, et al. Surgical curability and prognosis for standard versus extended resection for T1 carcinoma of the pancreas. Surg Gynecol Obstet 1992;175:259–65PubMed

25.

Takahashi S, Ogata Y, Miyazaki H, et al. Aggressive surgery for pancreatic duct cell cancer: feasibility, validity, limitations. World J Surg 1995;19:653–9PubMedCrossRef

26.

Schwarz RE, Smith DD. Extent of lymph node retrieval and pancreatic cancer survival: information from a large US population database. Ann Surg Oncol 2006;13:1189–200PubMedCrossRef

27.

Surveillance, Epidemiology and End Results (SEER) Program. Public-use data (1973–2003). National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch, released April 2006, based on the November 2005 submission. Available at: http://www.seer.cancer.gov. Accessed July 31, 2006

28.

Zippin C, Lum D, Hankey BF. Completeness of hospital cancer case reporting from the SEER Program of the National Cancer Institute. Cancer 1995;76:2343–50PubMedCrossRef

29.

Warren JL, Klabunde CN, Schrag D, Bach PB, Riley GF. Overview of the SEER-Medicare data: content, research applications, and generalizability to the United States elderly population. Med Care 2002;40:IV-3–18

30.

Surveillance, Epidemiology and End Results (SEER). About SEER—data access and quality. National Cancer Institute. Available at: http://www.seer.cancer.gov/about/uses.html. Accessed January 4, 2006

31.

Havener L. Standards for Cancer Registries, Volume III: Standards for completeness, Quality, Analysis and Management of Data. Springfield, IL: North American Association of Central Cancer Registries, 2004

32.

SEER—Extent of disease, 1988: codes and coding instructions. National Cancer Institute. Available at: http://www.seer.cancer.gov/publicdata/documentation.html. Accessed July 23, 2005

33.

Diehr P, Cain K, Connell F, Volinn E. What is too much variation? The null hypothesis in small-area analysis. Health Serv Res 1990;24:741–71PubMed

34.

Hosmer JW, Lemeshow S. Applied Logistic Regression. New York: John Wiley & Sons, 1989

35.

Cleveland WS. Robust locally weighted regression and smoothing scatterplots. J Am Stat Assoc J 1979;74:829–36CrossRef

36.

Birkmeyer JD, Sun Y, Wong SL, Stukel TA. Hospital volume and late survival after cancer surgery. Ann Surg 2007;245:777–83PubMedCrossRef

37.

Birkmeyer JD, Warshaw AL, Finlayson SR, Grove MR, Tosteson AN. Relationship between hospital volume and late survival after pancreaticoduodenectomy. Surgery 1999;126:178–83PubMed

38.

Rogers SO Jr, Wolf RE, Zaslavsky AM, Wright WE, Ayanian JZ. Relation of surgeon and hospital volume to processes and outcomes of colorectal cancer surgery. Ann Surg 2006;244:1003–11PubMedCrossRef

39.

Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. Am Stat Assoc J 1958;53:457–81CrossRef

40.

Cox DR. Regression models and life tables. J R Stat Assoc B 1972;29:187–220

41.

Diener MK, Knaebel HP, Heukaufer C, Antes G, Buchler MW, Seiler CM. A systematic review and meta-analysis of pylorus-preserving versus classical pancreaticoduodenectomy for surgical treatment of periampullary and pancreatic carcinoma. Ann Surg 2007;245:187–200PubMedCrossRef

42.

Patterns of Health Care in Ontario: The ICES Practice Atlas. 2nd edition. Ottawa: Canadian Medical Association, 1996

43.

McPherson K, Wennberg JE, Hovind OB, Clifford P. Small-area variations in the use of common surgical procedures: an international comparison of New England, England, and Norway. N Engl J Med 1982;307:1310–4PubMedCrossRef

44.

Karanicolas PJ, Davies E, Kunz R, et al. The pylorus: take it or leave it? systematic review and meta-analysis of pylorus-preserving versus standard Whipple pancreaticoduodenectomy for pancreatic or periampullary cancer. Ann Surg Oncol 2007

45.

Karpoff HM, Klimstra DS, Brennan MF, Conlon KC. Results of total pancreatectomy for adenocarcinoma of the pancreas. Arch Surg 2001;136:44–7PubMedCrossRef

46.

Ihse I, Anderson H, Andren S. Total pancreatectomy for cancer of the pancreas: is it appropriate? World J Surg 1996;20:288–93PubMedCrossRef

47.

Assan R, Alexandre JH, Tiengo A, Marre M, Costamailleres L, Lhomme C. Survival and rehabilitation after total pancreatectomy. A follow-up of 36 patients. Diabet Metab 1985;11:303–9

48.

Dresler CM, Fortner JG, McDermott K, Bajorunas DR. Metabolic consequences of (regional) total pancreatectomy. Ann Surg 1991;214:131–40PubMedCrossRef

49.

Allema JH, Reinders ME, van Gulik TM, et al. Prognostic factors for survival after pancreaticoduodenectomy for patients with carcinoma of the pancreatic head region. Cancer 1995;75:2069–76PubMedCrossRef

50.

Lim JE, Chien MW, Earle CC. Prognostic factors following curative resection for pancreatic adenocarcinoma: a population-based, linked database analysis of 396 patients. Ann Surg 2003;237:74–85PubMedCrossRef

51.

Neoptolemos JP, Dunn JA, Stocken DD, et al. Adjuvant chemoradiotherapy and chemotherapy in resectable pancreatic cancer: a randomised controlled trial. Lancet 2001;358:1576–85PubMedCrossRef

52.

Ricciardi R, Baxter NN. Association versus causation versus quality improvement: setting benchmarks for lymph node evaluation in colon cancer. J Natl Cancer Inst 2007;99:414–5PubMedCrossRef

53.

Cooper GS, Virnig B, Klabunde CN, Schussler N, Freeman J, Warren JL. Use of SEER-Medicare data for measuring cancer surgery. Med Care 2002;40:IV-43–8CrossRef

Title: Variations in Surgical Treatment and Outcomes of Patients With Pancreatic Cancer: A Population-Based Study
Authors: Anand Govindarajan, MD, MSc
Jensen C. C. Tan, MD
Nancy N. Baxter, MD, PhD
Natalie G. Coburn, MD, MPH
Calvin H. L. Law, MD, MPH
Publication date: 01-01-2008
Publisher: Springer-Verlag
Published in: Annals of Surgical Oncology / Issue 1/2008
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-007-9601-7

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Variations in Surgical Treatment and Outcomes of Patients With Pancreatic Cancer: A Population-Based Study

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2008

Sentinel Lymph Node Evaluation Does Not Improve Staging Accuracy in Colon Cancer

The Predominant Role of Surgery in the Prevention and New Trends in the Surgical Treatment of Women With BRCA1/2 Mutations

Pharmacokinetics of Oxaliplatin During Open Versus Laparoscopically Assisted Heated Intraoperative Intraperitoneal Chemotherapy (HIPEC): An Experimental Study

Second-Look Operation for Unresectable Pancreatic Ductal Adenocarcinoma at a High-Volume Center

Peritoneal Recurrence for Gastric Cancer: Can It Be Prevented?

Laparoscopic Resection of Abdominal Neuroblastoma