Feasibility, Safety, and Efficacy of Aggressive Multimodal Management of Elderly Patients with Pancreatic Ductal Adenocarcinoma

Guoliang Qiao; Zhi Ven Fong; Louisa Bolm; Carlos Fernandez Del-Castillo; Cristina R Ferrone; Maximiliano Servin-Rojas; Priyadarshini Pathak; Kelsey Lau-Min; Jill N Allen; Lawrence S Blaszkowsky; Jeffrey W Clark; Aparna R Parikh; David P Ryan; Colin D Weekes; Hannah M Roberts; Jennifer Y Wo; Theodore S Hong; Keith D Lillemoe; Motaz Qadan

doi:10.1097/SLA.0000000000006131

Feasibility, Safety, and Efficacy of Aggressive Multimodal Management of Elderly Patients with Pancreatic Ductal Adenocarcinoma

Ann Surg. 2023 Oct 13. doi: 10.1097/SLA.0000000000006131. Online ahead of print.

Authors

Guoliang Qiao¹, Zhi Ven Fong¹, Louisa Bolm², Carlos Fernandez Del-Castillo¹, Cristina R Ferrone¹, Maximiliano Servin-Rojas¹, Priyadarshini Pathak³, Kelsey Lau-Min³, Jill N Allen³, Lawrence S Blaszkowsky³, Jeffrey W Clark³, Aparna R Parikh³, David P Ryan³, Colin D Weekes³, Hannah M Roberts⁴, Jennifer Y Wo⁴, Theodore S Hong⁴, Keith D Lillemoe¹, Motaz Qadan¹

Affiliations

¹ Department of Surgery, Massachusetts General Hospital, Boston, MA.
² Department of Surgery, University Medical Center Schleswig-Holstein, Lubeck, Germany.
³ Department of Medicine, Massachusetts General Hospital, Boston, MA.
⁴ Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA.

PMID: 37830225
DOI: 10.1097/SLA.0000000000006131

Abstract

Objective: We aimed to evaluate the safety and efficacy of NAT followed by surgical resection in patients with PDAC aged ≥75 years.

Summary background data: Whether administration of neoadjuvant therapy (NAT) followed by surgical resection in elderly patients with pancreatic ductal adenocarcinoma (PDAC) is safe and effective is unknown.

Methods: The present study is a three-part comparison of older (≥ 75 years) versus younger (< 75 years) patients in different settings throughout the continuum of PDAC care. The first analysis was a comparison of older versus younger consecutive patients with non-metastatic PDAC who were initiated on FOLFIRINOX. The second was a comparison of older vs. younger patients who underwent NAT followed by surgical resection, and the third and final analysis was a comparison of older patients who underwent either NAT followed by surgical resection vs. upfront surgical resection. Postoperative complications, overall survival (OS), and time to recurrence (TTR), were compared. Propensity-score matching (PSM) analysis was performed to adjust for potential confounders.

Results: In the first analysis, a lower proportion of older patients (n=40) were able to complete the intended neoadjuvant FOLFIRINOX (8) cycles compared to younger patients (n=214) (65.0% vs. 81.4%, P=0.021). However, older patients were just as likely to undergo surgical exploration as younger patients (77.5% vs 78.5%, P=0.89) as well as surgical resection (57.5% vs 55.6%, P=0.70). In the second analysis, PSM was conducted to compare older (n=54) vs. younger patients (n=54) who underwent NAT followed by surgical resection. There were no significant differences in postoperative complications between the matched groups. While there was a significant difference in overall survival (OS) between older and younger patients (median OS: 16.43 months vs. 30.83 months, P=0.002), importantly, there was no significant difference in time to recurrence (TTR, median: 7.65 months vs. 11.83 months, P=0.215). In the third analysis, older patients who underwent NAT followed by surgical resection (n=48) were compared with similar older patients who underwent upfront surgical resection (n=48). After PSM, there was a significant difference in OS (median OS: 15.78 months vs. 11.51 months, P=0.037) as well as TTR (median TTR: 8.81 months vs. 7.10 months, P=0.046) representing an association with improved outcomes that favored the neoadjuvant approach among older patients alone.

Conclusions: This comprehensive three-part study showed that administration of NAT followed by surgical resection appears to be safe and effective among patients ≥ 75 years of age. An aggressive approach should be offered to older adults undergoing multimodal treatment of PDAC.