Dissecting racial disparities in the treatment of patients with locoregional pancreatic cancer

BACKGROUND:

Previous studies have demonstrated that black patients with pancreatic cancer are less likely to undergo resection and have worse overall survival compared with white patients. The objective of this study was to determine whether these disparities occur at the point of surgical evaluation or after evaluation has taken place.

METHODS:

The authors used the Surveillance, Epidemiology, and End Results (SEER)‐Medicare linked data (1992‐2002) to compare black patients and white patients with locoregional pancreatic cancer in univariate models. Logistic regression was used to determine the effect of race on surgical evaluation and on surgical resection after evaluation. Cox proportional hazards models were used to identify which factors influenced 2‐year survival.

RESULTS:

Nine percent of 3777 patients were black. Blacks were substantially less likely than whites to undergo evaluation by a surgeon (odds ratio, 0.57; 95% confidence interval, 0.42‐0.77) when the model was adjusted for demographics, tumor characteristics, surgical evaluation, socioeconomic status, and year of diagnosis. Patients who were younger and who had fewer comorbidities, abdominal imaging, and a primary care physician were more likely to undergo surgical evaluation. Once they were seen by a surgeon, blacks still were less likely than whites to undergo resection (odds ratio, 0.64; 95% confidence interval, 0.49‐0.84). Although black patients had decreased survival in an unadjusted model, race no longer was significant after accounting for resection.

CONCLUSIONS:

Twenty‐nine percent of black patients with potentially resectable pancreatic cancers never received surgical evaluation. Without surgical evaluation, patients cannot make an informed decision and will not be offered resection. Attaining higher rates of surgical evaluation in black patients would be the first step to eliminating the observed disparity in the resection rate. Cancer 2010. © 2010 American Cancer Society     

Validation of the 6th edition AJCC Pancreatic Cancer Staging System: report from the National Cancer Database

BACKGROUND

With the development of stage‐specific treatments for pancreatic cancer, controversies exist concerning optimal clinical and pathologic staging. The most recent edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual 6^th Edition included some notable modifications. In anticipation of the 7^th edition's publication, the authors evaluated the predictive ability of the current pancreatic adenocarcinoma staging system.

METHODS

By using the National Cancer Data Base (1992–1998), 121,713 patients were identified with pancreatic adenocarcinoma. All patients were restaged by AJCC 6^th edition guidelines. Stage‐specific overall survival was estimated by using the Kaplan‐Meier method and compared with log‐rank tests. Concordance indices were calculated to evaluate the discriminatory power of the staging system. Cox modeling was used to determine the relative impact of T, N, and M classification on survival.

RESULTS

For all patients, there was 5‐year survival discrimination by stage (P < .0001). For patients who underwent pancreatectomy, stage predicted 5‐year survival: stage IA, 31.4%; IB, 27.2%; IIA, 15.7%; IIB, 7.7%; III, 6.8%; IV, 2.8% (P < .0001). The concordance index for the staging system was 0.631 for all patients, 0.613 for those who underwent pancreatectomy, and 0.596 for patients who did not undergo resection. In patients who underwent pancreatectomy, tumor size, nodal status, and distant metastases were independent predictors of survival (P < .0001).

CONCLUSIONS

This is the first large‐scale validation of the pancreatic cancer staging system. AJCC 6^th edition staging guidelines are accurate with respect to survival. Further investigation is needed to integrate new molecular and biochemical markers into the staging scheme. Cancer 2007; 110:738–44. © 2007 American Cancer Society.     

Benefit of postoperative adjuvant therapy for pancreatic cancer

BACKGROUND:

Despite the recent completion of several trials of adjuvant therapy after resection for pancreatic adenocarcinoma, the absolute impact on survival and the identification of appropriate patients for treatment has remained controversial. In the current study, the authors sought to identify the impact of adjuvant therapy and factors associated with any improvement in survival after resection of pancreatic cancer.

METHODS:

Through the California Cancer Registry, all California residents diagnosed with pancreatic cancer between 1994 and 2002 were identified. Factors potentially impacting survival were analyzed, including patient demographics, tumor characteristics, and treatment provided. Univariate and multivariate survival analyses were performed by Kaplan‐Meier and Cox regression methods.

RESULTS:

A total of 26,518 patients were identified; 3196 (12.1%) underwent resection as their primary treatment. The median overall survival was 16 months for patients who underwent resection. Prognostic factors associated with better survival included negative lymph node status, well‐differentiated tumors, younger age, female sex, and the receipt of any adjuvant therapy. On multivariate analysis, adjuvant therapy demonstrated a statistically significant, although modest, impact on survival, with a hazards ratio of 0.79 (95% confidence interval, 0.72‐0.87; P < .001). The benefit of adjuvant therapy was only apparent in those patients with lymph node–positive or poorly differentiated tumors.

CONCLUSIONS:

Adjuvant therapy provided for a modest improvement in overall survival after surgical resection of pancreatic cancer. The absolute effect was most pronounced in those patients with poor prognostic indicators. To identify effective systemic therapy for this deadly cancer, future clinical trials of adjuvant therapy should focus on these groups of patients. Cancer 2009. © 2009 American Cancer Society.     

Racial differences in treatment and outcomes among patients with early stage bladder cancer

BACKGROUND:

Black patients are at greater of risk of death from bladder cancer than white patients. Potential explanations for this disparity include a more aggressive phenotype and delays in diagnosis resulting in higher stage disease. Alternatively, black patients may receive a lower quality of care, which may explain this difference.

METHODS:

Using Surveillance, Epidemiology, and End Results (SEER)‐Medicare data for the years from 1992 through 2002, the authors identified patients with early stage bladder cancer. Multivariate models were fitted to measure relations between race and mortality, adjusting for differences in patients and treatment intensity. Next, shared‐frailty proportional hazards models were fitted to evaluate whether the disparity was explained by differences in the quality of care provided.

RESULTS:

Compared with white patients (n = 14,271), black patients (n = 342) were more likely to undergo restaging resection (12% vs 6.5%; P < .01) and urine cytologic evaluation (36.8% vs 29.7%; P < .01), yet they received fewer endoscopic evaluations (4 vs 5; P < .01). The use of aggressive therapies (cystectomy, systemic chemotherapy, radiation) was found to be similar among black patients and white patients (12% vs 10.2%, respectively; P = .31). Although black patients had a greater risk of death compared with white patients (hazards ratio [HR], 1.23; 95% confidence interval [95% CI], 1.07‐1.42), this risk was attenuated only modestly after adjusting for differences in treatment intensity and provider effects (HR, 1.22; 95% CI, 1.06‐1.42).

CONCLUSIONS:

Although differences in initial treatment were evident, they did not appear to be systematic and had unclear clinical significance. Whereas black patients are at greater risk of death, this disparity did not appear to be caused by differences in the intensity or quality of care provided. Cancer 2010. © 2010 American Cancer Society.     

Pancreatic neuroendocrine tumors

BACKGROUND:

Although surgical resection is generally recommended for patients with localized pancreatic neuroendocrine tumors (PNETs), the impact of resection on overall survival is unknown. The authors investigated the survival advantage of pancreatic resection using a national database.

METHODS:

This is a retrospective survival analysis of patients with PNETs from the Surveillance, Epidemiology, and End Results database (1988‐2002).

RESULTS:

A total of 728 patients with PNETs were identified with a median survival of 43 months using Kaplan‐Meier survival methods. Resection of tumor was associated with significantly improved survival compared with those patients who were recommended for but did not undergo resection (114 months vs 35 months; P < .0001). This survival benefit was demonstrated for patients with localized, regional, and metastatic disease. A multivariable Cox proportional hazards model was constructed to assess the overall effect of surgical resection on survival, and demonstrated an adjusted odds ratio of 0.48 (95% confidence interval, 0.35‐0.66) compared with those who were recommended for surgery but did not proceed to surgery.

CONCLUSIONS:

The authors have demonstrated in a large national study that resection of primary tumor in patients with PNETs is associated with improved survival across all disease stages. Patients with localized, regional, and metastatic PNETs who are reasonable operative candidates should be considered for resection of their primary tumors. Cancer 2009. © 2009 American Cancer Society.     

Neoadjuvant therapy is associated with improved survival in resectable pancreatic adenocarcinoma

BACKGROUND:

Neoadjuvant therapy has been used to improve survival in operable pancreatic cancer. The authors' objective was to compare long‐term outcomes in patients receiving neoadjuvant versus adjuvant therapy for resectable pancreatic adenocarcinoma.

METHODS:

The California Cancer Surveillance Program for Los Angeles County retrospectively identified 458 patients with nonmetastatic pancreatic adenocarcinoma who underwent definitive pancreatic resection and received systemic chemotherapy between 1987 and 2006. The cohort was grouped by timing of systemic therapy—neoadjuvant or adjuvant. Clinicopathologic characteristics and overall survival were compared. Multivariate Cox regression analysis was used to determine the benefit of neoadjuvant therapy, independent of other significant factors.

RESULTS:

Of the 458 patients, 39 (8.5%) received neoadjuvant therapy, and 419 (91.5%) received adjuvant therapy. There was a significantly lower rate of lymph node positivity in the neoadjuvant group (45% vs 65%; P = .011) despite a higher rate of extrapancreatic tumor extension. On Kaplan‐Meier analysis, the neoadjuvant group had significantly better overall survival compared with the adjuvant group (median survival, 34 vs 19 months; P = .003). Overall survival was also improved in the neoadjuvant therapy patients with extrapancreatic disease (median survival, 31 vs 19 months; P = .018). On multivariate Cox regression analysis, neoadjuvant therapy was an independent predictor of improved survival (hazard ratio, 0.57; 95% confidence interval, 0.37‐0.89; P = .013).

CONCLUSIONS:

This is the first population‐based study to compare neoadjuvant versus adjuvant treatment strategies in resectable pancreatic cancer. Neoadjuvant therapy is associated with a lower rate of lymph node positivity and improved overall survival and should be considered an acceptable alternative to the surgery‐first paradigm in operable pancreatic cancer. Cancer 2011. © 2010 American Cancer Society     

Histologic characteristics enhance predictive value of American Joint Committee on Cancer staging in resectable pancreas cancer

BACKGROUND:

American Joint Committee on Cancer (AJCC) anatomic stage group is considered relatively nondiscriminatory for predicting differences in survival after pancreatectomy for ductal adenocarcinoma, a perception confirmed in the authors' patients and by other reports. The authors' aim was to investigate the potential for improving the predictive value of AJCC staging by incorporating individually predictive histologic features into AJCC tumor‐node‐metastasis classification of anatomic extent, and determine the simplest combination of tumor characteristics predicting survival.

METHODS:

The authors determined survival of 137 patients who underwent pancreatectomy for ductal adenocarcinoma with curative intent (stage Groups IA ‐ IIB) at Moffitt Cancer Center during the last 2 decades using data obtained from medical record review, the Moffitt Cancer Registry, and the Social Security Death Index. Histologic characteristics were confirmed by expert review.

RESULTS:

Median survival was 21.2 months after pancreatectomy with a 3‐year disease‐specific survival of 36%. Univariate Kaplan‐Meier analysis and multivariate Cox proportional hazard modeling found worse survival with local extrapancreatic extension, poorly differentiated histology, and lymphatic invasion within tumor (P < .05). Survival was not worse with nodal metastases, microscopically positive resection margins, and perineural or venous invasion, nor was survival better with cancer arising from an intraductal papillary mucinous neoplasm. Kaplan‐Meier estimates for different variable combinations showed prognosis was best for well‐ or moderately differentiated tumors without lymphatic invasion and confined to the pancreas (9.9 years median survival), worst for poorly differentiated tumors with lymphatic invasion and local extension beyond the pancreas (8.5 months median survival), and intermediate for well‐ or moderately differentiated tumors with either lymphatic invasion or local extension beyond the pancreas (21.2 months median survival).

CONCLUSIONS:

A simple combination of tumor differentiation, lymphatic invasion within the tumor, and local extrapancreatic extension predicts survival after pancreatectomy for ductal adenocarcinoma. Cancer 2009. © 2009 American Cancer Society.     

Deoxycitidine kinase is associated with prolonged survival after adjuvant gemcitabine for resected pancreatic adenocarcinoma

BACKGROUND:

Gemcitabine (2′,2′‐difluorodeoxycytidine) administration after resection of pancreatic cancer improves both disease‐free survival (DFS) and overall survival (OS). Deoxycytidine kinase (dCK) mediates the rate‐limiting catabolic step in the activation of gemcitabine. The authors of this report studied patient outcomes according to the expression of dCK after a postoperative gemcitabine‐based chemoradiation regimen.

METHODS:

Forty‐five patients with resected pancreatic adenocarcinoma received adjuvant gemcitabine based‐therapy in the context of multicenter phase 2 studies. Their tumors were evaluated retrospectively for dCK protein expression by immunohistochemistry. A composite score based on the percentage of dCK‐positive cancer cells and the intensity of staining was generated, and the results were dichotomized at the median values.

RESULTS:

The median follow‐up was 19.95 months (95% confident interval [CI], 3.3‐107.4 months). The lymph node (LN) ratio and dCK protein expression were significant predictors of DFS and OS in univariate analysis. On multivariate analysis, dCK protein expression was the only independent prognostic variable (DFS: hazard ratio [HR], 3.48; 95% CI, 1.66‐7.31; P = .001; OS: HR, 3.2; 95% CI,1.44‐7.13; P = .004).

CONCLUSIONS:

dCK protein expression was identified as an independent and strong prognostic factor in patients with resected pancreatic adenocarcinoma who received adjuvant gemcitabine therapy. The authors concluded that it deserves prospective evaluation as a predictive biomarker for patient selection. Cancer 2010. © 2010 American Cancer Society.     

Pathologic complete response in breast cancer patients receiving anthracycline‐ and taxane‐based neoadjuvant chemotherapy

BACKGROUND:

The current study was conducted to evaluate the influence of race/ethnicity and tumor subtype in pathologic complete response (pCR) following treatment with neoadjuvant chemotherapy.

METHODS:

A total of 2074 patients diagnosed with breast cancer between 1994 and 2008 who were treated with neoadjuvant anthracycline‐ and taxane‐based chemotherapy were included. pCR was defined as no residual invasive cancer in the breast and axilla. The Kaplan‐Meier product‐limit was used to calculate survival outcomes. Cox proportional hazards models were fitted to determine the relationship of patient and tumor variables with outcome.

RESULTS:

The median patient age was 50 years; 14.6% of patients were black, were 15.2% Hispanic, 64.3% were white, and 5.9% were of other race. There were no differences in pCR rates among race/ethnicity (12.3% in black, 14.2% in Hispanics, 12.3% in whites, and 11.5% in others, P = .788). Lack of pCR, breast cancer subtype, grade 3 tumors, and lymphovascular invasion were associated with worse recurrence‐free survival (RFS) and overall survival (OS) (P ≤ .0001). Differences in RFS by race/ethnicity were noted in the patients with hormone receptor‐positive disease (P = .007). On multivariate analysis, Hispanics had improved RFS (hazard ratio [HR], 0.69; 95% confidence interval [95% CI], 0.49‐0.97) and OS (HR, 0.63; 95% CI, 0.41‐0.97); blacks had a trend toward worse outcomes (RFS: HR, 1.28 [95% CI, 0.97‐1.68] and OS: HR, 1.32 [95% CI, 0.97‐1.81]) when compared with whites.

CONCLUSIONS:

In this cohort of patients, race/ethnicity was not found to be significantly associated with pCR rates. On a multivariate analysis, improved outcomes were observed in Hispanics and a trend toward worse outcomes in black patients, when compared with white patients. Further research was needed to explore the potential differences in biology and outcomes. Cancer 2010. © 2010 American Cancer Society.     

Glutathione S-transferase gene polymorphisms and risk and survival of pancreatic cancer

BACKGROUND.

Pancreatic cancer is a multifactorial disease with metastasis‐prone and therapy‐resistant nature. The authors hypothesized that genetic variants of glutathione S‐transferase (GST) affect detoxification of carcinogens and anticancer agents in the human pancreas and, thus, the risk and survival of pancreatic cancer.

METHODS.

Genotypes of GSTM1, GSTT1, and GSTP1 were determined in 352 patients with pancreatic ductal adenocarcinoma and in a control group of 315 healthy, non‐Hispanic whites (frequency‐matched by age and sex). Survival analysis was performed in a subset of 290 patients. Epidemiological and clinical information was obtained. A multiple unconditional logistic regression model, a Cox proportional hazards model, and log‐rank tests were used for statistical analysis.

RESULTS.

No significant main effects of any of 3 GST genes on the risk of pancreatic cancer were observed. Subgroup analysis showed that older individuals (aged ≥62 years) who carried the GSTP1*C (¹⁰⁵Val‐¹¹⁴Val) containing genotype tended to have a reduced risk compared with younger individuals who carried the non‐*C genotype (for sex and pack‐years of smoking, the adjusted odd ratio was 0.54; 95% confidence interval [95% CI], 0.29–1.02). In a survival analysis of 138 patients who received 5‐flurorouracil, patients who carried the GSTP1*C containing genotype had a significantly longer survival than patients who carried the non‐*C genotype (multivariate hazard ratio, 0.45; 95% CI, 0.22–0.94).

CONCLUSIONS.

The GSTP1*C variant conferred a possible protective effect against pancreatic cancer in older individuals and a significant survival advantage in patients who received 5‐florouracil. The current findings must be confirmed before further inferences can be made. Cancer 2007 © 2007 American Cancer Society.     

The influence of Hispanic ethnicity on nonsmall cell lung cancer histology and patient survival: An analysis of the Survival, Epidemiology, and End Results database

BACKGROUND:

Most studies exploring ethnic/racial disparities in nonsmall cell lung cancer (NSCLC) compare black patients with whites. Currently, the effect of Hispanic ethnicity on the overall survival of NSCLC is poorly understood. Therefore, the authors carried out a large‐scale, population‐based analysis using the Surveillance, Epidemiology, and End Results (SEER) data base to determine the impact of Hispanic ethnicity the survival of patients with NSCLC.

METHODS:

The authors identified 172,398 adult patients with pathologically confirmed NSCLC from the SEER data base who were diagnosed between 1988 and 2007. A multivariate Cox proportional hazards regression analysis was used to determine the impact of race/ethnicity on overall survival. Pair‐wise comparisons were used to determine whether Hispanic ethnicity influenced NSCLC histology or stage at diagnosis.

RESULTS:

Compared with non‐Hispanic white patients, Hispanic white patients had a statistically significant better overall survival (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.83‐0.87), and black patients had worse survival (HR, 1.091; 95% CI, 1.072‐1.109). Within the bronchioalveolar carcinoma (BAC) subtype, Hispanic‐white patients tend to be over represented (8.1% Hispanic whites vs 5.5% non‐Hispanic whites vs 3.7% blacks; P < .001).

CONCLUSIONS:

The current study demonstrated that Hispanic‐white patients with NSCLC had a decreased risk for overall mortality compared with non‐Hispanic whites and blacks. Moreover, Hispanic patients were over represented within the BAC histologic subtype. Thus, the overall survival advantage of Hispanic NSCLC patients may be because of their predilection toward developing certain histologic subtypes of NSCLC. Further studies are warranted to determine the etiologies of such predilections and may reveal certain genetic, environmental, and/or epigenetic factors associated with Hispanic ethnicity. Cancer 2012. © 2012 American Cancer Society.     

Response of borderline resectable pancreatic cancer to neoadjuvant therapy is not reflected by radiographic indicators

BACKGROUND:

Experience with preoperative therapy for other cancers has led to an assumption that borderline resectable pancreatic cancers can be converted to resectable cancers with preoperative therapy. In this study, the authors sought to determine the rate at which neoadjuvant therapy is associated with a reduction in the size or stage of borderline resectable tumors.

METHODS:

Patients who had borderline resectable pancreatic cancer and received neoadjuvant therapy before potentially undergoing surgery at the authors' institution between 2005 and 2010 were identified. The patients' pretreatment and post‐treatment pancreatic protocol computed tomography images were rereviewed to determine changes in tumor size or stage using modified Response Evaluation Criteria in Solid Tumors (RECIST) (version 1.1) and standardized anatomic criteria.

RESULTS:

The authors identified 129 patients who met inclusion criteria. Of the 122 patients who had their disease restaged after receiving preoperative therapy, 84 patients (69%) had stable disease, 15 patients (12%) had a partial response to therapy, and 23 patients (19%) had progressive disease. Although only 1 patient (0.8%) had their disease downstaged to resectable status after receiving neoadjuvant therapy, 85 patients (66%) underwent pancreatectomy. The median overall survival duration for all 129 patients was 22 months (95% confidence interval, 14‐30 months). The median overall survival duration for the patients who underwent pancreatectomy was 33 months (95% confidence interval, 25‐41 months) and was not associated with RECIST response (P = .78).

CONCLUSIONS:

Radiographic downstaging was rare after neoadjuvant therapy, and RECIST response was not an effective treatment endpoint for patients with borderline resectable pancreatic cancer. The authors concluded that these patients should undergo pancreatectomy after initial therapy in the absence of metastases. Cancer 2012. © 2012 American Cancer Society.     

Suicide in patients with pancreatic cancer

BACKGROUND:

Depression is highly prevalent in patients with pancreatic cancer and can result in fatal outcomes from suicides. The authors report suicide rates among patients with pancreatic cancer in the United States and identify factors associated with greater suicide rates.

METHODS:

The current study reviewed data in the SEER database for patients diagnosed with pancreatic adenocarcinoma from 1995‐2005. Logistic regression models were used to perform multivariate modeling for factors associated with suicide, while Kaplan‐Meier analysis was used to assess factors affecting survival.

RESULTS:

Among 36,221 patients followed for 22,145 person‐years, the suicide rate was 135.4 per 100,000 person‐years. The corresponding rate in the US population aged 65‐74 years was 12.5 per 100,000 person‐years, with a Standardized Mortality Ratio (SMR) of 10.8 (95% CI, 9.2‐12.7). Greater suicide rates were noted in males (Odds Ratio (OR) 13.5 [95% CI, 3.2‐56.9, P < .001]) and, among males, in patients undergoing an operative intervention (OR 2.5 [95% CI, 1.0‐6.5, P = .05]). Married men had a lesser risk of committing suicide (OR 0.3 [95% CI, 0.1‐0.6, P = .002]). Median survival among patients undergoing operative intervention was 2 months for those who committed suicide compared with 10 months for those who did not commit suicide.

CONCLUSIONS:

Male patients with pancreatic adenocarcinoma have a risk of suicide nearly 11 times that of the general population. Patients who undergo an operative intervention are more likely to commit suicide, generally in the early postoperative period. Cancer 2011. © 2010 American Cancer Society.     

Racial disparity in renal cell carcinoma patient survival according to demographic and clinical characteristics

BACKGROUND:

Patients with renal cell carcinoma (RCC) who are black tend to have poorer prognosis than similar patients who are white. This study examined whether the racial disparity in RCC patient survival varies by demographic and clinical characteristics.

METHODS:

Nearly 40,000 patients (4359 black and 34,991 white) diagnosed with invasive RCC from 1992 to 2007 were identified from 12 registries in the National Cancer Institute Surveillance, Epidemiology, and End Results program, covering approximately 14% of the US population. Relative survival rates through 2008 were computed using the actuarial method.

RESULTS:

Proportionally more blacks than whites were diagnosed with RCC under age 50 and with localized cancer. Overall, the 5‐year relative survival rates were 72.6% (95% confidence interval 72.0%‐73.2%) for white and 68.0% (66.2%‐69.8%) for black patients. Survival was higher among women than men and among younger than older patients. Survival decreased with advancing tumor stage and, within each stage, decreased with increasing tumor size. Patients with clear cell RCC, a more common form among whites, had poorer prognosis than patients with papillary or chromophobe subtypes, which are more common among blacks. Survival for patients who received no surgical treatment (10.5% of white patients and 14.5% of black patients) was substantially lower than for patients treated with nephrectomy, with similar survival among whites and blacks. In all other demographic and clinical subgroups of patients, whites consistently had a survival advantage over blacks.

CONCLUSIONS:

Patients with RCC who are white consistently have a survival advantage over those RCC patients who are black, regardless of age, sex, tumor stage or size, histological subtype, or surgical treatment. Cancer 2013. © 2012 American Cancer Society.     

Long-term outcomes of neoadjuvant chemotherapy before chemoradiation for locally advanced pancreatic cancer

BACKGROUND:

Neoadjuvant chemotherapy before chemoradiation therapy (CRT) may improve outcomes for patients with locally advanced pancreatic cancer, but optimal management remains controversial, and prior reports have limited follow‐up.

METHODS:

Seventy consecutive patients with unresectable (n = 46) or borderline resectable (n = 24) locally advanced pancreatic cancer were treated with CRT from 2005 to 2009. Patients typically received 50.4 grays in 28 fractions (91%) with concurrent 5‐fluorouracil (84%) or capecitabine (14%). Forty patients received CRT alone, and 30 patients received neoadjuvant chemotherapy before CRT for a median of 4 months, typically gemcitabine (93%). All patients without progression after neoadjuvant chemotherapy were offered CRT.

RESULTS:

Median follow‐up was 14.2 months (range, 3‐57 months). Fifty‐three percent of patients in the CRT group versus 83% in the neoadjuvant chemotherapy before CRT group had unresectable tumors at diagnosis; after completion of CRT, 20% of patients in both groups underwent resection. Compared with CRT alone, the neoadjuvant chemotherapy before CRT group demonstrated improved median overall survival (OS; 18.7 vs 12.4 months; P = .02) and progression‐free survival (11.4 vs 6.7 months; P = .02). On multivariate analysis, receipt of neoadjuvant chemotherapy (adjusted hazard ratio [HR], 0.49; 95% CI, 0.28‐0.87; P = .02) and surgical resection (adjusted HR, 0.38; 95% CI, 0.17‐0.85; P = .02) were associated with increased OS.

CONCLUSIONS:

Gemcitabine‐based neoadjuvant chemotherapy confers a significant OS advantage by allowing the selection of patients who will derive greatest benefit from CRT. Median survival with this approach was similar to that seen with surgical resection. Cancer 2012;118: 3026–35. © 2011 American Cancer Society.     

Systematic review and meta-analysis of prognostic role of splenic vessels infiltration in resectable pancreatic cancer

Background

Identification of factors associated with dismal survival after surgery in resectable pancreatic ductal adenocarcinoma is important to select patients for neoadjuvant treatment. The present meta-analysis aimed to compare the results of distal pancreatectomy for resectable adenocarcinoma of the pancreatic body-tail with and without splenic vessels infiltration.

Racial disparities in recurrence among patients with early‐stage endometrial cancer

BACKGROUND.

Population‐based studies suggest that, because of inequalities in treatment, black women with localized endometrial cancer have shorter survival compared with white women. The objective of the current investigation was to determine whether there is a racial disparity in outcome between black patients and white patients with early‐stage endometrial cancer treated similarly in a clinical trial setting.

METHODS.

A retrospective review of 110 black patients and 1049 white patients with stage I and II endometrial cancer (graded according to the International Federation of Gynecology and Obstetrics grading system) was performed using data from a randomized, placebo‐controlled trial performed by the Gynecologic Oncology Group that evaluated postoperative estrogen replacement therapy (ERT) and the risk of cancer recurrence. Demographic, pathologic, treatment, and outcome‐related data were collected and analyzed using regression and survival analysis.

RESULTS.

Estimates of recurrence‐free survival suggested that black patients may be more likely to have disease recurrence, particularly those receiving ERT. Within a median follow‐up of 3 years, 5 of 56 black patients with endometrial cancer in the ERT group were identified with recurrent disease compared with only 8 of 521 white patients. Adjusted for age, body mass index, and tumor grade, the relative risk of recurrence among blacks in the ERT group was 11.2 (95% confidence interval, 2.86‐43.59; P = .0005).

CONCLUSIONS.

The findings of the current study suggested that recurrence‐free survival may be shorter among black women with stage I endometrial cancer, even in a clinical trials setting in which patients receive similar treatment and follow‐up. This increased risk of recurrence appeared to be most evident in black women with endometrial cancer who maintained ERT after primary treatment. Cancer 2008. Published 2008 by the American Cancer Society.     

Results and patterns of failure in patients treated with adjuvant combined chemoradiation therapy for resected pancreatic adenocarcinoma

BACKGROUND:

Although adjuvant chemoradiation is used commonly in the United States for the treatment of resected pancreatic cancer, there is no consensus on the benefit of this therapy, because the results from randomized trials are conflicting. The authors of this report reviewed their experience in a consecutive, unselected series of patients who received adjuvant 5‐fluorouracil (5‐FU) and radiation therapy (RT) for resected pancreatic adenocarcinoma.

METHODS:

Eighty‐six patients with resected pancreatic adenocarcinoma who received adjuvant therapy from 1998 to 2005 were identified, and their medical records were reviewed. Ninety‐three percent of patients were treated with external beam RT to ≥50.4 grays, and 91% of patients received concurrent 5‐FU by continuous infusion. Forty‐five percent of patients went on to receive adjuvant gemcitabine.

RESULTS:

The median follow‐up was 31 months (range, 21‐62 months) among the 20 patients who remained alive. Less than half of patients had positive (33%) or close (<1 mm; 15%) resection margins, 81% of tumors were classified as T3, and 66% of patients had involved lymph nodes. The median overall survival (OS) for all patients was 22 months. Negative lymph node status (P = .016) was a significant prognostic factor for improved OS, whereas treatment with gemcitabine trended toward improved OS (P = .080). The median disease‐free survival (DFS) for all patients was 10 months: Treatment with gemcitabine (P = .044) and the receipt of any chemotherapy (P = .047) were significant predictors of DFS. Seventy‐five patients (87%) had disease recurrence, and the majority recurred with peritoneal metastases (55%) or liver metastases (53%). Patients who had negative lymph nodes trended toward a lower rate of distant failure (P = .060).

CONCLUSIONS:

The median survival of the current cohort was greater than that of the chemoradiation arms of European Organization for Research and Treatment of Cancer trials and European Study Group for Pancreatic Cancer 1 trials and was comparable to the survival observed on the Gastrointestinal Tumor Study Group chemoradiation arm. Lymph node status and treatment with adjuvant chemotherapy were significant predictors of OS and DFS, respectively. Future survival improvements should be directed at reducing peritoneal and liver metastases. Further randomized trials will be required to define the role of adjuvant therapy for pancreatic adenocarcinoma. Cancer 2009. © 2009 American Cancer Society.     

Do radiation use disparities influence survival in patients with advanced breast cancer?

BACKGROUND:

The authors previously identified racial/ethnic disparities in the use of radiation therapy (RT) in patients with advanced breast cancer (BC). They hypothesized that disparities in the use of RT were associated with survival differences favoring white patients.

METHODS:

The authors used the Surveillance, Epidemiology, and End Results database to identify white, black, Hispanic, and Asian patients with BC associated with ≥10 metastatic lymph nodes diagnosed between 1988 and 2005. Multivariate analyses of overall survival (OS) and disease‐specific survival (DSS) assessed age, sex, race, tumor size, histology, estrogen receptor status, progesterone receptor status, RT, and type of surgery. The authors further stratified for use of RT and type of surgery. Risk of mortality was reported as hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS:

Of 15,895 patients with advanced BC, 12,653 met entry criteria. On multivariate analysis, RT was associated with a decreased risk of all‐cause (HR, 0.78; 95% CI 0.74‐0.83; P < .001) and disease‐specific (HR, 0.81; 95% CI, 0.76‐0.86; P < .001) mortality; black race was associated with an increased risk of all‐cause (HR, 1.54; 95% CI, 1.42‐1.68; P < .001) and disease‐specific (HR, 1.53; 95% CI, 1.39‐1.68; P < .001) mortality. After stratifying by type of surgery and use of RT, blacks demonstrated poorer survival than their white counterparts, regardless of surgery type or receipt of RT.

CONCLUSIONS:

Only black patients had poorer OS and DSS relative to whites. When stratified by type of surgery and use of RT, blacks continued to demonstrate poorer survival. This survival disparity is unlikely to be because of lack of RT. Cancer 2012;. © 2011 American Cancer Society.