Clinical Pathway for Borderline Resectable Pancreatic Cancer Improves Survival

A clinical pathway developed by South Florida researchers may help to improve clinical outcomes for patients with borderline resectable pancreatic cancer. 

Although rare, pancreatic cancer is still the fourth leading cause of cancer death in the United States, with only about 6% of patients surviving longer than 5 years. Although surgery is considered to be the best treatment approach for this type of cancer, about 80-85% of patients present with an advanced stage of the disease, precluding them from operative procedures. Additionally, even in patients who are candidates for surgery, surgical treatment has been associated with high rates of positive margins, which are associated with worse overall survival.

Some pancreatic cancers may be identified as borderline resectable, meaning that resection is not precluded but the risk of positive margins is higher. Still, negative surgical margins have been achieved in some of these patients after neoadjuvant treatment, resulting in improved survival after surgery. For this reason, physicians require a standardized, evidence-based approach for identifying borderline resectable pancreatic cancer, so that these patients can receive neoadjuvant therapy and surgical intervention to improve their chances of survival.

At the H Lee Moffitt Cancer Center and Research Institute (Tampa, FL), a National Cancer Institute-designated National Comprehensive Cancer Network (NCCN) cancer center, researchers developed and implemented a clinical pathway to guide treatment decisions for patients with borderline resectable pancreatic adenocarcinoma. To develop the pathway, the team, led by Mokenge P Malafa, MD, first determined how physicians identified and diagnosed borderline resectable pancreatic cancer at the cancer center. Next, they reviewed the type, duration, and completion of neoadjuvant treatment used and evaluated how patients were re-staged after surgical intervention and whether there were any preoperative complications. Finally, researchers looked at the final pathology of patients’ disease. These data were used to develop a multidisciplinary clinical pathway, which starts with diagnostic and staging evaluation, and then proceeds with neoadjuvant therapy, re-staging, and surgical management, which are determined according to the consensus of the multidisciplinary tumor board conference.

A retrospective study was then carried out in order to determine whether the clinical pathway led to improved outcomes for patients. Researchers analyzed the records of 121 patients with borderline-resectable pancreatic cancer, as defined by the NCCN Pancreatic Cancer Clinical Guidelines, who were treated between January 1, 2006, and December 31, 2013. Of the 121 patients treated during that time period, 101 were treated on the team’s clinical pathway. A total of 94 patients completed neoadjuvant treatment, and 55 patients underwent surgical resection. Of those patients, 53 (98.4%) had negative margins.

A pathologic response to treatment was observed in all patients, with 45 (81.8%) achieving a partial response and 10 (14.5%) having a complete pathologic response. Median periods of disease-free survival, disease-specific survival, and overall survival in patients who underwent surgery were 23 months, 43 months, and 33 months, respectively, compared with median disease-specific survival and overall survival of 14 months for patients who did not undergo surgery. Median periods of disease-specific survival and overall survival for all 101 patients who were treated using the clinical pathway were 24 months and 18 months, respectively. Results were published in Annals of Surgical Oncology

The authors concluded, “Our results support our hypothesis that implementing a borderline resectable pancreatic  adenocarcinoma clinical pathway that uses a multidisciplinary approach to staging, patient selection, and management produces high rates of negative-margin resection and good oncologic patient outcomes.”—Sean McGuire

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Rashid OM, Pimiento JM, Gamenthaler AW, et al. Outcomes of a clinical pathway for borderline resectable pancreatic cancer [Published online ahead of print December 10, 2015]. Ann Surg Oncol. 2015. doi: 10.1245/s10434-015-5006-1.