Cancer of the pancreas remains one of the deadliest cancer types. Most patients (80%) are diagnosed with metastatic or locally advanced disease, making them ineligible for surgical resection, which is the only treatment offering a significant chance for long-term survival. For these patients, palliative chemotherapy remains the primary treatment option.
Best Practices
Despite advances in chemotherapy regimens, outcomes for pancreatic cancer patients have barely improved over the last decade. Aiming to address this issue and reduce variations in clinical practice, an enhanced implementation of best practices was defined and mobilized by the Dutch Pancreatic Cancer Group across all 17 Dutch pancreatic cancer care clusters. Best practices are procedures that have been proven to have the highest chance of leading to the most optimal outcome.
This concerted effort included training medical providers on the latest insights in perioperative and palliative chemotherapy, pancreatic enzyme replacement therapy, referrals to dietitians, and techniques such as the preference for metal over plastic stents for biliary drainage.
Impact
The researchers then compared both survival and quality of life for the patients before and after the enhanced implementation of best practices, involving a total of 5,887 patients with all stages of pancreatic cancer in a nationwide randomized clinical trial. Despite successful implementation and adherence to the guidelines, the baseline survival rates remained disappointingly low.
"Although nationwide some treatments improved, this did not translate into survival gains for patients," said Professor Marc Besselink of Amsterdam UMC Cancer Center Amsterdam. The results were published in JAMA Surgery.
No differences were seen in the quality of life (QOL) of patients between both groups, even though QOL is known to be positively affected by the best practices implemented. Prof. Besselink noted that feedback was only registered in a subset of patients (10%), possibly obscuring this result.
Tumor Directed Therapy
"What is particularly striking is that 60% of patients do not receive tumor-targeted treatment for pancreatic cancer. They do not receive chemotherapy, radiation, or surgery," said physician-researcher Dr. Simone Augustinus of the Dutch Pancreatic Cancer Group, who recently completed her doctorate with this research.
"We need to investigate this further,” says Professor Casper van Eijck, a surgeon at Erasmus MC. “It could be that doctors advise against chemotherapy for some patients who might actually benefit from it, or the patients may deliberately choose not to receive chemotherapy for various reasons.”
Professor Hanneke Wilmink, an internist-oncologist at Cancer Center Amsterdam, adds: "Follow-up research must now focus on identifying which patients could benefit most from palliative chemotherapy.” The researchers highlighted the need to explore the potential of liquid biopsies and tumor biomarkers in guiding treatment decisions.
Real-world Data
Worldwide, this is the first randomized study involving all patients with pancreatic cancer in one country. The authors noted a contrast between real-world, population-based data and the outcomes of highly selected patients in randomized trials, emphasizing the need for a better understanding of treatment effectiveness in the general patient population.
These insights into the real-world challenges of treating pancreatic cancer call for continued innovation and exploration of new treatment, with a focus on identifying strategies that can make a meaningful difference in the lives of patients with pancreatic cancer.
For more information contact Prof. Marc Besselink.
Involved Medical Centers
The Dutch Pancreatic Cancer Group includes Amsterdam UMC, Erasmus MC, UMC Groningen, Regional Academic Cancer Center Utrecht (RAKU), UMC Utrecht and St.Antonius Hospital, LUMC, Tjongerschans Heerenveen, Jeroen Bosch Hospital, Radboudumc, Maasstad Hospital, Catharina Hospital, Maastricht UMC+, OLVG, Integral Cancer Center Netherlands, Isala Zwolle, Medisch Spectrum Twente, and Reinier de Graaf Hospital.
Funding
The PACAP-1 trial was made possible by KWF Kankerbestrijding, Deltaplan Alvleesklierkanker, Mylan B.V., Allergan B.V. and Stichting Nationaal Fonds tegen Kanker.
This text is an English adaptation of a Dutch article published on AmsterdamUMC.org.