Metastases at Diagnosis
At the VA, 52% of patients have metastases when first diagnosed with pancreatic cancer, according to the study by Mehdi and colleagues. Five-to-10 year survival for metastatic pancreatic cancer at the VA rose from 0.96% in 2000 to 6.00% in 2012 and appears to have continued an upward trend. Between 2000 and 2014, one- to five-year survival rose from 9.29% to 22.99%.1
While some of the difference in survival rates could be attributed to the inclusion of pancreatic neuro-endocrine tumors, which have a better prognosis, in the VA data, “the study did show improvement in the rate of treatment and survival over time,” Mehdi told U.S. Medicine. Less than 0.5% of veterans in the study received hormonal therapy, the standard treatment for pancreatic neuro-endocrine tumors.
Between 2000 and 2014, the researchers found 12,951 incident cases of pancreatic cancer in the National VA Cancer Cube Registry. Of those, 6,775 had metastatic disease. Most cases were diagnosed in veterans between the ages of 60 and 70 years (38.02%) or older than age 70 (39.39%). Just 2.84% of all pancreatic cancer and 2.76% of metastatic pancreatic cancers were diagnosed in veterans younger than age 50, substantially less than the 5% to 10% seen in the general population.
Treatment rates for patients with metastatic pancreatic cancer rose from 27.84% in 2002 to 41.95% in 2014. The greater increase in survival than in treatment “correlate with the increased use of novel chemotherapy agents in recent years as they gained approval” from both the U.S. Food and Drug Administration and the National Comprehensive Cancer Network, the authors noted.
Given the exponential increase in survival, Mehdi recommended that “all patients should be referred to medical oncology for initial discussion. There are many circumstances in which patients are diagnosed by other providers and since these patients are very sick with very poor performance status, decisions are made for hospice care only.”
Some treatments might not be suitable for certain patients, but a growing number of treatment options can help veterans feel better and live longer.
“Treatment of metastatic pancreatic cancer extends life by several months and improves quality of life. Some patients after discussion with their provider might opt against it. Most of them are too sick with very poor performance status and hence not eligible for systemic chemotherapy,” but other options should be explored, Mehdi noted.
Many physicians do not know about new treatments or improving outcomes, “there is a current ‘therapeutic nihilism’ where there is a tendency for all stages of pancreatic cancer patients to be undertreated,” he added.
Patients with good performance status should be referred for clinical trials. Twenty-eight clinical trials are currently recruiting patients with metastatic pancreatic cancer.
For those unable to participate in a clinical trial, “systemic chemotherapy is offered to improve quality of life as well as improve survival,” Mehdi said. “FOLFIRINOX or modified FOLFIRINOX or a combination of gemcitabine and albumin-bound paclitaxel are considered standard of care in selected patients who are fit to undergo aggressive chemotherapy. Patients with poor performance status are offered single agent gemcitabine.”
FOLFIRINOX is a combination of folinic acid (also known as calcium folinate or leucovorin), fluorouracil (commonly called 5FU), irinotecan and oxaliplatin.
Azar I, Virk G, Esfandiarifard S, Wazir A, Mehdi S. Treatment and survival rates of stage IV pancreatic cancer at VA hospitals: a nation-wide study. J Gastrointest Oncol. 2019 Aug;10(4):703-711.
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