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  • br Whereas survival is improved with palliative systemic

    2022-05-17


    Whereas survival is improved with palliative systemic treatment, this benefit might be counterbalanced by quality of life concerns. FOLFIRINOX was studied in patients below the age of 76 with ECOG 0–1(median 61) and has significant side effects. However, a recent se-ries showed that 57% of the patients needed a dose reduction; but that this reduction did not impact the overall survival (11.7 (6.9–16.4 com-pared to 16.6 (0.37–32.8; p = .69) months without dose reduction in patients aged 70 and older, which is comparable to that obtained in younger patients [37]. However this comes at the cost of a greater im-pact on quality of life as a larger proportion experienced grade 3 neuro-toxicity, and most older patients are treated with gemcitabine or a gemcitabine doublet. Studies for older patients are also scarce in this area [24]. One retrospective study compared older and younger patients who received gemcitabine and patients under best supportive care [24]. The response rate, disease stabilization, improvement of tumor makers
    A
    Years
    Netherlands
    Moffitt
    B
    Years
    Netherlands
    Moffitt
    C
    Years
    Netherlands
    Moffitt
    and median survival time were similar in young and older patients, al-though bone marrow suppression and hematological toxicity of grade 3 or more was seen more frequently in older patients and older patients tended to need dose reduction of gemcitabine in the first ABT-888 [24]. The benefits of chemotherapy are clearly linked to baseline performance status, and there is no evidence of a benefit for patients with poor ECOG performance status. On the other hand, with proper supportive care such as e.g. provided with a geriatric oncology program, older pa-tients maintain quite well their functional status despite side effects of chemotherapy [41]. 
    Table 4
    Adjusted HR for patients treated at Moffitt (with Netherlands as reference category), strat-ified for stage, age and type of hospital in the Netherlands.
    Stage 3-years survival Adjusted HR (Moffitt) p-value
    Stratified according to age
    other
    other
    other
    Adjusted for sex, grade, year and age.
    A large number of studies compared ABT-888 younger and older patients who received surgery, however the results with respect to survival are diffi-cult to interpret due to selection bias. Nonetheless these studies show that pancreatoduodenectomy can be safely performed in selected older patients [13,47–50], although some series show that age is one of the determinants for postoperative mortality [10]. Recently there have been unquestioned advancements in patient selection, techniques, perioperative care and management of complications, which resulted in better outcomes for patients who underwent pancreatic resection [51,52]. In the present study, the proportion of patients who underwent surgery in each country was not significantly different between the two cohorts for early stage patients, although this might be due to a low number of patients in this group. For patients with T3 or node positive disease, there was a 10% difference in surgery rate with a higher propor-tion in the Netherlands. This higher proportion of surgery was especially marked for academic hospitals in the Netherlands. This can be explained by centralization of pancreatic cancer care in academic hospitals in the Netherlands. Chronological age is a poor predictor for functional status (physically, mentally and medical) [6] and selecting appropriate ther-apy for older patients remains challenging because of concerns with re-spect to the patients comorbidities, their functional and nutritional status, cognitive function, social support and their expected survival [6,53,54]. An accurate estimation of the expected perioperative morbid-ity and mortality is based on thorough preoperative (geriatric) patient assessment and is central to surgical decision-making with respect to the risks and benefits for an individual patient [33]. As a Whipple resec-tion is a major surgery, treating physicians may hesitate to refer elderly patients for surgery, concerned with the risk of poor post-operative quality of life [42]. There is however a lack of evidence with respect to quality of life studies for older patients with pancreatic cancer, although it is known from the literature that older patients have a higher compli-cation rate and a significant proportion will be admitted to a chronic care facility after surgery. Studies showed that one out of five patients (21%) over the age of 80 years in the first study and 59% in the second were discharged to an outside health care facility and that 51% of the pa-tients developed complications [6,43]. Comorbidities and functional