Update Tue 17 Nov 2020
Dr Charles Pilgrim

Defining pancreatic cancer resectability 

Agreeing upon a standardised definition of what constitutes surgical resectability is a critical area of need in the treatment of pancreatic cancer. A pilot of a project aiming to develop a synoptic report defining resectability status in pancreatic cancer commenced at two health sites, The Austin and The Alfred, in October 2020. This pilot will run for one year. The project was born out of discussion on areas of deficiencies in the statewide data presented at the Pancreatic Cancer 2017 Summit.

Clinicians from across Victoria gathered at the Summit to identify unwarranted variations in clinical practice and outcomes that could be addressed through statewide action. One of the prioritised variations was the recognition that administration of systemic therapy for patients with pancreatic ductal adenocarcinoma (PDAC) is critical to their longterm outlook.

In a series of post-Summit working party meetings, the importance of patients actually receiving effective systemic therapy was discussed. Delivering chemotherapy prior to surgery for patients with borderline resectable PDAC was acknowledged as an emerging and promising new approach. Central to considering this ‘neoadjuvant approach’ is the delineation of what constitutes borderline resectable disease versus what is clearly resectable or alternatively, what is clearly locally advanced and unresectable. The working party agreed on the importance of classifying pancreatic cancer using this terminology as it informs optimal treatment pathways and is more useful in clinical decision making than the AJCC (American Joint Committee on Cancer) pathological staging manual definition, only available following surgical resection. 

A statewide audit to investigate the use of systemic therapy was conducted. The audit confirmed inconsistencies in the classification of borderline resectable (BR) disease. The Summit working party suggested that agreeing on and adopting a common statewide definition of resectability in PDAC would would be critical to minimise variation in care and help ensure appropriate and consistent management of patients across Victoria. It would also assist with identifying patients for clinical trials and reporting treatment outcomes. 

Subsequently, SMICS and NEMICS worked together to propose a project in response to the identified need to agree on a statewide definition of BR pancreatic cancer. A project steering committee and working group representing pancreatic surgery centres across the state was established. The working group proposed the use of the ‘International consensus on definition and criteria of borderline resectable pancreatic ductal carcinoma 2017’1 and these guidelines were unanimously accepted. However, the need to embed this into clinical practice remained, and clinical consultation determined that a standardised CT reporting template for radiologists was required. This would allow accurate reporting according to the agreed guidelines by radiologists for surgeons at MDMs, and therefore appropriate treatment decisions for patients. 

Working group members were involved in the co-design of a template for clinical reporting. Development of the template was complex and required a true reflection of the process radiologists undertake to determine the disease status. The current pilot will allow for further refinement, should it be required, to ensure sufficient accuracy of the template. 

In undertaking the tool development, the radiologists showed a preference towards an electronic solution. The application REDCap was chosen as a suitable platform. As the resectability status is already collected and stored by the Upper Gastrointestinal Cancer Registry (UGICR) and is also collected via REDCap it became obvious that the storage of patient project data with the UGICR was appropriate. However, there was considerable oversight required regarding patient information security before the pilot could proceed. 

Another element of the process was the integration of the template into health service sites and a number of complexities needed to be overcome for this to be implemented. 

Should the pilot prove successful, there will be the option of offering a tested and verified template to Victorian health services. Further consideration of the location for the storage of patient data may however be required.
It is hoped that the agreement to use the 2017 international resectability guidelines and implementation of the new CT template will help Victorians with pancreatic cancer by:

  • assisting in complete, pertinent and accurate reporting of disease staging and resectability status in patients with non-metastatic PDAC 
  • assisting multidisciplinary teams in the decision-making process for the management of patients with non-metastatic PDAC 
  • minimising futile operative procedures from being performed on patients with locally advanced disease
  • leading to timely and appropriate referral to palliative care.


​​​​​​​1. https://pubmed.ncbi.nlm.nih.gov/29191513/

 

Pancreatic Cancer Summit Priorities Update

Monday 29/10/2018 

  • Victorian Tumour Summits has produced the Pancreatic Cancer 2017 Summit Prioritised Variations video. This video is a resource for clinicians, by clinicians. Featuring Drs Charles Pilgrim and Belinda Lee. 

 

Pancreatic Cancer Summit in pictures

 

What was the Pancreatic Cancer Summit?

Diagnosis and treatment of pancreatic cancer has a significant physical and emotional impact on patients and their loved ones.  The Victorian Tumour Summits are clinician led forums seeking to identify unwarranted variations in tumour based clinical practice and cancer outcomes that could be addressed through state-wide action. Seventy stakeholders from across Victoria gathered on November 24 to discuss variations in care and identify opportunities for improvement.

Watch the presentation by Professor Robert Thomas:

 

Watch the presentation by Ms Kathryn Whitfield:

 

Watch the data presentation by Dr Charles Pilgrim:

Watch a summary of the day by Dr Charles Pilgrim:

 

What is Data Telling Us?

  • One-year relative survival increased from 27% to 34% between 2011-15.
  • Post-operative mortality is low by international standards: 2.1% (30 days); 2.7% (90 days); 19.7% (1-year).
  • A decrease in the number of Victorian hospitals conducting low volumes of pancreatic resections (1-3 per year) from 10 to 4 between the 2014/15 and 2016/17 financial years.
  • Only 5% of patients who had curative surgery for non-metastatic pancreatic ductal adenocarcinoma had neoadjuvant therapy.
  • 23% of patients who had curative surgery for non-metastatic pancreatic ductal adenocarcinoma did not have adjuvant therapy.
  • The state-wide average for documented multidisciplinary meeting discussion was 70% in 2013-15.
  • 75% of deaths for pancreatic cancer occurred during a hospital admission.

Post-Summit Update

Of these variations, several were prioritised for further investigation and action:

  1. Adjuvant therapy – 23% of patients who had curative surgery for non-metastatic pancreatic ductal adenocarcinoma did not have adjuvant therapy.
  2. Multidisciplinary meetings – 70% was the state average for multidisciplinary meeting discussion in the years 2013-2015.
  3. Palliative care – 75% of pancreatic cancer deaths occur in hospital.

The clinical working party reconvened in March 2018 to revisit outcomes of the summit discussion and review additional evidence of prioritised variations.  

Further work has occurred to analyse cases who did not receive adjuvant therapy. It appears patients who underwent surgery in the NEMICS & BSWRICS regions were less likely to receive adjuvant therapy. Compared to patients who did receive therapy, these patients were:

  • Older
  • Spent a greater number of hours in ICU during their surgery episode
  • Had a longer length of stay during their surgery episode
  • Had a higher 30- and 90-day mortality rate following surgery

Of these patients, 26% were less than 70 years of age, had no known comorbidities and were alive 90 days following surgery.

In relation to multidisciplinary meetings, the working party highlighted the need for up-to-date data to determine the cause of the discussion rate for pancreatic cancer patients.  The group recognised it is likely that stage IV patients are not discussed due to limited multidisciplinary meeting resources.  

Data on hospital deaths was considered to indicate possible issues with the current usage of state-wide palliative care services.  Based on palliative care clinical feedback from studies on other cancer types, timeliness of contact with palliative care services could have a positive outcome on reducing the percentage of patients with pancreatic cancer dying in hospital. A focus for action has yet to be determined.

As of 2018 most clinical teams caring for pancreatic cancer patients in Victoria are aware of the variations in care prioritised at the summit, as well as the upcoming optimal cancer care pathways implementation program.  If you have had an opportunity to discuss how these variations relate to the care you provide and how you would create a measurable investigation, contact Mirela.Matthews@austin.org.au on (03) 9496 3455.

What is Pancare?

The Pancare Foundation was established to be the long-standing voice of those affected by pancreatic, liver, biliary, oesophageal and stomach cancers. Pancare work to save and improve lives through public awareness, support, education and research.

Pancare has produced a series of guides for patients and carers as they undergo their cancer journey:

  • Pancreatic Cancer Patient Handbook - provides a general introduction to pancreatic cancer, information on tests and investigations that help confirm a diagnosis and provides an overview of possible treatment options and the wider impact of the diagnosis.
  • Pancreatic Cancer Dietary Handbook - highlights important information about managing your diet if you have or have had pancreatic cancer.

Download patient and carer handbooks here https://www.pancare.org.au/support/patient-care/

For hard copies contact Pancare on 1300 881 698 or email info@pancare.org.au

 
 

Pancreatic Cancer Summit working party

 

Dr Rob Blum
Prof Christopher Christophi
Mr Dan Croagh
Mr David Deutscher
Mr Adrian Fox
A/Prof Peter Gibbs
Mr George Kalogeropoulos
Dr Richard Khor
A/Prof Brian Le
Dr Belinda Lee
Mr Mehrdad Nikfarjam
Mr Charles Pilgrim
Dr Babak Tamjid
A/Prof Niall Tebbutt
A/Prof Ben Thomson
A/Prof Valery Usatoff
Prof John Zalcberg
 


 

Project team

 

Ms Mirela Matthews
Ms Amy Sutherland
Ms Megan Dendle
Mr Luc te Marvelde
Ms Ella Stuart
 
 
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