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BACKGROUND: Communication between caregivers and clinical team members is critical for transitional care, but its quality and potential impact on outcomes are not well understood. This study reports on caregiver-reported quality of communication with clinical team members in the postpancreatectomy period and examines associations of these reports with patient and caregiver outcomes. METHODS: Caregivers of patients with pancreatic and periampullary malignancies who had undergone pancreatectomy were surveyed. Instrument measures assessed care experiences using the Caregiver Perceptions About Communication with Clinical Team Members (CAPACITY) instrument. The instrument has two main subscales: communication, assessing the extent to which providers helped caregivers comprehend details of clinical visits, and capacity, defined as the extent to which providers assessed whether caregivers were able to care for patients. RESULTS: Of 265 caregivers who were approached, 240 (90.6%) enrolled in the study. The mean communication and capacity subscale scores were 2.7 ± 0.6 and 1.5 ± 0.6, respectively (range, 0-4 [higher = better]). Communication subscale scores were lower among caregivers of patients who experienced (vs. those who did not experience) a 30-day readmission (2.6 ± 0.5 vs. 2.8 ± 0.6, respectively; p = .047). Capacity subscale scores were inversely associated with restriction in patient daily activities (a 0.04 decrement in the capacity score for every 1 point in daily activity restriction; p = .008). CONCLUSIONS: After pancreatectomy, patients with pancreatic and periampullary cancer whose caregivers reported worse communication with care providers were more likely to experience readmission. Caregivers of patients with greater daily activity restrictions were less likely to report being asked about the caregiver's skill and capacity by clinicians. PLAIN LANGUAGE SUMMARY: This prospective study used a validated survey instrument and reports on the quality of communication between health care providers and caregivers as reported by caregivers of patients with pancreatic and periampullary cancer after pancreatectomy. In an analysis of 240 caregivers enrolled in the study, lower communication scores (the extent to which providers helped caregivers understand clinical details) were associated with higher odds of 30-day patient readmission to the hospital. In addition, lower capacity scores (the extent to which providers assessed caregivers' ability to care for patients) were associated with greater impairment in caregivers. The strikingly low communication quality and capacity assessment scores suggest substantial room for improvement, with the potential to improve both caregiver and patient outcomes.
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Cuidadores , Comunicação , Pancreatectomia , Neoplasias Pancreáticas , Humanos , Neoplasias Pancreáticas/cirurgia , Cuidadores/psicologia , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Adulto , Ampola Hepatopancreática , Inquéritos e Questionários , Readmissão do Paciente/estatística & dados numéricos , Neoplasias do Ducto Colédoco/cirurgiaRESUMO
OBJECTIVE: To assess whether long-term survivors of pancreatic surgery show increased risk to develop impaired bone mineral density, osteoporosis, and vitamin D deficiency. BACKGROUND: Pancreatic resection poses a risk for malabsorption of fat-soluble vitamins and other micronutrients essential for bone mineralization. Here, we evaluated the long-term effects of pancreatic resection on bone mineral density (BMD) and its clinical sequelae. METHODS: This was a two-pronged analysis of post-pancreatectomy patients with a follow-up period greater than 3 years comprising (1) a large, propensity score-matched, cohort study based on a multinational federated research network (FRN) and (2) a retrospective single institution review of clinical and radiographic patient data. In the FRN analysis, an initial cohort of 8,423 post-pancreatectomy patients were identified and propensity score-matched with normal controls. The primary endpoint was the 10-year risk of developing osteoporotic pathological fractures and secondary endpoints included diagnosis of osteoporosis, vitamin-D deficiency, and related therapies. The single institution retrospective analysis identified 224 patients who underwent pancreatic resection between 2005 and 2019. BMD was quantified in CT images acquired before and after surgery. BMD trends and related factors were assessed in a time-series mixed effect linear regression model. RESULTS: A total of 8,080 propensity score-matched pairs were included in the FRN analysis. The analysis revealed a 2.4-fold increase in pathological fractures (P<0.0001) and 1.4-1.5 fold increase in osteoporosis/osteomalacia (P<0.0001) and vitamin-D deficiency (P<0.0001) in post-pancreatectomy patients. Vitamin-D supplements were more common in the pancreatectomy group (OR 1.4, 95% CI 1.28-1.53, P<0.0001), as were specific osteoporosis/osteomalacia treatments such as calcitonin, denosumab, romosozumab, abaloparatide, and teriparatide (OR 2.24, 95%CI 1.69-2.95, P<0.0001). Retrospective analysis of CT imaging revealed that BMD declined more rapidly following pancreatic resection compared to normal historical controls (P=0.015). Older age, pancreatic cancer, and pancreaticoduodenectomy were associated with increased rates of BMD loss (P<0.05, each). CONCLUSIONS: After pancreatic resection, patients are at higher risk for BMD loss and subsequent fractures. As the cohort of pancreatic resection survivorship grows, attention will need to be paid to focused prevention efforts to reduce BMD loss, osteoporosis, and fractures in these vulnerable patients, with specific attention to the pancreatic cancer population.
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OBJECTIVE: The objective of this study was to determine baseline health-related quality of life (QoL) in patients with pancreatic adenocarcinoma, periampullary cancers, and benign pancreaticobiliary (PB) conditions at the time of the first visit to a PB surgery clinic, and to explore the relationship between QoL, demographics, clinical parameters, complications, and survival. SUMMARY BACKGROUND DATA: Few studies have examined baseline QoL measures, the impact of comorbidities, age, sex, and smoking on subsequent postoperative complications and survival in patients with pancreatic adenocarcinoma, related PB cancers, and with benign PB conditions. METHODS: Data were collected from scheduled patients at a PB surgery clinic between 2013 and 2018. The Brief Pain Inventory, Fact-Hepatobiliary Scale, and Facit-Fatigue questionnaires were administered. QoL parameters were compared between PB cancer patients and those with benign disease. RESULTS: A total of 462 individuals with PB cancers and benign diseases exhibited baseline physical well-being, functional well-being, fatigue, and overall QoL at or below the 75th percentile of wellness at the time of the first office visit. Younger age, smoking, and mental health comorbidities contributed significantly to decreased QoL. PA patients were 7 times more likely to die in the follow-up period than the benign disease group. Black patients had higher pain scores and were 3 times more likely to have a postsurgery complication. Sex differences were identified regarding fatigue, pain, and overall QoL. CONCLUSIONS: This large cohort of PB cancer and benign disease patients exhibited significantly impaired baseline QoL. GI problems, weight loss, smoking, cardiovascular, pulmonary disease, and history of anxiety and depression contributed significantly to reduced QoL. The study sheds a cautionary light on the burden of PB disease at the time of surgical evaluation and its relationship to diminished QoL.
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Adenocarcinoma , Neoplasias Gastrointestinais , Neoplasias Pancreáticas , Humanos , Masculino , Feminino , Qualidade de Vida/psicologia , Adenocarcinoma/cirurgia , Neoplasias Pancreáticas/cirurgia , Neoplasias Gastrointestinais/complicações , Dor/etiologia , Fadiga , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Pancreatic ductal adenocarcinoma (PDA) is a highly lethal cancer. Clinicians commonly refer to surgical therapy as resection with curative intent. However, PDA cure rates after resection remain unknown and the definition of cure remains vague. We investigated how patients (the majority undergoing resection), family members, and clinicians understand the concept of cure, to better inform discussions with patients regarding PDA prognosis. METHODS: In a prospective survey, cohorts were asked to indicate the best definition of cure from three choices: 5-year survival endpoint (typically used in the literature), a biological endpoint without biochemical or radiographic signs of disease (similar to the NCI definition), or a practical endpoint where life span approximates similarly aged patients without PDA. Fleiss' kappa statistic was calculated to measure inter-rater agreement. RESULTS: Patients, family members, and health care professionals (N = 200) agreed that renormalization of life expectancy was the preferred definition of cure in the context of pancreatic cancer. Inter-rater agreement was highest for the patient and family member groups (Fleiss' kappa 0.27 and 0.40, respectively, P < 0.001), while variability was observed between health care professionals (Fleiss' kappa 0.11, P < 0.001). CONCLUSIONS: In all groups surveyed, the probability for a normal life expectancy is the preferred long-term metric in patients with early-staged pancreatic cancer. Renormalization of life expectancy appears to be an important therapy goal for PDA patients and it is advisable to address this topic during clinical discussions.
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Adenocarcinoma/terapia , Carcinoma Ductal Pancreático/terapia , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Idoso , Algoritmos , Carcinoma Ductal Pancreático/mortalidade , Carcinoma Ductal Pancreático/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Inquéritos e Questionários , Análise de SobrevidaRESUMO
This historical vignette describes the professional career of Gerald J. Marks, the founder of the Society of American Gastrointestinal and Endoscopic Surgeons and the International Federation of Societies of Endoscopic Surgeons. Dr. Marks is also the founding Associate Editor of Surgical Endoscopy, which celebrated its 30th anniversary in 2017. Dr. Marks is a renowned colorectal surgeon, an accomplished watercolor artist, and a fascinating personality.
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Endoscopia Gastrointestinal/história , Endoscopia/história , Sociedades Médicas/história , Cirurgiões/história , História do Século XX , História do Século XXI , Humanos , Publicações Periódicas como Assunto , Estados UnidosRESUMO
BACKGROUND: Peripancreatic fluid collections after distal pancreatectomy and splenectomy are commonly identified on postoperative cross-sectional imaging. This study aimed to determine the incidence, natural history, and indications for intervention. METHODS: We conducted a retrospective review of patients with peripancreatic fluid collections after distal pancreatectomy with or without splenectomy between 2013 and 2018, approved by our institutional review board. The chi-square test was used for categorical variables, the Mann-Whitney U test for continuous variables, and Fisher's exact test was used for values in which the sample size was less than 5 to compare data. RESULTS: During the study period, 235 patients underwent distal pancreatectomy with or without splenectomy, and 182 patients with postoperative imaging were included. In the cohort of patients with postoperative imaging, 83 (46%) had peripancreatic fluid collections, of which 46 (55%) were symptomatic fluid collections (SFCs) and 37 (45%) were asymptomatic fluid collections (AFCs). Those with SFC had a higher incidence of postoperative morbidity (46% vs 8%; P = .0002), most commonly postoperative pancreatic fistula (90%). Of patients with SFC, 34 (74%) underwent treatment via percutaneous drainage (n = 26), endoscopic drainage (n = 7), or antibiotics alone (n = 1). AFCs (n = 37) were observed. Collections that were intervened upon resolved significantly faster than those observed, 3.5 months vs 13.2 months (P < .0001), respectively. CONCLUSION: Asymptomatic patients may be observed with or without serial imaging and the AFC will typically resolve spontaneously with time. Patients who develop symptoms should generally be intervened upon with drainage if deemed feasible, given that this reduces the time to resolution.
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Drenagem , Pancreatectomia , Fístula Pancreática , Complicações Pós-Operatórias , Esplenectomia , Humanos , Pancreatectomia/efeitos adversos , Pancreatectomia/métodos , Esplenectomia/métodos , Esplenectomia/efeitos adversos , Estudos Retrospectivos , Feminino , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Drenagem/métodos , Fístula Pancreática/epidemiologia , Fístula Pancreática/etiologia , Idoso , Adulto , IncidênciaRESUMO
BACKGROUND: Limited English proficiency (LEP) is a limited ability to read, write, speak, and understand English. About 145,000 individuals with LEP will be diagnosed with a new cancer annually, and English remains the dominant language spoken in the U.S. medical system. OBJECTIVES: The goal of this article is to discuss the issues faced by patients with LEP and cancer who are unable to communicate effectively with oncology providers. METHODS: This overview used published U.S. government statistics, information from consensus and policy organizations, and clinical studies published between 2017 and 2022. FINDINGS: Federal laws prohibit discrimination based on immigration status. People with LEP experience delayed cancer diagnoses and often receive inadequate treatment. Patients with LEP often have limited understanding of the medical system and do not receive language-concordant information about their cancer and treatment options.
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Proficiência Limitada em Inglês , Humanos , Consenso , Oncologia , Enfermagem Oncológica , PacientesRESUMO
BACKGROUND: Distress screening of cancer patients is mandated by the American College of Surgeons Commission on Cancer. Clinical implementation remains limited, particularly in surgical oncology settings in individuals with pancreaticobiliary cancers. STUDY DESIGN: This study evaluated differences in mean distress scores based on the National Comprehensive Cancer Network Distress Thermometer & Problem List for patients with pancreaticobiliary cancers, benign pancreatic conditions, and for their significant others (SOs). The distress screening was conducted at the first office visit and postoperatively in a subset of those who had surgery. Distress Thermometer (DT) scores were dichotomized at ≤5 vs >5 and at ≥7 and correlated with Problem List items. The US ZIP Code database was used to correlate income range, percent poverty, and unemployment in the patient's self-identified ZIP code. Regression models were fitted to identify independent predictors of distress. RESULTS: A total of 547 patients and 184 SOs were evaluated. Thirty percent of patients had DT scores >5, with pancreatic adenocarcinoma patients reporting the highest levels of distress. SOs of pancreatic adenocarcinoma patients reported even greater distress than the patients themselves. As the number of pre-existing medical problems increased; so did DT scores. Distress correlated with physical and emotional problems and worry about insurance coverage and transportation. Higher income level predicted higher DT scores, although poverty predicted lower DT scores. Depression was present in 12% of the patients. Distress improved in those undergoing surgery. CONCLUSIONS: Distress and depression in pancreaticobiliary cancer patients and SOs are prevalent. The findings of this study have multiple actionable implications and require diagnosis, treatment, and referral to supportive care resources.
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Adenocarcinoma , Neoplasias Gastrointestinais , Neoplasias , Neoplasias Pancreáticas , Humanos , Depressão/diagnóstico , Depressão/epidemiologia , Depressão/etiologia , Estresse Psicológico/etiologia , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/cirurgia , Inquéritos e Questionários , Neoplasias PancreáticasRESUMO
BACKGROUND: The purpose of this study was to examine the relationship between various respiratory conditions, including hypercapnic respiratory disease, and a multitude of resected pancreatic lesions. METHODS: This retrospective case-control study queried a prospectively maintained database of patients who underwent pancreaticoduodenectomy between January 2015 and October 2021. Patient data, including smoking history, medical history, and pathology reports, were recorded. Patients with no smoking history and no concomitant respiratory conditions were designated as the control group. RESULTS: A total of 723 patients with complete clinical and pathological data were identified. Male current smokers showed increased rates of PDAC (OR 2.33, 95% CI 1.07-5.08, p = 0.039). Male patients with COPD had a markedly increased association with IPMN (OR 3.02, CI 1.08-8.41, p = 0.039), while females with obstructive sleep apnea had a four-fold increase in risk of IPMN compared to women in the control group (OR 3.89, CI 1.46-10.37, p = 0.009). Surprisingly, female patients with asthma had a decreased incidence of pancreatic and periampullary adenocarcinoma (OR 0.36, 95% CI 0.18-0.71. p < 0.01). CONCLUSION: This large cohort study reveals possible links between respiratory pathologies and various pancreatic mass-forming lesions.
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PURPOSE: Patients with pancreatic and periampullary cancers may experience significant reduction in their quality of life and often rely on family and unpaid caregivers for assistance after surgery. However, as caregivers are not systematically identified, little is known about the nature, difficulty, and personal demands of assistance they provide. We aim to assess the frequency and difficulty of specific assistance caregivers provide and identify potential interventions that could alleviate the caregiving demands. METHODS: This was a prospective, multi-institutional study of caregivers accompanying patients with periampullary and pancreatic cancer at their 1-month postpancreatectomy office visit. An instrument that drew heavily on the National Study of Caregiving was administered to caregivers. RESULTS: Of 240 caregivers, more than half (58.3%) of caregivers were the patients' spouse, a quarter (25.8%) were daughters or sons, 12.9% other relatives, and 2.9% nonrelatives. Caregivers least frequently provided assistance with transportation (14.6% every day) and most frequently provided assistance with housework (65.0% every day, P = .003) and diet (56.5% every day, P = .004). Caregivers reported the least difficulty helping patients with exercise (1.5% somewhat difficult). Caregivers reported significantly more difficulty with assisting with housework (14.5% somewhat difficult, P < .001) and diet (14.9% somewhat difficult, P < .001). Caregivers identified the immediate postpancreatectomy and early discharge periods as the most stressful phases. They also reported having received very little information about available services that could have supported their efforts. CONCLUSION: Caregivers of patients with periampullary or pancreatic cancer provide considerable assistance in the postoperative period and many reported difficulty in assisting with housework and diet. Work is needed to better prepare and support caregivers to better enable them to adequately care for patients with pancreas and periampullary cancer.
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Neoplasias Pancreáticas , Qualidade de Vida , Humanos , Cuidadores , Pâncreas , Neoplasias Pancreáticas/cirurgia , Cuidados Pós-Operatórios , Estudos Prospectivos , Masculino , FemininoRESUMO
BACKGROUND: We hypothesized that pancreatic and periampullary adenocarcinoma recurrence after surgical resection may be affected by the shedding of malignant epithelial cells during surgical dissection and that this may have implications for disease recurrence and survival. STUDY DESIGN: In this ongoing, investigator-initiated prospective randomized controlled trial, patients with pancreatic and periampullary adenocarcinoma were randomized intraoperatively, postresection into 3 study arms: peritoneal lavage using 10 L normal saline or distilled water, or control group with no lavage. Peritoneal fluid was sampled for cytologic analysis (cytospin, cellblock, immunohistochemistry-Ber-EP4 antibody) at 4 stages: (1) abdominal entry pre-dissection, (2) resection bed after tumor extirpation, (3) ex vivo resected specimen, and (4) resection bed postlavage. RESULTS: Between April 2016 and May 2018, 193 patients who underwent randomization for the study also underwent the described cytologic sampling. Of these, 167 patients (86.5%) were ultimately found to have pancreatic or periampullary adenocarcinoma. Before dissection (1) on cytospin analysis, 4.9% were positive, which rose to 10.2% intraoperatively (2), 16.7% ex vivo (3), and decreased to 4.3% (4) after lavage. Lymph node metastasis, margin involvement, and perineural invasion did not correlate with locoregional recurrence (LR). Tumor cells in the ex vivo cytospin (3) correlated with LR (odds ratio 3.8 [95% CI 1.6 to 9.2], p = 0.005) and LR disease-free survival (p = 0.007). Cox regression analysis revealed ex vivo cytospin positivity to be strongly associated with poorer LR disease-free survival (hazard ratio 2.26 [95% CI 1.16 to 4.42], p = 0.017). CONCLUSIONS: Cytologic sampling from ex vivo specimen irrigation after surgical resection of pancreatic and periampullary adenocarcinoma may have implications for LR, survival, and treatment, suggesting a possible cancer cell shedding phenotype.
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Adenocarcinoma , Ampola Hepatopancreática , Neoplasias do Ducto Colédoco , Neoplasias Pancreáticas , Adenocarcinoma/patologia , Ampola Hepatopancreática/patologia , Humanos , Recidiva Local de Neoplasia/cirurgia , Neoplasias Pancreáticas/patologia , Pancreaticoduodenectomia , Prognóstico , Estudos ProspectivosRESUMO
BACKGROUND: Family and other unpaid caregivers play an active role in the recovery of individuals with pancreatic and periampullary cancer after pancreatectomy. However, little is known about caregivers' experiences and how to better support them. METHODS: Caregivers accompanying patients to 1-month postpancreatectomy visits at 3 hospitals completed an electronic survey between November 2018 and February 2020. We examine measures of absenteeism and work productivity loss among the subset of caregivers who reported working for pay and comparatively assess caregiver experiences by employment status. All analyses were performed as 2-sided tests. RESULTS: Of 265 caregivers approached for study participation, 240 (90.6%) enrolled. Caregivers were primarily female (70.8% female, 29.2% male) and spouses (58.3%) or adult children (25.8%) of patients, with a median age of 60 years. Of the 240 caregivers included in the study, 107 (44.6%) worked for pay. Nearly half (44.4%) of working caregivers reported being absent from work because of caregiving amounting to a 14% loss in work hours. While at work, 58.9% of working caregivers reported increased work difficulty as a result of caregiving. Taken together, an estimated 59.7% loss in work productivity was experienced because of caregiving in the month following pancreatectomy. After adjustment for sociodemographic factors, working (vs nonworking) caregivers reported increased financial (odds ratio [OR] = 2.32; P = .04) and emotional (OR = 1.93; P = .04) difficulties and daily activity restrictions (OR = 1.85; P = .048). CONCLUSIONS: Working caregivers of patients with pancreatic and periampullary cancer experience negative impacts on work and productivity, and caregiving-related financial and emotional difficulties may be amplified. This study highlights the need for workplace policies to support unpaid cancer caregiving.
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Sobrecarga do Cuidador , Cuidadores , Neoplasias , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Atividades Cotidianas , Filhos Adultos , Cuidadores/psicologia , Eficiência , Inquéritos e QuestionáriosRESUMO
Decreased physical functioning, either transient or enduring, is encountered by many individuals at various points in the cancer trajectory. Oncology nurses are well positioned to promote functional recovery, as they have intensive contact with cancer patients in multiple settings and throughout all phases of the disease continuum. This article reviews effective screening tools that nurses can use to identify the rehabilitation needs of individual patients and initiate appropriate interventions or referrals for additional rehabilitation services. It also outlines realistic rehabilitation protocols that can help oncology nurses to reduce and prevent impairments that may occur during cancer and its treatment. As will be discussed, patients' functional performance can also be directly improved by enhanced incorporation of rehabilitation principles into oncology nursing practice.
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Atividades Cotidianas , Avaliação das Necessidades , Neoplasias/reabilitação , Avaliação em Enfermagem/métodos , Qualidade de Vida , Humanos , Avaliação de Estado de Karnofsky , Neoplasias/enfermagem , Inquéritos e Questionários , SobreviventesRESUMO
BACKGROUND: Approximately 20% of patients diagnosed with pancreatic cancer will be eligible for hepato-pancreatico-biliary (HPB) surgery. Studies indicate that high-quality patient education is pivotal in reducing anxiety, improving clinical and performance outcomes, and increasing patient satisfaction. OBJECTIVES: This quality improvement project sought to determine the perceived level of preparedness for patients undergoing HPB surgery and to identify information and knowledge gaps in preoperative education. METHODS: Convenience sampling was used to collect postoperative information via questionnaire from 50 patients regarding areas of importance. FINDINGS: Preoperative information gaps for patient and family education were identified. Improving preparedness for HPB surgery has the potential to improve clinical outcomes, increase quality and patient satisfaction, decrease length of stay, and reduce time to adjuvant therapy.
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Procedimentos Cirúrgicos do Sistema Biliar , Neoplasias Pancreáticas , Melhoria de Qualidade , Humanos , Neoplasias Pancreáticas/cirurgia , Cuidados Pré-OperatóriosRESUMO
Purpose: Our institution's hepatopancreaticobiliary surgery service (HPBS) has demonstrated low rates of venous thromboembolism (VTE). We sought to determine whether the HPBS's regimented multimodal VTE prophylaxis pathway, which includes the use of mechanical prophylaxis, pharmacological prophylaxis, and ambulation, plays a role in achieving low VTE rates. Methods: We compared pancreatic surgeries in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) participant user file with our institution's data from 2011 to 2016 using univariate, multivariate, and matching statistics. Results: Among 36,435 NSQIP operations, 850 (2.3%) underwent surgery by the HPBS. The HPBS achieved lower VTE rates than the national cohort (2.0% vs. 3.5%, p = 0.018). Upon multivariate analysis, having an operation performed by the HPBS independently conferred lower odds of VTE incidence in the matched cohort (odds ratio = 0.530, p = 0.041). Conclusions: We identified an independent correlation between the HPBS and decreased VTE incidence, which we believe to be due to strict adherence to and team participation in a high risk VTE prophylaxis pathway, including inpatient pharmacological prophylaxis, thromboembolic deterrent stockings, sequential compression devices, and mandatory ambulation.
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BACKGROUND: Chronic obstructive respiratory disorders (ORDs) are linked to increased rates of cancer-related deaths. Little is known about the effects of hypercapnia (elevated CO2) on development of pancreatic ductal adenocarcinoma (PDAC) and drug resistance. STUDY DESIGN: Two PDAC cell lines were exposed to normocapnic (5% CO2) and hypercapnic (continuous/intermittent 10% CO2) conditions, physiologically similar to patients with active ORD. Cells were assessed for proliferation rate, colony formation, and chemo-/radiotherapeutic efficacy. In a retrospective clinical study design, patients with PDAC who had undergone pancreatic resection between 2002 and 2014 were reviewed. Active smokers were excluded to remove possible smoking-related protumorigenic influence. Clinical data, pathologic findings, and survival end points were recorded. Kaplan-Meier and Cox regression analyses were performed. RESULTS: Exposure to hypercapnia resulted in increased colony formation and proliferation rates in vitro in both cell lines (MIA-PaCa-2: 111% increase and Panc-1: 114% increase; p < 0.05). Hypercapnia exposure induced a 2.5-fold increase in oxaliplatin resistance (p < 0.05) in both cell lines and increased resistance to ionizing radiation in MIA-PaCa-2 cells (p < 0.05). Five hundred and seventy-eight patients were included (52% were male, median age was 68.7 years [interquartile range 60.6 to 76.8 years]). Cox regression analysis, assessing TNM staging, age, sex, and ORD status, identified ORD as an independent risk factor for both overall survival (hazard ratio 1.64; 95% CI, 1.2 to 2.3; p < 0.05) and disease-free survival (hazard ratio 1.68; 95% CI, 1.06 to 2.67). CONCLUSIONS: PDAC cells exposed to hypercapnic environments, which is common in patients with ORD, showed tumor proliferation, radioresistance, and chemoresistance. Patients with a history of ORD had a worse overall prognosis, suggesting that hypercapnic conditions play a role in the development and progression of PDAC and stressing the need for patient-tailored care.
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Carcinoma Ductal Pancreático/tratamento farmacológico , Carcinoma Ductal Pancreático/etiologia , Resistencia a Medicamentos Antineoplásicos , Hipercapnia/complicações , Neoplasias Pancreáticas/tratamento farmacológico , Neoplasias Pancreáticas/etiologia , Idoso , Carcinoma Ductal Pancreático/patologia , Linhagem Celular Tumoral , Proliferação de Células , Doença Crônica , Progressão da Doença , Feminino , Humanos , Hipercapnia/etiologia , Pneumopatias Obstrutivas/complicações , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/patologia , Estudos RetrospectivosRESUMO
BACKGROUND: This study was designed to determine whether a standardized recovery pathway could reduce post-pancreaticoduodenectomy hospital length of stay to 5 days without increasing complication or readmission rates. STUDY DESIGN: Pancreaticoduodenectomy patients (high-risk patients excluded) were enrolled in an IRB-approved, prospective, randomized controlled trial (NCT02517268) comparing a 5-day Whipple accelerated recovery pathway (WARP) with our traditional 7-day pathway (control). Whipple accelerated recovery pathway interventions included early discharge planning, shortened ICU stay, modified postoperative dietary and drain management algorithm, rigorous physical therapy with in-hospital gym visit, standardized rectal suppository administration, and close telehealth follow-up post discharge. The trial was powered to detect an increase in postoperative day 5 discharge from 10% to 30% (80% power, α = 0.05, 2-sided Fisher's exact test, target accrual: 142 patients). RESULTS: Seventy-six patients (37 WARP, 39 control) were randomized from June 2015 to September 2017. A planned interim analysis was conducted at 50% trial accrual resulting in mandatory early stoppage, as the predefined efficacy end point was met. Demographic variables between groups were similar. The WARP significantly increased the number of patients discharged to home by postoperative day 5 compared with controls (75.7% vs 12.8%; p < 0.001) without increasing readmission rates (8.1% vs 10.3%; p = 1.0). Overall complication rates did not differ between groups (29.7% vs 43.6%; p = 0.24), but the WARP significantly reduced the time from operation to adjuvant therapy initiation (51 days vs 66 days; p = 0.005) and hospital cost ($26,563 vs $31,845; p = 0.011). CONCLUSIONS: The WARP can safely reduce hospital length of stay, time to adjuvant therapy, and cost in selected pancreaticoduodenectomy patients without increasing readmission risk.
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Recuperação Pós-Cirúrgica Melhorada , Pancreaticoduodenectomia , Abdome/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Redução de Custos/estatística & dados numéricos , Feminino , Seguimentos , Custos Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pancreaticoduodenectomia/economia , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Philadelphia , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Resultado do TratamentoRESUMO
PURPOSE: Heritable genetic variations can affect the inflammatory tumor microenvironment, which can ultimately affect cancer susceptibility and clinical outcomes. Recent evidence indicates that IDO2, a positive modifier in inflammatory disease models, is frequently upregulated in pancreatic ductal adenocarcinoma (PDAC). A unique feature of IDO2 in humans is the high prevalence of two inactivating single-nucleotide polymorphisms (SNP), which affords the opportunity to carry out loss-of-function studies directly in humans. In this study, we sought to address whether genetic loss of IDO2 may influence PDAC development and responsiveness to treatment.Experimental Design: Transgenic Ido2 +/+ and Ido2 -/- mice in which oncogenic KRAS is activated in pancreatic epithelial cells were evaluated for PDAC. Two patient data sets (N = 200) were evaluated for the two IDO2-inactivating SNPs together with histologic, RNA expression, and clinical survival data. RESULTS: PDAC development was notably decreased in the Ido2 -/- mice (30% vs. 10%, P < 0.05), with a female predominance similar to the association observed for one of the human SNPs. In patients, the biallelic occurrence of either of the two IDO2-inactivating SNPs was significantly associated with markedly improved disease-free survival in response to adjuvant radiotherapy (P < 0.01), a treatment modality that has been highly debated due to its variable efficacy. CONCLUSIONS: The results of this study provide genetic support for IDO2 as a contributing factor in PDAC development and argue that IDO2 genotype analysis has the immediate potential to influence the PDAC care decision-making process through stratification of those patients who stand to benefit from adjuvant radiotherapy.
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Biomarcadores Tumorais , Indolamina-Pirrol 2,3,-Dioxigenase/genética , Neoplasias Pancreáticas/genética , Neoplasias Pancreáticas/patologia , Proteínas Proto-Oncogênicas p21(ras)/genética , Alelos , Animais , Linhagem Celular Tumoral , Transformação Celular Neoplásica/genética , Transformação Celular Neoplásica/metabolismo , Modelos Animais de Doenças , Progressão da Doença , Feminino , Genótipo , Humanos , Masculino , Camundongos , Camundongos Transgênicos , Mutação , Neoplasias Pancreáticas/radioterapia , Polimorfismo de Nucleotídeo Único , Resultado do Tratamento , Ensaios Antitumorais Modelo de XenoenxertoRESUMO
The prevalence of major depressive disorder (MDD) in pancreatic cancer (PC) has been reported up to 7 times higher than the general population. Despite repeated studies that show worse quality of life, survival outcomes, and treatment compliance in cancer patients with depression, baseline antidepressant use ranges from 15% to 27%. A meta-analysis of 6 prospective trials specific to PC estimates that 43% of patients with PC experience depression after diagnosis. This is especially alarming in patients with PC, who may experience a prodrome of symptoms including depression and loss of drive. In fact, this prodrome of symptoms may very well be due to an overexpression of indoleamine 2,3-dioxgenase, an enzyme in the kynurenine pathway that leads to serotonin depletion and the buildup of cytotoxic metabolites in the brain. In this literature review, we outline all previous studies pertinent to PC and depression, as well as the molecular underpinnings that may contribute to states of depression, and report on previous randomized control trials in cancer populations that investigate the use of antidepressants to treat depressive symptoms and improve quality of life both prophylactically and after the onset of major depressive disorder. In addition, we detail a case report outlining the precipitous decline in health in 1 patient with PC and depression.
Assuntos
Carcinoma Ductal Pancreático/psicologia , Depressão/psicologia , Transtorno Depressivo Maior/psicologia , Neoplasias Pancreáticas/psicologia , Idoso , Antidepressivos/uso terapêutico , Depressão/diagnóstico , Depressão/tratamento farmacológico , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/tratamento farmacológico , Humanos , Masculino , Qualidade de VidaRESUMO
Background: The perceived benefit of utilizing patients' own imaging studies as a preoperative educational tool has not been studied. Methods: Pancreaticobiliary surgeons reviewed key findings of imaging studies with patients to educate about their diagnosis and inform treatment recommendations. Patient surveys were administered pre- and postvisit by an independent researcher to assess the impact of this practice. Results: Only 55% of patients stated that it was important to see their imaging studies before the consultation. However, after the visit, 90% of patients understood their disease process better, and 86% of patients had a clearer understanding of their planned operation having seen their imaging studies. This represents significant improvement in patients' understanding of their medical condition (p < 0.05). Conclusion: Reviewing imaging findings with patients is an underappreciated aspect of the surgical consultation. It is a powerful educational tool that takes little time, improves patient understanding, and enhances patient experience.