Effect of Surgical Margins on Overall Survival in Resectable Pancreatic Cancer Open Access

Abstract

Background Surgical resection remains the best treatment option for pancreatic ductal adenocarcinoma. However, controversy remains about the role of negative margin in resection. Using the National Cancer Data Base (NCDB), our aims were to investigate: 1) effect of surgical margins on overall survival (OS) in resected pancreatic cancer patients; 2) factors associated with margin status.

Methods Resected pancreatic adenocarcinoma cases from 2004-2013 were identified from the NCDB. Margin status was coded as negative (R0), microscopically positive (R1), and macroscopically positive (R2) from pathology reports. Univariate and multivariable logistic regression was used to assess the association between covariates and negative margin. Propensity scores (PS) were developed for each surgical margin status and used to produce matched samples for survival analysis.  Cox proportional hazard modeling and Kaplan Meier plots examined the association between surgical margin status and OS.

Results Fifteen thousand one hundred nineteen patients underwent resection of pancreatic ductal adenocarcinoma. Of these, 11,596 patients (76.7%) were R0, 1,992 patients (13.2%) were R1, and 1,531 patients (10.1%) were R2. Median survival after PS matching for R0, R1 and R2 was 19.1, 13.3 and 13.8 months, respectively (P < 0.0001). No significant difference was found between R1 and R2 (P = 0.0693); however, R0 patients demonstrated better OS than R1 patients (P < 0.0001) (Hazard Ratio (HR) R1 vs. R0 = 1.54, 95% confidence interval (CI): 1.38 - 1.71; HR R2 vs. R0 = 1.41, 95% CI: 1.27 - 1.57). Factors associated with margin status included: facility type, insurance status, tumor stage, tumor size, and lymph nodes.

Conclusions For pancreatic adenocarcinoma resection, a negative surgical margin was associated with better OS. While the NCDB has limitations common to all retrospective databases, its national sample and survival status data contribute to the surgical debate related to margin status in this setting.

Table of Contents

BACKGROUND.................................................................................................................. 1

METHODS.......................................................................................................................... 2

Hypothesis........................................................................................................................ 2

National Cancer Data Base............................................................................................. 2

Study Population............................................................................................................. 2

Surgical Margin Status.................................................................................................... 3

Statistical Analysis........................................................................................................... 3

RESULTS............................................................................................................................. 5

Patient Demographics and Clinical Characteristics........................................................ 5

Survival Analyses............................................................................................................. 5

Covariates Associated with Negative Margin Status...................................................... 6

DISCUSSION....................................................................................................................... 7

Potential limitations......................................................................................................... 8

FUTURE DIRECTIONS...................................................................................................... 9

REFERENCES................................................................................................................... 10

TABLES............................................................................................................................. 13

FIGURES AND FIGURE LEGENDS................................................................................ 19

APPENDICES.................................................................................................................... 22

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Epidemiology - MPH & MSPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Keyword	surgical resection margin status overall survival pancreatic cancer
Committee Chair / Thesis Advisor	Fedirko, Veronika, Emory University
Committee Members	Kooby, David, Emory University Gillespie, Theresa, Emory University Liu, Yuan, Emory University
Partnering Agencies	National or regional non-profit organization (e.g., American Cancer Society)

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