ORIGINAL ARTICLE – PANCREATIC TUMORS
Health Disparities Impact Expected Treatment of Pancreatic
Ductal Adenocarcinoma Nationally
Waseem Lutﬁ, BS, Mazen S. Zenati, MD, MPH, PhD, Amer H. Zureikat, MD, Herbert J. Zeh, MD, and
Melissa E. Hogg, MD, MS
Scaife Hall, Pittsburgh
Background and Purpose. National adherence to treat-
ment guidelines for pancreatic ductal adenocarcinoma
(PDAC) is a concern. This study aims to evaluate national
expected treatment (ET) adherence for all PDAC stages.
We hypothesized that both patient and hospital demo-
graphics are associated with national ET disparities for
Methods. Clinical stage I through IV PDAC patients were
evaluated using the National Cancer Data Base from 2004
to 2013. ET was deﬁned as surgery for stage I/II,
chemotherapy or radiation for stage III, and chemotherapy
for stage IV. Unexpected treatment (UT) was deﬁned as no
surgery for stage I/II, surgery for stage III, and radiation or
surgery for stage IV. No treatment is denoted by NT.
Results. 171,351 patients were identiﬁed, of whom 56,589
(33.0%) were stage I/II, 23,459 (13.7%) were stage III, and
91,303 (53.3%) were stage IV. Of patients, 48.4% received
ET, 14.7% received UT, and 36.9% received NT. ET rates
were 41.1% for stage I/II, 65.4% for stage III, and 48.5%
for stage IV patients. On multivariable analysis, older age,
non-White race, lower socioeconomic status, being unin-
sured or Medicaid, increased comorbidities, nonacademic
centers, and low-volume hospitals were independent neg-
ative predictors of receiving ET (P \ 0.01). On subgroup
analysis, high-volume academic centers had similar
negative predictors of ET despite higher ET adherence
overall (P \ 0.01).
Conclusions. Patient and hospital factors impact ET of
PDAC on a national level. These treatment disparities for
PDAC are concerning, even at high-volume academic
centers. Future studies need to identify the causes of
treatment disparities for PDAC with intervention measures
aimed to relieve treatment disparities.
National adherence to treatment guidelines for
resectable pancreatic ductal adenocarcinoma (PDAC) is a
concern. For early-stage patients in particular, there has
historically been underutilization of surgery to treat
Despite the fact that guideline-recom-
mended multimodality therapy has been on the rise for
early-stage patients, it is still underutilized on a national
Guideline adherence ensures that patients are
receiving the best treatment options for a disease which has
historically poor survival of \ 5%.
A decade ago, a landmark study demonstrated that only
30% of stage I PDAC patients receive surgical resection.
Given that surgical resection offers the only chance of cure,
this study revealed an eye-opening failure to operate on a
national scale. As centralization of cancer care has occur-
red over the last two decades, studies have analyzed
whether centralization of treatment to high-volume centers
has impacted adherence to treatment guidelines.
are multiple studies evaluating treatment disparities for
but there is yet to be a national study
evaluating treatment adherence for all stages.
We recently analyzed our institutional data, ﬁnding
sociodemographic disparities in treatment for all stages of
That study demonstrated that treatment dispari-
ties can still exist at a high-volume center. In this current
study, the goal was to evaluate expected treatment (ET)
This study was presented as a short oral presentation at the 13th
annual Academic Surgical Congress on 1 February 2018.
Ó Society of Surgical Oncology 2018
First Received: 11 February 2018;
Published Online: 24 April 2018
M. E. Hogg, MD, MS
Ann Surg Oncol (2018) 25:1860–1867