Retrospective Cohort Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Sep 26, 2020; 8(18): 4022-4033
Published online Sep 26, 2020. doi: 10.12998/wjcc.v8.i18.4022
First-line chemotherapy in very elderly patients with metastatic pancreatic cancer: Gemcitabine monotherapy vs combination chemotherapy
Sung Yong Han, Dong Uk Kim, Young Mi Seol, Suk Kim, Nam Kyung Lee, Seung Baek Hong, Hyung-Il Seo
Sung Yong Han, Dong Uk Kim, Department of Internal Medicine and Biomedical Research Institute, Division of Gastroenterology, Pusan National University Hospital, Busan 49241, South Korea
Young Mi Seol, Department of Internal Medicine and Biomedical Research Institute, Division of Hematology-Oncology, Pusan National University Hospital, Busan 49241, South Korea
Suk Kim, Nam Kyung Lee, Seung Baek Hong, Department of Radiology, Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
Hyung-Il Seo, Department of Surgery, Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
Author contributions: Seol YM designed the research; Han SY, Lee NK, and Hong SB performed research; Han SY and Seo HI contributed to data analysis; Han SY wrote the paper; Kim DU and Kim S contributed to the critical revision of the paper.
Supported by The National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT), No. 2018R1C1B5086234.
Institutional review board statement: The study protocol was approved by the Institutional Review Board of the Pusan National University (IRB No. H-2005-019-091).
Conflict-of-interest statement: The authors declare no conflict of interest for this article.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Young Mi Seol, MD, PhD, Assistant Professor, Department of Internal Medicine and Biomedical Research Institute, Division of Hematology-Oncology, Pusan National University Hospital, Gudeok ro 179, Seo-gu, Busan 49241, South Korea. seol2100@hanmail.net
Received: May 27, 2020
Peer-review started: May 27, 2020
First decision: June 13, 2020
Revised: June 18, 2020
Accepted: August 22, 2020
Article in press: August 22, 2020
Published online: September 26, 2020
Processing time: 117 Days and 3.3 Hours
Abstract
BACKGROUND

Combination chemotherapy (gemcitabine plus nab-paclitaxel and FOLFIRINOX) is widely used as the standard first-line treatment for pancreatic cancer. Considering the severe toxicities of combination chemotherapy, gemcitabine monotherapy (G mono) could be used as a first-line treatment in very elderly patients or those with a low Eastern Cooperative Oncology Group status. However, reports on the efficacy of G mono in patients older than 75 years are limited.

AIM

To evaluate the efficacy of G mono and combination chemotherapy by comparing their clinical outcomes in very elderly patients with pancreatic cancer.

METHODS

We retrospectively analyzed 104 older patients with pancreatic cancer who underwent chemotherapy with G mono (n = 45) or combination therapy (n = 59) as a first-line treatment between 2011 and 2019. All patients were histologically diagnosed with ductal adenocarcinoma. Primary outcomes were progression-free survival and overall survival. We also analyzed subgroups according to age [65-74 years (elderly) and ≥ 75 years (very elderly)]. Propensity score matching was performed to compare the outcomes between the two chemotherapy groups.

RESULTS

The baseline characteristics were significantly different between the two chemotherapy groups, especially regarding age, ratio of multiple metastases, tumor burden, and Eastern Cooperative Oncology Group performance status. After propensity score matching, the baseline characteristics were not significantly different between the chemotherapy groups in elderly and very elderly patients. In the elderly patients, the median progression-free survival (62 d vs 206 d, P = 0.000) and overall survival (102 d vs 302 d, P = 0.000) were longer in the combination chemotherapy group. However, in the very elderly patients, the median progression-free survival (147 d and 174 d, respectively, P = 0.796) and overall survival (227 d and 211 d, respectively, P = 0.739) were comparable between the G mono and combination chemotherapy groups. Adverse events occurred more frequently in the combination chemotherapy group than in the G mono group, especially thromboembolism (G mono vs nab-paclitaxel vs FOLFIRINOX; 8.9% vs 5.9% vs 28%, P = 0.041), neutropenia (40.0% vs 76.5% vs 84.0%, P = 0.000), and neuropathy (0% vs 61.8% vs 28.0%, P = 0.006).

CONCLUSION

In elderly patients, combination therapy is more effective than G mono. However, G mono is superior for the management of metastatic pancreatic cancer in very elderly patients.

Keywords: Combination chemotherapy; Gemcitabine; Pancreatic cancer; Elderly; Ductal carcinoma; Adverse drug event

Core Tip: Combination therapy (gemcitabine plus nab-paclitaxel and FOLFIRINOX) is known to be more effective than gemcitabine monotherapy in pancreatic cancer patients over 65 years of age. However, the effect in the very elderly (age 75 and over) is not well known. Our retrospective study aims to compare the efficacies of gemcitabine monotherapy vs combination therapy in very elderly pancreatic cancer patients. Our data showed that in elderly patients, combination therapy was more efficient compared to gemcitabine monotherapy. However, gemcitabine monotherapy may be a better option for managing metastatic pancreatic cancer in very elderly patients compared to combination therapy.