Treatment

Evidence summary and stakeholder input

The following is a summary of the findings from the evidence gathering activities and stakeholder consultations undertaken to inform development of the Roadmap. For more information on the development of the Roadmap see the About page.

Last updated: 31 March 2022

Evidence summary

There is strong evidence to suggest that high-volume hospitals have better clinical outcomes for complex cancer surgery such as pancreatic resections.¹ While there is disagreement about the exact number of cases needed to be treated in a given period to be considered a high-volume centre, it is clear that the very small number of pancreatic resections done within many Australian centres makes it harder for them to achieve optimal outcomes. Centres that do not have sufficient caseloads should establish processes to routinely refer surgical cases to high-volume centres.² 

Recommended treatment options differ depending on the stage at diagnosis, and the performance status of the patient.  Those with localised disease are offered surgery followed by adjuvant chemotherapy.  Those with borderline resectable or locally advanced disease undergo neoadjuvant chemotherapy first and then may proceed to surgery, while those with unresectable or metastatic disease undergo chemotherapy alone. Patients with poor performance status are provided with the best supportive care.³

Localised, borderline, locally advanced disease 

Forty-five percent of patients in the Upper Gastrointestinal Cancer Registry (UGICR) were diagnosed with non-metastatic disease. Of those patients, 29% received neoadjuvant chemotherapy, 78% underwent surgery, and 46% received adjuvant chemotherapy.  

Metastatic disease  

The remaining 55% of patients were diagnosed with metastatic disease. Of those patients 3% received neoadjuvant chemotherapy, 2% underwent surgery, 1% received adjuvant chemotherapy, 47% received chemotherapy, and 11% received radiation therapy.  

Specialist review 

While the majority (92%) of patients in the UGICR were reviewed by a medical or radiation oncologist, only two thirds of patients aged 85 years of age or over were seen by a medical or radiation oncologist. 

Of the patients reviewed by an oncologist, 65% went on to have treatment, and of those treated, less than two thirds received treatment within the pancreatic cancer OCP recommended timeframe of four weeks of initial diagnosis.

Therapy

Treatment rates were lower in those with unresectable disease (locally advanced or metastatic disease) compared with those with resectable or borderline resectable disease (53% vs. 93%).  

For those with unresectable disease, treatment was received less commonly. Where treatment was given, chemotherapy was the most common form of therapy, however, it was rarely provided to those aged 85 years or over. Around 90% of patients with locally advanced disease did not receive chemotherapy due to comorbidities, performance status, or patient choice. 

Less than one-third of all patients underwent surgical resection and of those with resectable tumours, the majority (90%) of patients underwent pancreaticoduodenal resection (Whipple procedure). 

Adjuvant therapy was administered in 55% of people with resectable disease and 31% of those with borderline resectable disease. Adjuvant chemotherapy was used in 70% of patients but only 0.5% of patients aged 85 years or over. One third of patients with resectable and borderline resectable disease did not receive chemotherapy due to poor performance status. Neoadjuvant chemotherapy was rarely used in those with resectable cancers (22%) but was more common (79%) in those with borderline resectable disease.  

Radiotherapy use in the context of surgical resection was uncommon (<15%).  

Two-thirds (66%) of patients in the UGICR received treatment within 30 days of presentation at a multidisciplinary team meetings (MDM), but almost 14% of patients waited 60 days or more. 

Overall, 50% of a sample of Aboriginal and Torres Strait Island people diagnosed between 2001 and 2020 received some form of cancer treatment. Of these 15% received surgery, 43% received chemotherapy and 10% radiotherapy. Being seen by a multidisciplinary team (MDT), being of a younger age, and having diabetes were associated with receiving treatment. Significantly more patients received treatment after the introduction of the pancreatic cancer OCP in 2015 than before (57% compared with 43%, respectively) and receipt of treatment was associated with a 12-month survival advantage.

Guidelines 

While extensive guidance exists for the treatment of pancreatic cancer, opportunities exist to ensure that all pancreatic treatment is provided in accordance with recommended evidence-based Australian guidelines and protocols. Where there are gaps in available local guidelines, existing international guidelines should be adapted for the Australian context.

There are opportunities to improve surgical outcomes through the implementation of protocolised pre- and post-operative pancreatic cancer care and further opportunities to improve patient outcomes by ensuring that all pancreatic cancer chemotherapy and chemoradiation therapy reflects the best evidence-based care. Increasing uptake of chemotherapy in both the neoadjuvant and adjuvant setting could be achieved by better education of clinicians on the benefits of treatment in the surgical setting. 

Stakeholder input

The following is a summary of the findings from the stakeholder consultations undertaken to inform development of the Roadmap. For more information on the development of the Roadmap see the About page. 

Stakeholders identified a range of treatment issues in pancreatic cancer including the lack of effective treatments and the burden of existing treatments.

A large variability in care delivered to and received by Aboriginal and Torres Strait Islander people with pancreatic cancer was raised. This care variability was associated with rurality and having to travel for investigations, treatment and follow-up.

The proximity of available treatment, the availability of specialists in regional sites, and travel burden, in particular for Aboriginal and Torres Strait Islander patients and their families were identified as barriers to treatment by a range of stakeholders.

Suggested opportunities for improvements in treatment included utilisation of stereotactic radiation therapy, chemotherapy delivered closer to home, centralisation of surgical services in accredited high-volume centres of excellence, networks of excellence, and broadening the concept of centralisation beyond centres of high-volume surgical expertise to multidisciplinary centres combining diagnostic, treatment, supportive care and research expertise. Increasing availability of specialists in regional areas, chemotherapy delivered in the home, and the use of telehealth were opportunities identified to improve access to treatment.

Information for patients and families about available treatments, potential side effects and likelihood of success, together with clear communication from health professionals on all treatment options, was also highlighted. In addition, recognition and respect for the individual and family identity, and consideration of personal circumstances in scheduling appointments, treatment and follow up was raised by Aboriginal and Torres Strait Islander stakeholders.

Guidelines and referral pathways for health professionals were identified as important enablers for improving the quality and consistency of pancreatic cancer care.

Guidelines on surgical volume and development of optimal care guidance for surgical interventions, as well as the importance of access and equity of access to high volume centres was highlighted.

Stakeholders noted that awareness of the OCPs was limited at the service level and supported improving awareness and uptake of the pancreatic cancer OCP and the Optimal Cancer Pathway for Aboriginal and Torres Strait Islander people with cancer.

Key priority areas, strategies and activities 

Each key priority area has supporting strategies and associated activities for implementation in the short, medium or long term that have been identified to achieve the priority.