As the US population ages and life expectancies increase, the incidence of pancreatic and hepatic (liver) cancers are also on the rise. For the past seven years, Florida Hospital Cancer Institute (FHCI) surgical oncologist Sebastian de la Fuente, MD, has been studying the impact of these demographic changes on the treatment of patients.
Pancreatic cancer is a disease that predominantly affects the elderly with an average age of diagnosis at 70 and an average age of death at 72. Treatment with surgical resection followed by adjuvant chemotherapy offers the greatest chance of survival. Dr. de la Fuente and his colleagues at Florida Hospital and the University of Central Florida recently conducted a study to investigate if age alone, regardless of co-morbidities and pathologic stage of the cancer, affects the rate at which pancreatic cancer patients are offered adjuvant chemotherapy following resection surgery. The results were published in the Journal of Geriatric Oncology.
For this study, they queried the National Cancer Database (NCDB) to analyze basic demographics and treatment characteristics and found that there was a statistical difference in age for patients who received adjuvant therapy following pancreatic resection and those who did not. The rate of adjuvant therapy in older patients was 35 percent — much lower than for all age groups which was 58 percent. This was regardless of postoperative complications and functional status.
Previous research has demonstrated that undergoing pancreatic resection alone without subsequent chemotherapy is a predictor of poor prognosis in older patients. Dr. de la Fuente and his team also found that 62 percent of those patients who received chemotherapy were given a single-agent regimen despite growing evidence that multi-agent chemotherapeutic regimens may provide better outcomes. The research team concluded that older patients should be offered tailored treatment plans that would allow them to complete the intended extent of treatment for their cancer.
“We know that the only chance for someone to get cured of a pancreatic cancer is if they are able to undergo chemotherapy and surgery, and in some cases radiation, explains Dr. de la Fuente. “The sequence and timing of such therapies varies and depends on several factors, but if a patient cannot get one of the treatment arms for whatever reason, then that cancer will likely be fatal.”
It has been estimated that 30 percent of young patients will not be able to receive chemotherapy after surgery because of surgical complications, but when age is taken into consideration, up to 80 percent of elderly patients will not be able to receive chemotherapy after surgery. Dr. de la Fuente believes one tailored strategy could be to treat all elderly pancreatic cancer patients with chemotherapy upfront prior to performing the surgery.
“We need to research the effectiveness of this approach along with others to see if we can develop customized treatment plans that take into consideration the specific needs and challenges of older patients to improve their care,” he says.
A previous study by Dr. de la Fuente published in HPB explored the safety of pancreatic resections in elderly patients by using the National Surgical Quality Improvement (NSQIP) database to analyze 30-day postoperative mortality and complication rates. That research concluded that age was a significant determinant of postoperative morbidity and mortality, and as a result, age and functional status should be taken into consideration when counseling pancreatic cancer patients about surgery.
Like pancreatic cancer, the US is also seeing an increase in hepatic cancers among patients over 65. In a third study that was published in the Journal of Surgical Oncology, Dr. de la Fuente examined hepatic resection surgical outcome measures of patients under 70 compared to patients over 70, also using the NSQIP. They found that the older patient group experienced significantly higher complication rates and mortality.
“What we continually find is that elderly patients with cancer are not usually treated in a multidisciplinary way and as a result, aren’t getting the same benefits of treatments used in younger patients,” explains Dr. de la Fuente. “In general, there is a lack of organized geriatric programs to treat these patients as well as a lack of understanding of how cancer affects older people.”
Dr. de la Fuentes believes there is a need to research new treatment options for the growing population of elderly patients, including care teams that encompass medical oncologists, surgical oncologists, radiation oncologists and geriatricians.
“At Florida Hospital, we are also currently exploring if less invasive techniques could benefit elderly patients with gastric cancers,” he explains. “My hope is to eventually develop a comprehensive geriatric surgery program for cancer patients.”
Recognized as “Who is Who in Emerging Leaders” in 2006, Dr. de la Fuente is a surgical oncologist, board certified in general surgery and fellowship trained in advanced surgical oncology. He has written over 45 peer-reviewed scientific journal articles, 17 book chapters and was awarded The Conquer Cancer Foundation of the American Society of Clinical Oncology (ASCO) Merit Award for his work on esophageal cancer. Dr. de la Fuente also serves as the Director of Research at the Florida Hospital Surgical Residency Program and Director of the Hepato-Pancreato-Biliary (HPB) fellowship.
Dr. de la Fuente received his medical degree from University of Salvador in Buenos Aires, Argentina, and then completed a research fellowship in gastrointestinal surgery and a general surgery residency at Duke University Medical Center in Durham, North Carolina. In 2012, he completed a surgical oncology fellowship at H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida.
To learn more about care for pancreatic or hepatic cancer, visit the Florida Hospital Cancer Institute website.