Development of a Neoadjuvant Treatment Pathway to Standardize Pancreatic Cancer Care and Improve Outcomes Across a Large Diverse Health System

BackgroundManagement of localized pancreatic cancer is variable. We describe the development of a neoadjuvant therapy pathway (NATP) to standardize care across a large healthcare system. MethodsWe conducted an IRB-approved retrospective analysis of NATP patients between June 2019 and March 2022. The primary endpoint was NATP completion, and secondary endpoints included overall survival (OS) and quality measures. ResultsFifty-nine patients began NATP, median age 70, locally advanced 44.1%. Median time on NATP was 6.1 months. The initial chemotherapy was FOLFIRINOX (64.2%) and gemcitabine/nab-paclitaxel (GnP; (35.6%)) followed by radiation in 32 (54.2%) patients. Forty-four (74.6%) completed the NATP and 30 (50.8%) underwent surgical exploration with 86.7% undergoing successful resection (61.5% R0, 23.1% R1) while 14 remained unresectable. NATP completion was associated with increased likelihood of resection (p<0.001). At median follow-up of 13.4 months, median OS was 20.9 months (95% CI 13.3- 28.5) and 1- and 2-year OS was 82.5% and 49.7%. NATP completion resulted in improved OS with median OS not reached and 1- and 2-year OS of 89.7% and 59.4% (p=0.004). Median time to NATP start was 20 days after MDR and median time to surgery was 35 days. Age, ECOG, surgical stage, chemotherapy regimen and NATP completion were significant univariable predictors of OS with ECOG status remaining significant on multivariable analysis. ConclusionOur outcomes provide a baseline for future guidance in improving care across a large system. Efforts to complete NATP and improve patient ECOG may result in more patients undergoing surgery and improve survival.