Unresectable and Metastatic Pancreatic Adenocarcinoma in the Elderly: A 10-Year, Single-Center Experience

Introduction: Pancreatic adenocarcinoma is the fourth leading cause of cancer deaths in Canada and mainly affects individuals older than 60 years of age. It is associated with particularly high 1 and 5-year mortality rates of 75% and 94% respectively. Because of its retroperitoneal location, pancreatic cancer follows a relatively silent clinical course and is more often diagnosed at an advanced stage, thereby ruling out the possibility of surgical resection and cure. When faced with a diagnosis of unresectable pancreatic adenocarcinoma, patients may be offered palliative chemotherapy. Unfortunately, a paucity of data exists regarding the use, efficacy and safety profile of chemotherapeutic agents in the elderly population with pancreatic cancer; this specific population being often excluded from randomized trials. With already 1 in 6 Canadians aged older than 65 years old and an aging population, clinicians are bound to be faced with oncologic decisions regarding treatment of those under-represented elderly patients with pancreatic adenocarcinoma. It is therefore imperative to study this population in order to offer adapted and proven treatment protocols and ensure adequate and optimal care. Methods: This is a retrospective observational study of all patients aged older than 75 years old with a diagnosis of unresectable or metastatic pancreatic cancer at the CHUS between June 2005 and June 2015. Data was retrieved using the local patient database program Ariane. Results: During the study period, 186 patients were included according to the entry criteria. Median age at diagnosis was 82 years old with a slight female gender predominance (52% vs 48%). Location of the primary tumor was in the head of the pancreas in 46% of cases, and evenly distributed between the pancreatic body and tail. Diagnosis was made by the general practitioners or gastroenterologists in 73.4% of cases. High blood pressure, diabetes mellitus and coronary atherosclerosis were the most frequently encountered comorbidities. Other biochemistry parameters at diagnosis suggested a more fragile population; median albumin level of 32 g/L, median creatinine value of 155 μmol/L and minor anemia (median = 11.7 g/dL). Among the 96 patients who were offered chemotherapy, only 10 accepted this palliative treatment. ECOG status was unfortunately far from uniformly documented, although among the 10 patients treated, all had either ECOG 0 or 1 scores. Nine received Gemcitabine as first line whereas one patient was treated with Folfirinox. Seven completed the treatment with the standard regimen dosage for each cycle. Patients received a median of 5 cycles and end of treatment was dictated by severe asthenia complicating treatment. Only 2 patients, non-responders, received second-line agents (5FU/LV) that were subsequently stopped, again for non-response. Conclusion: Results of this unicentric observational retrospective study suggest an overall diminished clinical performance status in elderly patients (>75 years old) diagnosed with unresectable or metastatic pancreatic cancer when compared to their younger counterparts. Due to our small sample size, it remains difficult to draw conclusions on ideal patient selection criterion and palliative treatment for advanced pancreatic cancer in the elderly. The present study does, however, underline the dire need for further studies on the matter.

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