The treatment of locally advanced pancreatic cancer: DISCUSSION (Part 3)

In: Pancreatic cancer

24 Jul 2012

Practitioner feedback

Methods: Practitioner feedback was obtained through a mailed survey of 152 clinicians in Ontario (29 medical oncologists, 20 radiation oncologists and 103 surgeons). The survey consisted of items evaluating the methods, results and discussion used to inform the draft recommendations and whether the draft recommendations above should be approved as a practice guideline. Written comments were invited. Follow-up reminders were sent at two weeks (post card) and four weeks (complete package mailed again). The Gastrointestinal Cancer DSG reviewed the results of the survey.

Results: Ninety-four surveys (64%) were returned. Forty-eight respondents (51%) indicated that the practice-guideline-in-progress report was relevant to their clinical practice and they completed the survey. Seventeen respondents (35%) provided written comments. The main points contained in the written comments were that the survival benefit of 5-FU plus radiotherapy is modest and may not be worth the complications, that gemcitabine may be a reasonable alternative to 5-FU plus radiotherapy, and that gemcitabine data be presented in the results. Another stated that symptomatic care only should be included as one of the alternative recommendations. Modifications and/or actions: The only randomized data on gemcitabine are in the study by Burris et al, and this trial is discussed in detail in another guideline developed by the

Gastrointestinal Cancer DSG, which addresses the use of gemcitabine for the treatment of advanced pancreatic cancer. Some patients with locally advanced disease were included in the trial by Burris et al, but the results for these patients were not reported separately. For this reason, data on gemcitabine were not included in the Results section of the present guideline report, but this information is included in the Discussion instead. See Table 3 for practice guideline.

TABLE 3 Practice guideline

Target population These recommendations apply to adult patients with locally advanced (unresectable but nonmetastic) adenocarcinoma of the exocrine pancreas
Recommendations The intent of treatment of locally advanced pancreatic cancer is palliation in symptomatic patients and prolongation of life in medically suitable cases
Key recommendations Recommendations are to offer combined chemotherapy and radiotherapy to suitable patients who desire treatment Outside of a clinical trial, 5-fluorouracil (5-FU) given as bolus or infusion is the preferred chemotherapeutic agent to combine with radiotherapy. The optimal mode and duration of 5-FU delivery is unclear
Qualifying statements Specific anticancer treatments (such as resection, chemotherapy and radiation) may be supplemented with supportive care (such as pain control, nutritional support, biliary stenting and bowel decompression as needed) if appropriate The evidence on which current conventional practice is based is relatively weak Chemotherapy alone with gemcitabine is an acceptable alternative


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