br Results br Overall patients of years
Overall, 2837 patients of 70 years and older were included: 2523 from the Netherlands (early stage 179; T3 or Metformin positive 603; ad-vanced 1639 and unknown stage 102 patients) and 314 from Moffitt Cancer Center (early stage 15, T3 or node positive 124, advanced 168 and unknown stage 7 patients). Table 1 shows the characteristics of the patients, according to stage at diagnosis. Age, sex and grade were not differentially distributed between the cohorts, with the exception of age in patients with T3 or node positive disease (median age Netherlands 75.0 and Moffitt 77.0 years; p = .02).
Table 2 shows the treatment strategy in both cohorts according to stage. Most early stage patients with pancreatic cancer received no neo-adjuvant treatment, both in the Netherlands (97.2%) and at Moffitt (88.9%). Surgical resection for early stage disease was more often per-formed at Moffitt though the difference was not significant (60.0% ver-sus 39.7%; p = .1). Adjuvant treatment was initiated more frequently at Moffitt (66.7% versus 18.3%; p b .001). For early stage patients who had no surgery, chemo-radiation (33.3% versus 0%) or chemotherapy (16.7% versus 3.7%) was more often part of the treatment strategy at Moffitt than in the Netherlands(p b .001).
In patients with T3 or node positive disease, neoadjuvant chemo-radiation was more often part of the treatment strategy at Moffitt (16.7% versus 0.3%; p b .001). The proportion of patients who received surgery was lower at Moffitt than in the Netherlands (53.2% versus 63.3%; p = .04). In patients that underwent surgery, adjuvant therapy was more often administrated at Moffitt (74.2% versus 30.4%; p b .001). In patients who received no surgery, treatment strategies were different with a higher proportion of no treatment in the Netherlands and a higher proportion of systemic treatment at Moffitt (p b .001).
Characteristics of patients, according to stage at diagnosis.
Age Median (range)
Age Median (range)
Age Median (range)
With respect to palliative treatment for patients with advanced pan-creatic cancer, treatment strategies were also different (p b .001); in particular, the proportion of patients receiving chemotherapy was higher at Moffitt (17.4% in the Netherlands versus 64.5% at Moffitt).
This international comparison of older patients with pancreatic can-cer treated at Moffitt Cancer Center and the Netherlands shows differ-ences in treatment strategies, especially in systemic treatment administration with a higher proportion at Moffitt. Overall Survival rates were higher for patients treated at Moffitt, and were in a large part explained by the differences in treatment. The survival difference was less pronounced when compared with patients with T3 or node positive disease treated at an academic hospital in the Netherlands.
4.1. Neo-adjuvant Treatment
For T3 or node positive disease, earlier data from the US showed that the proportion of older patients receiving neoadjuvant therapy was similar to younger patients (although a smaller proportion of older patients received adjuvant therapy) . In the present study, the proportion of patients who received neoadjuvant chemoradiation was higher for patients at Moffitt (16.7% versus 0.3% for patients with T3 or node positive disease). One possible explanation is a difference in the approach to borderline resectable disease, where a neoadjuvant chemotherapy with or without radiation is often used in the US to at-tempt to improve resectability, and is described as an option in the NCCN guidelines but not yet in the Dutch guidelines (2011). Currently the benefit of neoadjuvant chemoradiation is being investigated in a multicenter clinical trial in the Netherlands. Furthermore, a geriatric on-cologist is included in the multidisciplinary tumor board at Moffitt and
3.2. Survival Treatment strategies in both cohorts, according to stage.
Treatment Netherlands Moffitt p-value
Table 4 shows the differences in survival stratified by age and strat-ified by type of hospital in the Netherlands; Attachment 1 shows the treatment in the academic hospital in the Netherlands in comparison to Moffitt. A significantly improved survival rate at Moffitt was more pronounced for patients over the age of 75 years with early stage or T3 or node positive disease; for patients with advanced disease the survival rate was better at Moffitt in all age groups. Comparing survival between academic hospitals in the Netherlands and Moffitt showed no
a Proportion calculated for the operated patients.
b Selection of patients who received no surgery.