Increasing pancreatic cancer is not paralleled by pancreaticoduodenectomy volumes in Brazil: A time trend analysis

Abstract

Background

Currently, surgical resection represents the only curative treatment for pancreatic cancer (PC), however, the majority of tumors are no longer resectable by the time of diagnosis. The aim of this study was to describe time trends and distribution of pancreaticoduodenectomies (PDs) performed for treating PC in Brazil in recent years.

Methods

Data were retrospectively obtained from Brazilian Health Public System (namely DATASUS) regarding hospitalizations for PC and PD in Brazil from January 2008 to December 2015. PC and PD rates and their mortalities were estimated from DATASUS hospitalizations and analyzed for age, gender and demographic characteristics.

Results

A total of 2364 PDs were retrieved. Albeit PC incidence more than doubled, the number of PDs increased only 37%. Most PDs were performed in men (52.2%) and patients between 50 and 69 years old (59.5%). Patients not surgically treated and those 70 years or older had the highest in-hospital mortality rates. The most developed regions (Southeast and South) as well as large metropolitan integrated municipalities registered 76.2% and 54.8% of the procedures, respectively. LMIM PD mortality fluctuated, ranging from 13.6% in 2008 to 11.8% in 2015.

Conclusions

This study suggests a trend towards regionalization and volume-outcome relationships for PD due to PC, as large metropolitan integrated municipalities registered most of the PDs and more stable mortality rates. The substantial differences between PD and PC increasing rates reveals a limiting step on the health system resoluteness. Reduction in the number of hospital beds and late access to hospitalization, despite improvement in diagnostic methods, could at least in part explain these findings.

Introduction

Pancreatic cancer (PC) is the 4th leading cause of death worldwide [1]. In Brazil, PC is the 13th most prevalent cancer in men and the 10th most prevalent in women [2]. PC incidence and mortality rates are increasing in most parts of the world, being higher in high-income areas, intermediate in South and Central America and Eastern Asia, and lower in low-income areas [3], [4]–5]. Although there has been an overall reduction in tobacco-related neoplasms in Europe and North America, PC mortality trends for the next years and decades is not favorable [6], [7], [8]–9].

The only potentially curative therapy for PC is complete surgical resection but, at the time of diagnosis, 80%–90% of the tumors are no longer resectable [10], [11]. Most PCs involve the pancreatic head, location that determines whether the patient will undergo a pancreaticoduodenectomy (PD), the Whipple procedure. PD is an abdominal operation with a significant risk of postoperative morbidity and mortality [12], [13]. Risk factors for pancreatic surgery are related to the pancreatic characteristics, age of the patients, comorbidities, and also to the procedure itself [13]. On the other hand, due to consistent progress in surgical procedures, operative rates for pancreatic tumors have increased significantly, being offered even to older patients with additional comorbidities [14], [15]. Recent data suggest that a certain critical caseload volume is required to undertake this kind of surgery with low mortality, because the results probably are influenced by case volume per surgeon and institution [16], [17]. Major centers in Western countries report remarkably low rates of perioperative mortality, of less than 5% [18], [19]. Nevertheless, there are considerable variations among centers worldwide. Hence, the value of regionalization and centralization of PD procedures has been under debate [20], [21].

In Brazil, a recent study observed that PC incidence rates increased 87% from 2005 to 2012. Such increase in PC rates was mainly driven by people over 50 years old [22]. However, population-based data on cancer treatment are still limited in the country. Therefore, the aim of this study was to analyze rates, age-related in-hospital mortality and time trends of PD for PC in Brazil. In particular, demographic and geographic aspects related to urbanization and conurbation were taken into account, in order to evaluate possible patterns of regionalization and their potential influence in outcomes.