Pancreatic resection in elderly patients over the age of 70 with primary pancreatic cancer: a retrospective analysis

The incidence of pancreatic cancer peaks over the age of 70. Surgical resection provides an opportunity for a cure, however, pancreatic surgery remains controversial in the elderly population. Our aim is to assess the effect of age on pancreatic surgery for primary pancreatic cancer.

A total of 155 patients underwent pancreatic resection for primary pancreatic cancer between 2000 and 2018. There were 60 elderly patients (≥70 years) and 95 non-elderly patients (<70 years). Clinicopathological variables, postoperative morbidity, mortality, and long-term survival were compared between both groups. Multivariate Cox regression analysis was performed to evaluate independent predictors of disease-free survival.

Elderly patients with primary pancreatic cancer had a significantly higher frailty score (modified frailty index: 0.097 vs 0.089, P = .014) and multiple comorbidities (comorbidities ≥4: 27% vs 12%, P = .016). Total bilirubin concentration and CA19.9 levels were similar between both groups (elderly vs non-elderly: median total bilirubin concentration, 16.0 μmol/L vs 13.5 μmol/L, P = .884; median CA19.9, 136.5 kU/L vs 74.0 kU/L, P = .713). The majority of patients had pancreatic adenocarcinoma with early-stage disease (elderly vs non-elderly: Pancreatic adenocarcinoma, 72% vs 81%, P = .173; Stage I/II, 95% vs 93.7%, P = .733). Pancreaticoduodenectomy was the most frequently performed procedure with no significant differences between the two groups (elderly vs non-elderly: 58% vs 68%, P = .097). Delayed gastric-emptying was the most common postoperative complication (elderly vs non-elderly: 22% vs 11%, P = .066). Elderly patients were more likely to develop acute kidney injury (8% vs 0%, P = .008). Overall complication rate, defined as Clavien-Dindo ≥2, and in-hospital mortality were similar between both groups (elderly vs non-elderly: overall complication, 58% vs 46%, P = .145; in-hospital mortality, 2% vs 2%, P > .999), however, median length of hospital stay was longer in the elderly group (16 days vs 12 days, P = .006). More elderly patients had negative margins (88% v 66%, P = .002), however, they were less likely to receive adjuvant chemotherapy treatment (37% v 54%, P < .05). The elderly cohort had a significantly shorter mean overall survival of 58.3 months (95% CI, 34.0-82.6) compared with 107.5 months in the non-elderly group (P = .039). Mean disease-free survival was 35.8 months (95% CI, 19.2-52.4) in the elderly group and 68.8 months (95% CI, 45.3-92.2) in the non-elderly group (P = .120). Multivariate analysis revealed that T-stage (T3, T4) was an independent predictor of disease-free survival (HR 1.929; 95% CI, 1.078, 3.452; P = .027), after adjusting for age and nodal disease.

Postoperative morbidity, mortality, and long-term disease-free survival was similar between the elderly and non-elderly group. A high T-stage, after adjusting for age and nodal disease, predicted poor disease-free survival following curative surgical treatment in patients with primary pancreatic cancer. Chronological age alone is not an absolute contraindication to surgical resection of primary pancreatic cancer in carefully selected elderly patients.