Defining pancreatic cancer resectability

Agreeing upon a standardised definition of what constitutes surgical resectability is a critical area of need in the treatment of pancreatic cancer. A pilot of a project aiming to develop a synoptic report defining resectability status in pancreatic cancer commenced at two health sites, The Austin and The Alfred, in October 2020. This pilot will run for one year.

The project was born out of discussion on areas of deficiencies in the statewide data presented at the Pancreatic Cancer 2017 Summit.

Clinicians from across Victoria gathered at the Summit to identify unwarranted variations in clinical practice and outcomes that could be addressed through statewide action. One of the prioritised variations was the recognition that administration of systemic therapy for patients with pancreatic ductal adenocarcinoma (PDAC) is critical to their longterm outlook.

In a series of post-Summit working party meetings, the importance of patients actually receiving effective systemic therapy was discussed. Delivering chemotherapy prior to surgery for patients with borderline resectable PDAC was acknowledged as an emerging and promising new approach. Central to considering this ‘neoadjuvant approach’ is the delineation of what constitutes borderline resectable disease versus what is clearly resectable or alternatively, what is clearly locally advanced and unresectable. The working party agreed on the importance of classifying pancreatic cancer using this terminology as it informs optimal treatment pathways and is more useful in clinical decision making than the AJCC (American Joint Committee on Cancer) pathological staging manual definition, only available following surgical resection.

A statewide audit to investigate the use of systemic therapy was conducted. The audit confirmed inconsistencies in the classification of borderline resectable (BR) disease. The Summit working party suggested that agreeing on and adopting a common statewide definition of resectability in PDAC would would be critical to minimise variation in care and help ensure appropriate and consistent management of patients across Victoria. It would also assist with identifying patients for clinical trials and reporting treatment outcomes.

Subsequently, SMICS and NEMICS worked together to propose a project in response to the identified need to agree on a statewide definition of BR pancreatic cancer. A project steering committee and working group representing pancreatic surgery centres across the state was established. The working group proposed the use of the ‘International consensus on definition and criteria of borderline resectable pancreatic ductal carcinoma 2017’1 and these guidelines were unanimously accepted. However, the need to embed this into clinical practice remained, and clinical consultation determined that a standardised CT reporting template for radiologists was required. This would allow accurate reporting according to the agreed guidelines by radiologists for surgeons at MDMs, and therefore appropriate treatment decisions for patients.

Working group members were involved in the co-design of a template for clinical reporting. Development of the template was complex and required a true reflection of the process radiologists undertake to determine the disease status. The current pilot will allow for further refinement, should it be required, to ensure sufficient accuracy of the template.

In undertaking the tool development, the radiologists showed a preference towards an electronic solution. The application REDCap was chosen as a suitable platform. As the resectability status is already collected and stored by the Upper Gastrointestinal Cancer Registry (UGICR) and is also collected via REDCap it became obvious that the storage of patient project data with the UGICR was appropriate. However, there was considerable oversight required regarding patient information security before the pilot could proceed.

Another element of the process was the integration of the template into health service sites and a number of complexities needed to be overcome for this to be implemented.

Should the pilot prove successful, there will be the option of offering a tested and verified template to Victorian health services. Further consideration of the location for the storage of patient data may however be required.

It is hoped that the agreement to use the 2017 international resectability guidelines and implementation of the new CT template will help Victorians with pancreatic cancer by:

  • assisting in complete, pertinent and accurate reporting of disease staging and resectability status in patients with non-metastatic PDAC;

  • assisting multidisciplinary teams in the decision-making process for the management of patients with non-metastatic PDAC; and

  • minimising futile operative procedures from being performed on patients with locally advanced disease leading to timely and appropriate referral to palliative care.