Implementation of a Standardized Approach to Borderline Resectable Pancreatic Cancer in a Multisite Community Oncology Program

Background: Treatment paradigms for borderline resectable pancreatic cancer (BRPC) are evolving with increasing use of neoadjuvant chemotherapy (NAC) and neoadjuvant chemoradiation (NACR). Variations in the definition of BRPCand neoadjuvant approaches have made standardizing care for BRPC difficult. We report an effort to standardize management of BRPC throughout Sanford Health, a large community oncology network. Methods: Starting in October 2013, cases of PC without known metastatic disease were categorized as BRPC if they met ≥1of the following criteria: 1) abutment of superior mesenteric, common hepatic or celiac arteries with <180° involvement, 2) venous involvement deemed potentially suitable for reconstruction, and/or 3) biopsy proven lymph node involvement. Patients with BRPC were treated with NAC followed by reimaging and surgery if venous involvement had improved; if disease remained borderline resectable, patients underwent NACR and surgical exploration as long as reimaging did not reveal evidence of progressive disease. Results: Forty-three patients from 10/2013-4/2017 were diagnosed with BRPC. Twelve of 42 (29%) patients proceeded to surgical exploration directly after NAC; 23 (55%) received NACR. Overall, 28/43 (65%) underwent exploration with 19 (44%) able to undergo resection. Of those, 14/19 (74%) attained R0 resection and 11/19 (58%) were pathologic N0. No pretreatment or treatment variables were associated with resection rates; resection was the only variable associated with survival. Conclusions: This report demonstrates the feasibility of implementing a standardized approach to BRPC across multiple sites over a wide geographic area. Adherance to protocol therapies was good and surgical outcomes are similar to many reported series.