Patient-reported symptom severity following curative-intent resection for pancreas adenocarcinoma

Background: Pancreatic adenocarcinoma (PA) portends poor long-term prognosis, even with curative-intent surgery. Despite improvements in perioperative care, post-operative morbidity remains as high as 70%, with significant potential impact on quality of life, which is particularly relevant considering the predicted median survival of 20 months. Data on quality-of-life following pancreaticoduodenectomy (PD) is limited, but important to better support patients. Within Ontario, Patient Reported Outcomes (PROs) are recorded prospectively for patients registered at Regional Cancer Centres, utilizing the Edmonton Symptom Assessment System (ESAS). We sought to identify symptom burden and trajectories following PD for PA, and examine factors associated with high symptom burden. Methods: We conducted a retrospective cohort study of PA resected with PD from 2009 to 2015, who reported at least one ESAS score in the year following PD. ESAS, a validated score assessing 9 common cancer symptoms, was linked to provincial administrative healthcare datasets to ascertain treatments and patient demographics. Moderate-to-severe symptoms were defined as score ≥4 out of 10. Overall prevalence of monthly moderate-to-severe symptoms was determined for each symptom, and presented graphically for the first year after surgery. Multivariable modified Poisson regression identified factors associated with reporting of moderate-to-severe symptoms, and reported as relative risk (RR) with 95% confidence interval (95%CI). Results: Of 698 PA patients undergoing PD with ESAS data, 63% were Stage II and 67% received adjuvant chemotherapy. Median survival was 21 months. 5994 symptom assessments were recorded. Moderate-to-severe tiredness (71%), lack of appetite (61%), and impaired well-being (65%) were the most commonly reported symptoms, while moderate-to-severe shortness of breath (23%), nausea (30%), and depression (37%) were the least commonly reported. The proportion of moderate-to-severe symptoms was highest in the first two months immediately after surgery (range: 11-63% per symptom) and decreased over time to stabilize at 4 months (range: 6-34% per symptom). This trend was similarly seen across treatment groups. On multivariable analysis, female gender and patients with greater comorbidity were independently associated with higher risk of reporting moderate-to-severe symptoms. Receipt of adjuvant therapy was associated with symptom burden, with higher risk of moderate-to-severe tiredness for surgery alone, and higher risk of moderate-to-severe nausea, for adjuvant chemoradiation, compared to adjuvant chemotherapy. Conclusion: There is a high prevalence of moderate-to-severe symptom scores following PD for PA, with encouraging improvement over four months. In the largest cohort reporting on symptom burden for this population, we have identified factors associated with symptom severity. This understanding of symptom trajectories and sub-groups at higher risk is important to design strategies to improve targeted symptom management and patient-centred care. It can also support patient counseling regarding pre-operative preparation for the impact of surgery, and post-operative expectations regarding improvement and recovery. Future work is warranted to examine use and efficiency of interventions to manage symptoms.