Implementation of Best Practices in Pancreatic Cancer Care in the Netherlands
Authors: Mackay Tara M. , Latenstein Anouk E. J. , Augustinus Simone , van der Geest Lydia G. , Bogte Auke , Bonsing Bert A. , Cirkel Geert A. , Hol Lieke , Busch Olivier R. , den Dulk Marcel , van Driel Lydi M. J.W. , Festen Sebastiaan , de Groot Derk-Jan A. , de Groot Jan-Willem B. , Groot Koerkamp Bas , Haj Mohammad Nadia , Haver Joyce T. , van der Harst Erwin , de Hingh Ignace H. , Homs Marjolein Y. V. , Los Maartje , Luelmo Saskia A. C. , de Meijer Vincent E. , Mekenkamp Leonie , Molenaar I. Quintus , Patijn Gijs A. , Quispel Rutger , Römkens Tessa E. H. , van Santvoort Hjalmar C. , Stommel Martijn W.J. , Venneman Niels G. , Verdonk Robert C. , van Vilsteren Frederike G. I. , de Vos-Geelen Judith , van Werkhoven C. Henri , van Hooft Jeanin E. , van Eijck Casper H. J. , Wilmink Johanna W. , van Laarhoven Hanneke W. M. , Besselink Marc G. ,   Dutch Pancreatic Cancer Group, Bos Hendrik , Bosscha Koop , Brosens Lodewijk A. A. , Creemers Geert-Jan , Curvers Wouter L. , Derks Sarah , van Dieren Susan , van Geenen Erwin Jan M. , Haberkorn Brigitte C.M. , Hemmink G.J. Maarten , Hoge Chantal , Inderson Akin , Jacobs Maarten A.J.M. , Kerver Emile D. , Liem Mike S.L. , Lubbinge Hans , Schreinemakers Jennifer M.J. , Schut Heidi , Seerden Tom , Verheij Joanne , Vulink Annelie , Wientjes Caroline A. , Wit Fennie , Wessels Frank J. , Zonderhuis Babs 
Published: February 2024

Importance

Implementation of new cancer treatment strategies as recommended by evidence-based guidelines is often slow and suboptimal.

Objective

To improve the implementation of guideline-based best practices in the Netherlands in pancreatic cancer care and assess the impact on survival.

Design, setting, and participants

This multicenter, stepped-wedge cluster randomized trial compared enhanced implementation of best practices with usual care in consecutive patients with all stages of pancreatic cancer. It took place from May 22, 2018 through July 9, 2020. Data were analyzed from April 1, 2022, through February 1, 2023. It included all patients in the Netherlands with pathologically or clinically diagnosed pancreatic ductal adenocarcinoma. This study reports 1-year follow-up (or shorter in case of deceased patients).

Intervention

The 5 best practices included optimal use of perioperative chemotherapy, palliative chemotherapy, pancreatic enzyme replacement therapy (PERT), referral to a dietician, and use of metal stents in patients with biliary obstruction. A 6-week implementation period was completed, in a randomized order, in all 17 Dutch networks for pancreatic cancer care.

Main Outcomes and Measures

The primary outcome was 1-year survival. Secondary outcomes included adherence to best practices and quality of life (European Organisation for Research and Treatment of Cancer [EORTC] global health score).

Results

Overall, 5887 patients with pancreatic cancer (median age, 72.0 [IQR, 64.0-79.0] years; 50% female) were enrolled, 2641 before and 2939 after implementation of best practices (307 during wash-in period). One-year survival was 24% vs 23% (hazard ratio, 0.98, 95% CI, 0.88-1.08). There was no difference in the use of neoadjuvant chemotherapy (11% vs 11%), adjuvant chemotherapy (48% vs 51%), and referral to a dietician (59% vs 63%), while the use of palliative chemotherapy (24% vs 30%; odds ratio [OR], 1.38; 95% CI, 1.10-1.74), PERT (34% vs 45%; OR, 1.64; 95% CI, 1.28-2.11), and metal biliary stents increased (74% vs 83%; OR, 1.78; 95% CI, 1.13-2.80). The EORTC global health score did not improve (area under the curve, 43.9 vs 42.8; median difference, −1.09, 95% CI, −3.05 to 0.94).

Conclusions and Relevance

In this randomized clinical trial, implementation of 5 best practices in pancreatic cancer care did not improve 1-year survival and quality of life. The finding that most patients received no tumor-directed treatment paired with the poor survival highlights the need for more personalized treatment options.

Trial Registration

ClinicalTrials.gov Identifier: NCT03513705