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Hepato-pancreato-biliary

E241: Trends in the Use of Observation for Small Nonfunctional Pancreatic Neuroendocrine Tumors

Introduction: Increasing evidence and current guidelines support the use of active surveillance for small asymptomatic nonfunctional pancreatic neuroendocrine tumors (pNETs). The purpose of this study was to assess nationwide trends in the use of observation for pNETs ≤2 cm and to evaluate factors associated with surgical resection.

Methods: Patients with non-metastatic pNETs ≤2 cm treated at high volume facilities (defined as ≥3 pNETs seen per year on average) were identified from the National Cancer Database. Trends in the use of observation vs surgical resection between 2010-2020 were evaluated with the Mann Kendall test. The association between clinical, demographic, and facility-related factors and receipt of resection were assessed using a contemporary cohort from 2015-2020 via univariate and multivariable analyses.

Results: Among 5,579 patients with pNETs ≤2 cm, 2,027 (36.3%) underwent observation whereas 3,552 (63.7%) underwent resection. Active surveillance increased throughout the study period (2010: 16.4% to 2020: 44.6%, p< 0.001, Figure 1) which remained consistent for pNETs ≤1 cm (2010: 18.5%, 2020: 51.9%, p< 0.001) and 1-2 cm (2010: 15.4%, 2020: 41.9%, p< 0.001). On multivariable analysis, increasing age (OR 0.96, CI 0.95 – 0.97, p< 0.001), increasing year of diagnosis (2020 vs 2015: OR 0.43, CI 0.35 – 0.55, p< 0.001), and treatment at an academic center (reference: non-academic center, OR 0.72, CI 0.63 – 0.83, p< 0.001) were associated with observation. In contrast, female sex (OR 1.19, CI 1.05 – 1.35, p=0.006), farther travel distance (OR 1.00, CI 1.00 – 1.00, p=0.004), primary tumor in the body/tail of the pancreas (reference: head of pancreas, OR 1.45, CI 1.25 – 1.68, p< 0.001), and tumor 1.01-2 cm (reference: ≤1 cm, OR 1.62, CI 1.41 – 1.85, p< 0.001) were associated with increased odds of surgery.

Conclusions: Consistent with emerging evidence and evolving guidelines, the use of observation for small pNETs has significantly increased over the past decade. Younger patients treated at non-academic hospitals with tumors in the body/tail measuring between 1-2 cm are more likely to undergo surgical resection. Given the morbidity associated with pancreatectomy and unclear survival advantage associated with surgical resection, additional research into the reasons why only a minority of patients are offered active surveillance is needed.

Learning Objectives:

  • Upon completion, participant will be able to identify that the management of small pancreatic neuroendocrine tumors has changed over time.
  • Upon completion, participant will be able to list the variables associated with patients undergoing resection for pancreatic neuroendocrine tumors <2 cm.
  • Upon completion, participant will be able to identify variables associated with patients undergoing observation for pancreatic neuroendocrine tumors <2 cm.