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Original article
Resection of pancreatic cancer in Europe and USA: an international large-scale study highlighting large variations
  1. Lei Huang1,
  2. Lina Jansen1,2,
  3. Yesilda Balavarca3,
  4. Esther Molina-Montes4,
  5. Masoud Babaei1,
  6. Lydia van der Geest5,
  7. Valery Lemmens5,
  8. Liesbet Van Eycken6,
  9. Harlinde De Schutter6,
  10. Tom B Johannesen7,
  11. Claus W Fristrup8,
  12. Michael B Mortensen9,
  13. Maja Primic-Žakelj10,
  14. Vesna Zadnik10,
  15. Nikolaus Becker11,
  16. Thilo Hackert12,
  17. Margit Mägi13,
  18. Tiziana Cassetti14,
  19. Romano Sassatelli14,
  20. Robert Grützmann15,
  21. Susanne Merkel15,
  22. Ana F Gonçalves16,
  23. Maria J Bento16,
  24. Péter Hegyi17,
  25. Gábor Lakatos18,
  26. Andrea Szentesi17,
  27. Michel Moreau19,
  28. Tony van de Velde20,
  29. Annegien Broeks20,
  30. Milena Sant21,
  31. Pamela Minicozzi21,
  32. Vincenzo Mazzaferro22,
  33. Francisco X Real23,24,
  34. Alfredo Carrato25,
  35. Xavier Molero26,27,
  36. Marc G Besselink28,
  37. Núria Malats4,
  38. Markus W Büchler12,
  39. Petra Schrotz-King3,
  40. Hermann Brenner1,2,3
  1. 1 Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
  2. 2 German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
  3. 3 Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
  4. 4 Geneticand Molecular Epidemiology Group, Spanish National Cancer Research Centre (CNIO), CIBERONC, ISCIII, Madrid, Spain
  5. 5 Netherlands Cancer Registry (NCR), Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, Netherlands
  6. 6 Belgian Cancer Registry (BCR), Brussels, Belgium
  7. 7 Registry Department, The Cancer Registry of Norway (CRN), Oslo, Norway
  8. 8 Danish Pancreatic Cancer Database (DPCD), Odense, Denmark
  9. 9 Danish Pancreatic Cancer Group, HPB Section, Department of Surgery, Odense University Hospital, Odense, Denmark
  10. 10 Epidemiology and Cancer Registry, Institute of Oncology Ljubljana, Ljubljana, Slovenia
  11. 11 Clinical Cancer Registry, DKFZ and NCT, Heidelberg, Germany
  12. 12 Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
  13. 13 Estonian Cancer Registry, National Institute for Health Development, Tallinn, Estonia
  14. 14 Pancreatic Cancer Registry of Reggio Emilia Province, Unit of Gastroenterology and Digestive Endoscopy AUSL-RE, Local Health Authority-IRCCS, Reggio Emilia, Italy
  15. 15 Department of Surgery, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
  16. 16 Departments of Epidemiology, Portuguese Oncology Institute of Porto (IPOP), Porto, Portugal
  17. 17 Institute for Translational Medicine, University of Pécs, Pécs, Hungary
  18. 18 Department of Oncology, St. Istvan and St. Laszlo Hospital and Out-Patient Department, Budapest, Hungary
  19. 19 Department of Surgical Oncology, Jules Bordet Institute (IJB), Brussels, Belgium
  20. 20 Biometrics Department, The Netherlands Cancer Institute (NKI), Amsterdam, Netherlands
  21. 21 Analytical Epidemiology and Health Impact Unit, Department of Preventive and Predictive Medicine, Fondazione IRCCS, Istituto Nazionale dei Tumori (INT), Milan, Italy
  22. 22 Hepato-Biliary Surgery Unit, Istituto Nazionale dei Tumori (INT), and University of Milan, Milan, Italy
  23. 23 Epithelial Carcinogenesis Group, Spanish National Cancer Research Centre (CNIO), CIBERONC, Madrid, Spain
  24. 24 Department de Ciencies Experimentals i de la, Universitat Pompeu Fabra, Barcelona, Spain
  25. 25 Department of Oncology, Ramon y Cajal University Hospital, IRYCIS, Alcala University, CIBERONC, Madrid, Spain
  26. 26 Hospital Universitari Vall d’Hebron, Exocrine Pancreas Research Unit and Vall d’Hebron Research Institute (VHIR), Universitat Autonoma de Barcelona, Campus de la UAB, Barcelona, Spain
  27. 27 CIBEREHD and CIBERESP, Madrid, Spain
  28. 28 Dutch Pancreatic Cancer Group, Academic Medical Centre Amsterdam, Amsterdam, Netherlands
  1. Correspondence to Lina Jansen, Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg 69120, Germany; l.jansen{at}


Objective Resection can potentially cure resectable pancreatic cancer (PaC) and significantly prolong survival in some patients. This large-scale international study aimed to investigate variations in resection for PaC in Europe and USA and determinants for its utilisation.

Design Data from six European population-based cancer registries and the US Surveillance, Epidemiology, and End Results Program database during 2003–2016 were analysed. Age-standardised resection rates for overall and stage I–II PaCs were computed. Associations between resection and demographic and clinical parameters were assessed using multivariable logistic regression models.

Results A total of 153 698 records were analysed. In population-based registries in 2012–2014, resection rates ranged from 13.2% (Estonia) to 21.2% (Slovenia) overall and from 34.8% (Norway) to 68.7% (Denmark) for stage I–II tumours, with great international variations. During 2003–2014, resection rates only increased in USA, the Netherlands and Denmark. Resection was significantly less frequently performed with more advanced tumour stage (ORs for stage III and IV versus stage I–II tumours: 0.05–0.18 and 0.01–0.06 across countries) and increasing age (ORs for patients 70–79 and ≥80 versus those <60 years: 0.37–0.63 and 0.03–0.16 across countries). Patients with advanced-stage tumours (stage III–IV: 63.8%–81.2%) and at older ages (≥70 years: 52.6%–59.5%) receiving less frequently resection comprised the majority of diagnosed cases. Patient performance status, tumour location and size were also associated with resection application.

Conclusion Rates of PaC resection remain low in Europe and USA with great international variations. Further studies are warranted to explore reasons for these variations.

  • pancreatic cancer
  • surgical resection
  • variation
  • age
  • TNM stage
  • population-based

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  • Contributors Conception or design: LH, LJ, YB, MB, PS-K, HB. Acquisition, analysis or interpretation of data: LH, LJ, YB, EM-M, M Babaei, LvdG, VL, LVE, HDS, TBJ, CWF, M Mortensen, MPŽ, VZ, NB, TH, M Mägi, TC, RS, RG, SM, AFG, M Bento, PH, GL, AS, M Moreau, TvvV, AB, MS, PM, VM, FXR, AC, XM, M Besselink, NM, M Büchler, PS-K, HB. Drafting of the manuscript: LH. Critical revision of the manuscript for important intellectual content: LH, LJ, YB, EM-M, M Babaei, LvdG, VL, LVE, HDS, TBJ, CWF, M Mortensen, MPŽ, VZ, NB, TH, M Mägi, TC, RS, RG, SM, AFG, M Bento, PH, GL, AS, M Moreau, TvvV, AB, MS, PM, VM, FXR, AC, XM, M Besselink, NM, M Büchler, PS-K, HB. Statistical analysis: LH, YB, EM-M (for PanGenS only). Administrative, technical or material support: M Büchler, PS-K, HB. Supervision: LJ, HB. All authors have given final approval of the manuscript for submission and publication.

  • Funding This study was partly supported by the German Cancer Aid (Deutsche Krebshilfe, #111365), European Cooperation in Science and Technology-COST Action (#BM1204: EUPancreas) and Fondo de Investigaciones Sanitarias (FIS), Instituto de Salud Carlos III-FEDER, Spain (#PI1501573).

  • Disclaimer The funders had no involvement in study design; in the collection, analysis or interpretation of data; in the writing of the report or in the decision to submit the paper for publication.

  • Competing interests None declared.

  • Ethics approval This study was approved by Ethics Committee of the Medical Faculty Heidelberg.

  • Provenance and peer review Not commissioned; externally peer reviewed.