Title: Surgery outcomes for pancreatic cancer: linkage of the APDC with the NSW CCR Efty Stavrou, Deborah Baker, Nicola Creighton, James Bishop
1Surgery outcomes for pancreatic cancer linkage
of the APDC with the NSW CCREfty Stavrou,
Deborah Baker, Nicola Creighton, James Bishop
2Background
- Incidence and mortality rates pancreatic cancer
stable over past 10 years - Risk factors include
- Age
- Smoking
- Increased BMI
- Occupational exposure to chemicals
- Long standing diabetes mellitus
- Genetics/family history
- 90 ductal adenocarcinomas
- Five-year survival of disease is poor (6 males
8 females) - Fifth most common cause of cancer deaths in
Australia
3Background
- Patients present with symptoms late in course of
disease - Symptoms include
- Upper abdominal and back pain
- Jaundice
- Unexplained weight loss
- Nausea / vomiting
- Onset of diabetes, attack of pancreatitis
- Surgery is only potential cure for pancreatic
cancer - Only 20-30 undergo pancreatic resection due to
late presentation of disease - In past, high post-operative mortality and
morbidity - High volume hospitals have low surgical mortality
- Surgery improves five-year survival
4Aims
- To investigate
- (i) what patient and cancer characteristics are
associated with a pancreatectomy being undertaken - (ii) what difference exists in survival between
those undergoing pancreatic resection and those
who do not - What factors are associated with overall survival
- All primary invasive cases of pancreatic cancer
diagnosed in NSW residents between 2000 and 2005,
inclusive, and recorded in the NSW Central Cancer
Registry (CCR) will be linked to episodes of care
in NSW public and private hospitals recorded in
the NSW Admitted Patient Data Collection (APDC)
databases.
5Methods
- Data sources
- The Central Cancer Registry (CCR) receives
notifications of cancer in NSW. It is managed by
the Cancer Institute NSW for the NSW Health
Department, and operates under the authority of
the Public Health Act 1991. The Registry
maintains a record of all cases of cancer
diagnosed in NSW residents since 1972. The
registry is run according to the International
Association of Cancer Registries guidelines. -
- The Admitted Patients Data Collection (APDC)
includes records for all hospital separations
from all NSW public and private hospitals and day
procedure centres and is maintained by NSW Health
Department.
6Methods
- Master Linkage Key
- Identifying information (eg name, address, date
of birth, gender) from the CCR and the APDC were
included in the Master Linkage Key (MLK)
maintained by the Centre for Health Record
Linkage (CHeReL) for record linkage. Records
were matched using probabilistic record linkage
methods and ChoiceMaker software. The CCR and
the APDC data were linked as follows - NSW CCR cases for pancreatic cancer (ICD-O3
codes C25.0-C25.9) diagnosed between 1 July 2000-
31 December 2005 (inclusive). - APDC records for the period 1 July 2000 30
June 2006 (to allow patients diagnosed in the
latter half of 2005 to receive treatment).
7CCR (CI NSW)
APDC
CCR ID (encrypted) Identifying information (e.g.
name, sex, DOB, )
Patient ID (encrypted) Identifying information
(e.g. name, sex, DOB, )
LINKAGE UNIT (CheReL) Matching CCR Identifying
information with APDC identifying
information Allocate a person identifier for each
person in the research project (Project Person
ID) Send person ID and source ID to relevant data
custodians
APDC Receives file from linkage unit Adds
ASLWH data removes ALSWH ID
CCR (CI NSW) Receives file from linkage
unit Adds CCR data and removes CCR ID
Patient ID (encrypted) Project Person ID
CCR ID (encrypted) Project Person ID
ANALYSIS GROUP Merge the CCR and APDC
de-identified files to create the analysis
dataset
Project Person ID Patient data (e.g. hospital
code, procedure type, area health service of
hospital etc)
Project Person ID CCR data (e.g. type of cancer,
date of diagnosis)
Project Person ID CCR data (e.g. type of cancer,
date of diagnosis) APDC data (e.g. procedure
type, procedure date)
8Methods
- Master Linkage Key
- Two project keys were created from the Master
Linkage Key - A CCR Key containing the encrypted record number
from CCR and the Project Person Number for that
record which was returned to CCR data custodian. - An APDC Key containing the encrypted record
number from APDC and the Project Person Number
for that record which was returned to APDC
custodian. - The custodians of the APDC and the NSW CCR
decrypted the encrypted source record numbers
from the data-sets and attached the relevant
information to the data-sets which were released
to the study investigators. The investigators
matched the datasets using the Project Person
Numbers. - A total of 28,249 APDC records for the specified
time period were matched to 3,834 pancreatic
cancer cases in the CCR. The parameters for the
extract from the MLK were such that the false
positive and false negative rate were each lt0.1.
9Methods
- Other variables
- Cases were allocated to the 2001 local government
areas (LGA) based on residential address at the
time of diagnosis. - Accessibility/ Remoteness Index for Australia
(ARIA) values were applied to cases via the LGA
based on the 2001 census information from the
Australian Bureau of Statistics - Socioeconomic status was estimated using the
Index of Relative Socioeconomic Disadvantage
(IRSD), one of four Socio Economic Indexes for
Areas (SEIFA) created by the ABS. - Degree of spread was based on the degree of
spread at diagnosis, a variable derived from the
NSW CCR from the maximum extent of the cancer
across all reports and notifications dated within
four months of the date of diagnosis. - Pancreatic resection was based on ICD-10AM
procedural codes (block 0978) and ICD10AM used as
proxy co-morbidity measurement (CVD, Diabetes,
COPD, Renal disease) - Hospitals grouped into peer-groups bases on NSW
Health peer hospital groups (eg Principal
referral, Major Metropolitan) - Hospitals grouped by number of pancreatectomies
undertaken in five years into Low volume (10),
Mid volume (11-20) and High volume (gt20)
10Methods
- Statistical Analyses
- Examination of the factors associated with a
patient undergoing pancreatectomy or not was
performed using logistic regression and reported
as crude (univariate) and adjusted odds ratios.
Statistical significance was taken at the plt0.05
(two-tail) level. - Survival analysis was undertaken to examine the
association between undergoing a pancreatectomy
or not from date of diagnosis to date of death
from any cause. - People who were not known to have died by 31st
December 2004 were censored at this date.
Survival rates are reported using the
Kaplan-Meier product limit method and Cox
proportional hazard regression was used to
estimate hazard ratios.
11Results OR of undergoing a resection or not
Adjusted for ARIA, IRSD, AHS
Variable No Pancreatectomy (n27,703 ) Pancreatectomy (n442 ) Crude OR Adjusted OR p-value
Age group lt50 years 50-69 years 70 years 1,608 (5.8) 11,210 (40.5) 14,885 (53.7) 56 (12.7) 234 (52.9) 152 (34.4) 2.82 (1.96-4.08) 1.77 (1.41-2.23) Referent 2.13 (1.43-3.17) 1.30 (1.01-1.67) Referent lt0.001 0.04
Histology Adenocarcinoma Other specified carcinoma Unspecified carcinoma Unspecified types 14,306 (52.6) 739 (2.7) 9,139 (33.6) 3,028 (11.1) 363 (87.1) 18 (4.3) 27 (6.5) 9 (2.2) Referent 0.83 (0.48-1.43) 0.12 (0.08-0.19) 0.08 (0.03-0.19) Referent 0.96 (0.54-1.72) 0.15 (0.10-0.23) 0.12 (0.05-0.29) 0.89 lt0.001 lt0.001
Degree of spread Localised Regional Distant Unknown 6,044 (21.8) 5,468 (19.7) 9,853 (35.6) 6,338 (22.9) 104 (23.5) 248 (56.1) 61 (13.8) 29 (6.6) 2.41 (1.68-3.47) 6.98 (5.08-9.60) Referent 0.60 (0.35-1.03) 2.97 (2.03-4.35) 6.21 (4.44-8.68) Referent 1.11 (0.64-1.92) lt0.001 lt0.001 0.72
Respiratory disease No Yes 26,564 (95.6) 1,139 (4.1) 419 (94.8) 23 (5.2) Referent 1.43 (0.90-2.28) Referent 1.93 (1.17-3.18) 0.01
Cardiovascular disease No Yes 22, 835 (82.4) 4,868 (17.6) 298 (67.4) 144 (32.6) Referent 2.42 (1.93-3.04) Referent 2.93 (2.23-3.83) lt0.001
Glucose/Diabetes No Yes 23,128 (83.5) 4,575 (16.5) 330 (74.7) 112 (25.3) Referent 1.60 (1.25-2.06) Referent 1.21 (0.91-1.60) 0.20
Renal disease No Yes 26,310 (95.0) 1,393 (5.0) 426 (96.4) 16 (3.6) Referent 0.53 (0.28-1.00) Referent 0.98 (0.51-1.90) 0.95
CALD group English NESB 20,106 (72.6) 7,597 (27.4) 320 (72.4) 122 (27.6) 1.11 (0.87-1.42) Referent 1.26 (0.97-1.66) Referent 0.10
Tumour location Head Body Tail NOS Other 12,979 (46.7) 1,042 (3.8) 1,641 (5.9) 10, 818 (38.9) 1,331 (4.8) 284 (64.3) 11 (2.5) 48 (10.9) 58 (13.1) 41 (9.3) 4.77 (3.42-6.65) 2.55 (1.27-5.11) 5.69 (3.52-9.18) Referent 6.22 (3.79-10.21) 2.38 (1.68-3.38) 1.91 (0.94-3.89) 3.04 (1.84-5.03) Referent 2.77 (1.65-4.65) lt0.001 0.07 lt0.001 lt0.001
12Results
- Survival
- Median (all-cause) survival time for those who
underwent a resection was 591 days (95CI 510-700
days) - Median survival for those who did not undergo a
resection was only 283 days (95CI 282-288
days). - After accounting for potential confounding
factors, patients receiving a pancreatectomy had
statistically better all-cause survival (HR 0.61,
95 CI 0.51-0.73, plt0.001) than those who did
not.
13Results
- Other factors
- Better survival if
- Younger
- Local or regional degree of spread
- Diagnosed with adenocarcinoma
- Tumour located in Head of pancreas
- Live in major cities
- No co-morbidity
14Future plan
- Following surgery, what factors (eg hospital
peer-group hospital volume) are associated with - extended length of stay,
- 30 day mortality,
- readmission,
- unplanned return to theatre and
- overall survival
- Dissemination of outcomes to AHS, surgeons
practise changes?
15Acknowledgements