Development of a Neoadjuvant Treatment Pathway to Standardize Pancreatic Cancer Care and Improve Outcomes Across a Large Diverse Health System

Background Management of localized pancreatic cancer is variable. We describe the development of a neoadjuvant therapy pathway (NATP) to standardize care across a large healthcare system. Methods We conducted an IRB-approved retrospective analysis of NATP patients between June 2019 and March 2022. The primary endpoint was NATP completion, and secondary endpoints included overall survival (OS) and quality measures. Results Fifty-nine patients began NATP, median age 70, locally advanced 44.1%. Median time on NATP was 6.1 months. The initial chemotherapy was FOLFIRINOX (64.2%) and gemcitabine/nab-paclitaxel (GnP; (35.6%)) followed by radiation in 32 (54.2%) patients. Forty-four (74.6%) completed the NATP and 30 (50.8%) underwent surgical exploration with 86.7% undergoing successful resection (61.5% R0, 23.1% R1) while 14 remained unresectable. NATP completion was associated with increased likelihood of resection (p<0.001). At median follow-up of 13.4 months, median OS was 20.9 months (95% CI 13.3- 28.5) and 1- and 2-year OS was 82.5% and 49.7%. NATP completion resulted in improved OS with median OS not reached and 1- and 2-year OS of 89.7% and 59.4% (p=0.004). Median time to NATP start was 20 days after MDR and median time to surgery was 35 days. Age, ECOG, surgical stage, chemotherapy regimen and NATP completion were significant univariable predictors of OS with ECOG status remaining significant on multivariable analysis. Conclusion Our outcomes provide a baseline for future guidance in improving care across a large system. Efforts to complete NATP and improve patient ECOG may result in more patients undergoing surgery and improve survival. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded in part by the 1440 Canopy Cancer Collective ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: IRB of Northwell Health gave ethical approval for this work I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.