Missed Opportunities for Multimodality Therapy in Resectable Pancreatic Cancer: National Disparities and Consequences for Survival.

BACKGROUND: Multimodal therapy (MMT) combining surgery and chemotherapy remains the optimal management strategy irrespective of sequence for resectable pancreatic ductal adenocarcinoma (PDAC). Determinants of MMT receipt and sequencing remain incompletely understood, particularly regarding neoadjuvant strategies. We aimed to identify modifiable characteristics contributing to differences in MMT receipt and sequencing in the surgical PDAC population. METHODS: Using the 2023 National Cancer Database, we analyzed 11 202 adults with non-metastatic resectable PDAC (2010-2020). Patients were grouped into four treatment categories: surgery only, neoadjuvant chemotherapy plus surgery, adjuvant chemotherapy plus surgery, and combined neoadjuvant plus adjuvant chemotherapy with surgery. Outcomes included 5-year overall survival and multivariable logistic regression for chemotherapy receipt. RESULTS: Of 11 202 patients, 3605 (32.2%) underwent surgery alone, 6347 (56.7%) received adjuvant chemotherapy, 626 (5.6%) neoadjuvant chemotherapy, and 624 (5.6%) both. Surgery-only patients were older, Medicare-insured, and treated at community, low-volume centers, while MMT patients were younger and privately insured (p < 0.001). Five-year survival was highest with combined neoadjuvant and adjuvant therapy (31.9%). Older age, Medicaid insurance, community centers, low/intermediate-volume facilities, and higher comorbidity burden were associated with reduced odds of MMT receipt (p < 0.05). CONCLUSION: Disparities continue to exist for MMT in the PDAC surgical population, highlighting opportunities for improved patient education and enhanced multidisciplinary care.