Are We Undertreating Black Patients with Nonfunctional Pancreatic Neuroendocrine Tumors? Critical Analysis of Current Surveillance Guidelines by Race

Abstract

BACKGROUND: Pancreatic neuroendocrine tumor (PNET) survival outcomes differ by race. Current recommendations for surveillance of PNETs less than 2 cm in size are based on low malignant potential and low rates of lymph node metastases (LNM). We investigated whether these guidelines are universally applicable regardless of race. STUDY DESIGN: A multi-institutional analysis of patients with resected, nonfunctional, sporadic PNETs was performed initially using the US Neuroendocrine Study Group dataset with the National Cancer Database as a validation dataset. Patients with distant metastatic disease were excluded from analysis. RESULTS: A total of 453 (388 White and 65 Black) and 5,532 patients (4,772 White and 760 Black) were analyzed in the initial and validation datasets, respectively. White patients had a low incidence of LNM in tumors of less than 2 cm in both datasets (5% and 12%, respectively), which increased with tumor size. However, the incidence of LNM in Black patients was similar in the initial and validation datasets for tumors sized less than 2 cm (23% and 21%) and 2 to 3 cm (21% and 29%). Black patients had a significantly higher incidence of LNM in tumors less than 2 cm in size in the initial and validation datasets (p < 0.01) compared with White patients. CONCLUSIONS: The current recommendation for surveillance of PNETs of less than 2 cm in size is likely based on a low rate of LNM seen in a predominantly White population. The incidence of LNM in Black patients with tumors less than 2 cm in size is clinically relevant and concerning. Current guidelines may not be universally applicable, and a more aggressive approach to resection in Black patients with small PNETs may be warranted.

Long-Term Survival Outcomes After Minimally Invasive Surgery for Ileal Neuroendocrine Tumors

“…21 Pancreatic NETs of Black patients had a higher incidence of lymph node metastases in small primary tumors <2 cm in size, suggesting that a specific strategy might be needed for non-White patients. 22 However, a post hoc Cox proportional hazards regression analysis showed no clear mortality risk for Black patients (HR 0.36 [0.085-1.5], p = 0.16), thus denying race as a clear effect modifier in our cohort. Since our multivariable analysis did not assume interactions in the model, other unknown different treatment effects could bias the results.…”

A systematic review and meta-analysis of germline BRCA mutations in pancreatic cancer patients identifies global and racial disparities in access to genetic testing

“…The current lack of diversity identified in BRCA research is of concern as it does not assess human variability, 31 , 32 thus limiting the generalizability of research findings that may not account for differences in biological and sociocultural factors across populations impacting PC susceptibility and treatment outcomes. 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 For BRCA1 and BRCA2 genes, founder mutations have been identified across multiple ethnicities, 67 , 68 including African Americans and Hispanics, only seldom profiled in PC due to global and racial disparities in BRCA testing uptake. 26 , 27 This will likely compound the already existing inequities in cancer care described for patients with PC, 23 , 24 , 25 which translates to poorer survival amongst non-white populations, especially African Americans.…”

Nomogram for predicting the preoperative lymph node metastasis in resectable pancreatic cancer

“…Various studies demonstrated that race was related to lymph node metastasis and prognosis (Oweira et al 2017 ; Zheng-Pywell et al 2022 ). Rui Zheng-Pywell et al reveals that black patients had a higher risk of LNM in tumors less than 2 cm in size compared with white patients (Zheng-Pywell et al 2022 ). In our study, Asian PC patients such as Chinese, Japanese, and Korean were less likely to undergo LNM.…”