**2. Multidisciplinary management team**

One of the primary challenges of the modern healthcare system is the fractured nature in which care is provided [7]. Patients with PDAC may be seen by a primary care doctor or gastroen‐ terologist but may never be seen by a medical or surgical oncologist, depending on disease recognition and provider referral. In order to accomplish a more desirable outcome, a balance must be reached between access to care and the quality of care provided. In a disease presenting with many obstacles, providers having experience in managing PDAC and patients having access to the most advanced therapies, including clinical trials, can make a significant difference in outcomes. Research into these systemic healthcare factors has spurred the production of various causal effect models; one model, in particular, demonstrates the effect of the type of provider in charge of disease management and its impact on the patient receiving expected treatment [7, 8].

Historically, the pessimistic outlook for patients with PDAC has generated skepticism regarding the efficacy of therapy and resection. These attitudes adversely affect proven beneficial disease management involving the utilization of surgical and medical interventions, particularly evident in cases of early stage pancreatic cancer [7, 9, 10]. Bilimoria et al. were able to demonstrate that despite modern improvements in survival after pancreatectomy, 51.7% of Stage I patients did not undergo surgery for potentially resectable pancreatic cancer even after accounting for patients who did not undergo surgery due to severe comorbidities, advanced age, or patient refusal. Patients were less likely to undergo surgery if they were older, were black, had lower annual incomes, had less education, or were on Medicare or Medicaid [6]. This difference in management exhibits a significant correlation with the racial and socioeco‐ nomic discrepancy. Similar discrepancies in care due to race and socioeconomic status have been reported by several studies [11, 12]. Patients were more likely to receive surgery at academic institutions, high‐volume hospitals, and National Comprehensive Cancer Network or National Cancer Institute (NCCN/NCI) centers. This was the first study to describe and characterize such striking underuse of pancreatectomy while identifying factors predicting underutilization [6, 7, 11].

factors. Regardless of the factors influencing the increasing risk of acquiring PDAC, the aggressiveness of the disease itself should be a continued target in the attempt to control or decrease the disease morbidity and mortality [3–5]. PDAC has an aggressive tumor biology with a propensity for early metastasis. Less than 20% of patients with PDAC will present with

The reason for the poor survival in PDAC patients is multifactorial. Tumor biology, lack of screening and early diagnostic test, historically morbid surgical interventions, and systemic therapies with limited efficacy are factors that have been shown to significantly affect the outcomes of patients with PDAC. The combination of the aforementioned factors has led to pessimism within the medical community about the efficacy of pancreatic disease manage‐ ment [6]. However, several advances have been made over the years; and with such a highly lethal disease, any margin of progress can be a large gain. Some of these advances are related to the improvement in coordination of care to overcome systemic barriers that limit the overall efficacy in caring for the disease; other advances have been technical in nature; and finally,

One of the primary challenges of the modern healthcare system is the fractured nature in which care is provided [7]. Patients with PDAC may be seen by a primary care doctor or gastroen‐ terologist but may never be seen by a medical or surgical oncologist, depending on disease recognition and provider referral. In order to accomplish a more desirable outcome, a balance must be reached between access to care and the quality of care provided. In a disease presenting with many obstacles, providers having experience in managing PDAC and patients having access to the most advanced therapies, including clinical trials, can make a significant difference in outcomes. Research into these systemic healthcare factors has spurred the production of various causal effect models; one model, in particular, demonstrates the effect of the type of provider in charge of disease management and its impact on the patient receiving

Historically, the pessimistic outlook for patients with PDAC has generated skepticism regarding the efficacy of therapy and resection. These attitudes adversely affect proven beneficial disease management involving the utilization of surgical and medical interventions, particularly evident in cases of early stage pancreatic cancer [7, 9, 10]. Bilimoria et al. were able to demonstrate that despite modern improvements in survival after pancreatectomy, 51.7% of Stage I patients did not undergo surgery for potentially resectable pancreatic cancer even after accounting for patients who did not undergo surgery due to severe comorbidities, advanced age, or patient refusal. Patients were less likely to undergo surgery if they were older, were black, had lower annual incomes, had less education, or were on Medicare or Medicaid [6]. This difference in management exhibits a significant correlation with the racial and socioeco‐ nomic discrepancy. Similar discrepancies in care due to race and socioeconomic status have been reported by several studies [11, 12]. Patients were more likely to receive surgery at

disease amenable to surgical and potentially curative therapy [1, 3].

several advances have been made in the approach of systemic therapies.

**2. Multidisciplinary management team**

expected treatment [7, 8].

160 Challenges in Pancreatic Pathology

While the initial referral is critically important, once a patient has been referred to a surgeon or an oncologist, the provider's level of experience in managing PDAC is of equal, if not more, significance. The early involvement of a pancreatic cancer specialist has been proven to exhibit a most marked effect on early‐staged disease patients [7–9]. Physicians who care for PDAC patients on a regular basis have several advantages over those who rarely treat the disease. These advantages are evident when comparing perioperative and intraoperative statistics, such as estimated blood loss, case duration, length of postoperative hospital stay, perioperative death, and need for reoperations [13]. Evidence shows us that increased surgical or disease management experience decreases disease morbidity [7, 13]. Improving morbidity, in an already highly morbid disease, will help alter the pessimism surrounding PDAC through recognition of some impactful management options.

It is known that surgery is the only curative therapy for PDAC [6]. It is also known that either adjuvant or neoadjuvant therapy is the patient's best shot for a prolonged survival [7, 14, 15]. Recent evidence regarding oncological diseases has shown that the multidisciplinary approach will have beneficial effects on disease management [7–10]. As such, the development of multidisciplinary treatment teams and multimodal therapeutic interventions has become the benchmarks of PDAC patient management. Most patients, regardless of stage, require multiple subspecialty services including surgery, gastroenterology, medical and radiation oncology, nutrition, and palliative care [7]. These teams allow for the development and collaboration of specialty expertise, bringing a variety of perspectives to each PDAC case.

Although specific team composition may vary throughout center sites, studies continue to illustrate the overall correlation of this model with improved quality of care. Studies assessing the efficacy of this model have demonstrated decreased diagnosis‐to‐treatment time, increased probability of receiving treatment, prolonged survival, increased involvement of multi‐ modality therapy, and increased enrollment and participation in clinical trials. One signifi‐ cantly impactful factor in this model is the decreased diagnosis‐to‐treatment time. Evidence shows that approximately 80% of early Stage I/II diagnosed PDAC patients, not seen in specialized, multidisciplinary centers, fail to receive a potentially curative surgery or life‐ prolonging treatment [8, 9]. Of early‐stage (Stage I/II) disease patients who did not receive surgical resection, only 28% had a surgical referral. Of early‐stage patients who had received surgical intervention, it was noted that referral to a pancreatic disease specialized center or surgeon significantly impacted whether surgery was performed; 80% of early‐stage patients seen in a specialized pancreatic disease clinic received surgery, whereas only 20% of compa‐ rable patients *not* seen in a specialized clinic received surgery [7, 16].

Another factor to consider multidisciplinary approach to caring for pancreatic cancer patients is the greater accessibility and probability of the use of multimodal therapy. While studies continue to show variance in the statistical significance of multimodal therapies, they remain an important element in the development of more effective interventional therapies for such an aggressive cancer. Correspondingly, the inclusion of patients in clinical trials is another benefit of multidisciplinary team centers. Studies have shown up to a two times higher likelihood of patients participating in a clinical trial when seeing a multidisciplinary team. This plays an important role in acquiring a greater understanding of the disease and the develop‐ ment of more effective therapies [7, 16].

Ultimately, the historical lack of multidisciplinary care is only one of multiple factors attributed to the poor survivability curve seen in PDAC patients. However, in recent years, changes in the management of PDAC have started to shift the curve toward showing improvement in the acute care of patients as well as increasing the number of long‐term outcomes [17].
