Commentary on “The real-world study of the clinical characteristics, diagnosis, and treatment of advanced pancreatic cancer in China”

Real-word data is becoming increasingly important in medicine. As defined by the US Food and Drug Administration (FDA), real-world data are “the data relating to patient health status and/or the delivery of health care routinely collected from a variety of sources” (US Food and Drug Administration, Real-World Evidence 2022, https://www.fda.gov/science-research/science-and-research-special-topics/real-world-evidence). In clinical cancer research, real-world data became an important additional source of data complementing data obtained from large clinical studies. In the US, the Surveillance, Epidemiology, and End Results (SEER) Program was established 50 years ago to provide population-based data on cancer patients across the whole country. Since then, a large number of studies were conducted and comparable attempts in the Western World were made to use these data for a better understanding of the clinical course of cancer patients.[1,2] The study by Cui et al[3] entitled “The real-world study of the clinical characteristics, diagnosis, and treatment of advanced pancreatic cancer in China”, published in the Journal of Pancreatology describes the course of pancreatic cancer patients in China for the first time in this setting. This work is extraordinary for several reasons. First, it is a proficient composition and interpretation of the newly established Hospital-based Advanced Pancreatic Cancer Cohort in China (Hosp-APCC) that is a unique effort in this country. Given that China has made significant advancements in the last decades to catch up (and partially overtake) Europe and the US regarding quality and quantity in health care and science, this paper contributes to the pivotal role of Chinese research on pancreatic cancer. Second, the data presented in this study provide deep insight into the actual medical care in one of the world’s largest economies. In fact, China struggles with similar challenges compared to other countries in which medical care is superb in urban areas, but rather mediocre in sparsely populated regions. For example, approximately 30% of the patients diagnosed with locally advanced or even metastasized pancreatic cancer did not receive any therapy at all. Hence, only a minority of the patients receive the best medical treatment. Third, first-line treatment for patients with advanced pancreatic cancer in China differs compared to first-line treatment for pancreatic cancer patients in the US and Europe. For patients with non-resectable pancreatic cancer, chemotherapy with FOLFIRINOX is the treatment of choice in the US and Europe.[4] In contrast, the study by Cui et al[3] demonstrates that first-line therapy for advanced pancreatic cancer in China clearly differs. As shown by the authors, almost one-quarter of Chinese patients (23.4%) receive gemcitabine plus S1, followed by nab-paclitaxel plus gemcitabine (18.1%). Only 11.9% of the patients were treated with FOLFIRIONX as first-line treatment. These treatment strategies differ from international guidelines.[4] One possible explanation for this observation might be that S1 has different efficacy in the Asian population, and that only less than 5% of the cases were presented and discussed in multidisciplinary tumor boards. However, a real benefit of FOLFIRINOX as a first-line treatment for patients with advanced pancreatic cancer is still controversial. Recent real-world data from the US and Europe suggest that the overall survival for patients receiving FOLFIRINOX is longer than for patients receiving nab-paclitaxel/gemcitabine, but without reaching statistical significance (15.9 vs 14.4 months).[5] The divergent management of pancreatic cancer patients in China compared to the Western World results in shorter progression-free survival (PFS) compared to the results from other (clinical) studies. As demonstrated by Cui et al,[3] PFS for patients who received FOLFIRIOX was 4.6 months compared to 6.4 months as has been shown in the PRODIGE trial.[6] The reason for this observation remains speculative. Hence, comparable data from the US and Europe are needed to contextualize the data obtained from China. Acknowledgments None. Financial support None. Conflicts of interest The authors declare no conflicts of interest. Editor note: JK is associate editor of the Journal of Pancreatology. He was blinded from reviewing or making decisions on the manuscript. The article was subject to the standard procedures of the Journal, with peer review handled independently of this Editorial Board member.