Palliative Geriatric Assessment in Selection of Older Patients with Resectable Pancreatic Ductal Adenocarcinoma for Surgical Treatment

Surgical treatment of older patients with resectable pancreatic ductal adenocarcinoma (PDAC) is limited by comorbidities, frailty, and risk of postoperative functional deterioration. The study aimed to evaluate factors influencing shared decision-making in treatment allocation of geriatric patients with resectable PDAC and to compare survival and postoperative outcomes according to treatment strategy. Patients older than 65 years with primary resectable PDAC were prospectively enrolled. Patients were either directly indicated for surgery by a surgeon or referred for comprehensive palliative geriatric assessment when surgical fitness was uncertain. Patients assessed as fit underwent pancreatic resection, whereas unfit patients received oncologic and palliative treatment. Clinical, functional, and quality-of-life parameters were analyzed. Multivariate logistic regression included age-adjusted Charlson Comorbidity Index (aaCCI), Instrumental Activities of Daily Living (IADL), Karnofsky Performance Status (KPS), and selected EORTC QLQ-C30 variables. Sixty-nine patients were included; 19 directly selected for surgery (Control group - C), 22 assessed as fit after geriatric evaluation (Intervention group - I), and 28 assigned to palliative treatment (Palliative group - P). Median overall survival (mOS) did not significantly differ between groups (7.50 vs. 14.26 vs. 16.30 months; P vs. I, p = 0.054; I vs. C, p = 0.63; P vs. C, p = 0.058). When we compared mOS of all operated patients (C + I) versus palliative group, the difference reached statistical significance (16.30 months vs. 7.50 months, HR = 1.78, 95% CI 1.08–2.92, p = 0.02). Length of intensive care unit stay, severe postoperative complications, and chemotherapy administration were comparable. Significant differences between intervention and palliative groups were found in aaCCI (p = 0.016), IADL (p = 0.025), KPS (p = 0.001), fatigue (p = 0.042), and physical functioning (p = 0.028). Multivariate analysis identified aaCCI and IADL as independent predictors of treatment allocation. Comprehensive palliative geriatric assessment supports shared decision-making and may help identify older patients suitable for pancreatic surgery despite initial concerns regarding frailty. aaCCI and IADL represent practical clinical parameters for surgical selection; further validation in larger cohorts is required.