Does Cholecystectomy Prior to the Diagnosis of Pancreatic Cancer Affect Outcome? STEPHEN H. GRAY, M.D., M.S.P.H.,* MARY T. HAWN, M.D., M.P.H.,* MEREDITH L. KILGORE, PH.D.,† HUIFENG YUN, M.S.,† JOHN D. CHRISTEIN, M.D.* From the *Department of Surgery and the †School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama Early diagnosis and curative resection are significant predictors of survival in patients with pancreatic cancer. We hypothesize that cholecystectomy within 12 months of pancreatic cancer affects 1-year survival. The Surveillance Epidemiology and End Result (SEER) database linked to Medicare data was used to identify patients diagnosed with pancreatic cancer who underwent cholecystectomy 1 to 12 months prior to cancer diagnosis. The SEER database identified 32,569 patients from 1995 to 2002; 415 (1.3%) underwent cholecystectomy prior to cancer diagnosis. Patients who underwent cholecystectomy had a higher proportion of diabetes (40.2% vs 20.5%; P < 0.01), obesity (8.9% vs 3.1%; P < 0.01), jaundice (17.3% vs 0.7%; P < 0.01), cholelithiasis (70.4% vs 4.2%; P < 0.01), choledocholithiasis (0.7% vs 0.0%; P < 0.01), weight loss (17.3% vs 4.7%; P < 0.01), abdominal pain (79.5% vs 22.5%), steatorrhea (0.7% vs 0.0%; P < 0.01), and cholecystitis (32.3% vs 1.7% ; P < 0.0001). After controlling for tumor stage, patient demographics, and symp- toms, survival at 1 year was significantly lower in patients undergoing cholecystectomy (OR, 0.75; 95% CI, 0.58–0.97). Recent cholecystectomy is associated with decreased 1-year survival among patients with pancreatic cancer. For patients older than 65 years of age, further evaluation prior to cholecystectomy may be necessary to exclude pancreatic cancer, especially patients with jaundice, weight loss, and steatorrhea. P ANCREATIC CANCER IS THE fourth leading cause of cancer death in the United States with an overall 5-year survival rate of less than 4 per cent. 1 The American Cancer Society predicted 37,170 new cases and 33,370 deaths from pancreatic cancer in 2007. 2 The poor prognosis is related to nonspecific presenting symptoms, advanced disease at presentation, and lack of effective adjuvant and nonoperative treatment mo- dalities. Operative resection represents the only chance for cure, although 5-year survival rates of only approach 20 per cent at high-volume centers. 3–7 Un- fortunately, as a result of the late presentation of symptoms, only 10 per cent to 20 per cent of patients with pancreatic cancer are candidates for surgical re- section. Although symptoms often do not arise until late in the course of the disease, they often mimic other common disorders of biliary origin. Patients with pancreatic cancer who present with biliary-like symp- toms often undergo cholecystectomy prior to the di- agnosis of malignancy. Cholecystectomy is recommended for those who experience biliary colic, acute cholecystitis, cholangi- tis, or gallstone pancreatitis. 8 The introduction of lap- aroscopic cholecystectomy has led to increased chole- cystectomy rates and a decreased threshold for surgical intervention. 9–13 Biliary-type symptoms have shown improvement after cholecystectomy, although the definition of these symptoms has varied and are often vague. 14, 15 Unfortunately, actual symptoms caused by gallstones are incompletely understood, making it difficult to define symptoms that will be cured by cholecystectomy. 16 As a result of the lack of specificity of pancreatic cancer symptoms while still at an early stage of disease, patients are often treated for more common disorders such as gallstones prior to more extensive evaluation. Furthermore, prior studies have demonstrated that early stage at diagnosis and curative resection are the key factors determining outcome in patients with pan- creatic cancer. 6, 17 We hypothesize that cholecystecto- my within 12 months prior to the diagnosis of pancre- atic cancer affects outcomes. The aim of this study is to describe a cohort who underwent cholecystectomy Presented at the Annual Scientific Meeting and Postgraduate Course Program, Southeastern Surgical Congress, Birmingham, AL, February 9–12, 2008. Address correspondence and reprint requests to John D. Chris- tein, M.D., University of Alabama, 1530 3rd Avenue South, KB 417, Birmingham, AL 35294. E-mail: John.Christein@ccc.uab.edu. 602