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Chapter 348Patients and methodsPatient selectionAll adult patients newly diagnosed with PDAC between 2015 and 2018 who started systemic treatment were identified in the Netherlands Cancer Registry (NCR) for inclusion in this retrospective cohort study. The NCR is a population based database, hosted by the Netherlands Comprehensive Cancer Organization (IKNL) and covers all patients with a newly diagnosed malignancy in the total Dutch population of 17.2 million people in 2018. Notification sources were the Dutch nationwide pathology databank (PALGA) and supplemented with the Dutch National Hospital Care Registration (LBZ). In order to select patients who were treated with palliative intent, we excluded patients who underwent resection of the primary tumor or another local treatment with curative intent, e.g. neoadjuvant chemoradiotherapy in the PREOPANC trial (10), and patients with a documented curative intent treatment plan at diagnosis (based on arterial and venous involvement of the primary tumor and TNM tumor stage (https://dpcg.nl)). Patient characteristics (sex, age, performance status, previous cancer diagnosis, comorbidities), tumor (TNM stage, tumor histology, location of metastases), treatment (systemic treatment, radiotherapy, other local therapy) were recorded from the hospital%u2019s electronic health record system by trained registrars of the NCR. Response data were also recorded from the hospital%u2019s electronic health record system when available. Vital status was obtained by annual linkage to the Municipal Personal Records Database. This study was designed in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines (11). The scientific committees of the Dutch Pancreatic Cancer Group (DPCG) and the Netherlands Cancer Registry (NCR) approved the study. Medical ethical approval was not required.Palliative systemic therapyIn the selected patient group, type and timing of cancer treatments between diagnosis and death (or up to 3 years after diagnosis) were collected from the NCR database, as well as date(s) of progression. Systemic therapy regimens were classified as follows: FOLFIRINOX (5-FU in combination with irinotecan and oxaliplatin), gemcitabine + nab-paclitaxel, gemcitabine monotherapy, and other less commonly used regimens. Second line therapy was defined as treatment with agents not used in first line Reintroduction of FOLFIRINOX was defined as