In a certain sense, treatment selection by professionals is easier in early or late stage pancreatic cancer (ductal adenocarcinoma of the pancreas) because the options tend to be narrower: early yields surgery; late leans toward chemotherapy alone. The middle stages II and III, or locally advanced, potentially resectable pancreatic cancer, etc. tend to be more problematic in terms selecting the optimal course of action among the array of initial treatment options. The term that Farnell, et al. use for assessing this treatment option situation in the article reviewed is “poorly defined.”
The authors, all from the surgical service at the Mayo Clinic in Rochester, Minnesota, retrospectively reviewed a nine-year period beginning in 2002 for the outcome of survival duration in patients with stage 3 pancreatic cancer in the U.S. National Cancer Data Base, dividing them into those who received neoadjuvant therapy as the initial treatment modality with an intention for subsequent pancreatic cancer surgery, or as having received surgery first with adjuvant therapy to come later. The results were published in the October 2016 issue of the journal Surgery.
Almost 600 patients in these two categories were identified, about two-thirds in the neoadjuvant pancreatic cancer group and the rest in the surgery first group. However, over a quarter of the neoadjuvant patients were unable to receive pancreatic cancer surgery due to preoperative attrition, leaving 273 patients who were able to undergo both neoadjuvant therapy and pancreatic surgery. In the surgery first group approaching 14% of patients did not receive adjuvant therapy leaving 186 patients with pancreatic cancer who received both modalities.
The overall survival of these two groups with pancreatic cancer was 20.7 months for the neoadjuvant therapy group, and 13.7 months for the surgery first group (P = .0012).
This is an impressive survival advantage for state 3 patients with pancreatic cancer receiving neoadjuvant therapy prior to surgery, although the high rate of those unfortunately unable to ultimately receive the planned surgery is noted. This is a commendable and good step forward in trying to provide illuminating light in the otherwise somewhat murky area of the optimal treatment strategy for the presenting middle stages of pancreatic cancer. More research in this area is needed, including teasing out options for different circumstances, and ultimately involving prospective studies.
Dale O’Brien, MD