Use of Systemic Therapy for Resectable Pancreatic Cancer

For High-Definition, Click

Accurate staging and appropriate patient selection for surgery is vital in pancreatic cancer treatment. Even with a good resection and negative margins, the majority of patients will still experience disease relapse or recurrence, presumably because of the presence of micrometastases after surgery, even with localized disease. Thus, better outcomes for pancreatic cancer are dependent on improving systemic therapy.

An experienced multidisciplinary team that deals with patients who have pancreatic cancer on a regular basis is best equipped to select appropriate surgical candidates. Having an R2 resection that leaves micrometastases behind does not improve survival, and puts the patient through an unnecessary major surgery. Factors such as pain, weight loss, performance status, and CA 19-9 level can indicate whether the patient has more extensive disease than what can be seen on imaging.

If there is uncertainty or if a patient is borderline resectable, neoadjuvant chemotherapy with or without radiotherapy can be a good option to determine which tumors can be downstaged and to help avoid R2 resections in those with inoperable or metastatic cancers. However, as of yet it is unclear how neoadjuvant therapy affects overall outcomes.

Based on data from CONKO-001, a prospective randomized phase III study, a standard of care for adjuvant therapy is six months of gemcitabine-based treatment. There is no consensus at this point as to whether adding a second drug in combination with gemcitabine or adding radiotherapy improves survival. These questions are currently being investigated in ongoing clinical trials.