Neoadjuvant chemotherapy or upfront surgery in localized pancreatic cancer: a contemporary analysis

Abstract

Neoadjuvant chemotherapy is considered a new treatment option for potentially resectable pancreatic cancer. However, data are not well established on overall survival and delaying surgery in resectable pancreatic cancer, as well as on those patients that ultimately cannot undergo surgery. We analyzed pancreatic cancer patients treated in a tertiary hospital from January 2016 to December 2020. Patients with resectable stage I and II pancreatic cancer were evaluated regarding surgery, neoadjuvant treatment, and other clinical demographics. The survival function was estimated using the Kaplan–Meier method, and the relationship between the variables of interest and the overall survival (OS) was assessed by adopting the proportional regression Cox models. A total of 216 patients were evaluated. 81 of them with resectable/borderline resectable disease and 135 with unresectable /metastatic disease at diagnosis. Median OS for stage I and II disease were 36 and 28 months, respectively. For resectable pancreatic cancer median OS was 28 months, for borderline resectable pancreatic cancer median OS was 11 months. Median OS for stage III (locally advanced) and stage IV (metastatic) were 10 and 7 months, respectively (p < 0.0001). Median OS of 9 months were obtained for patients with stage I and II that did not undergo surgery compared to 25 months in patients that underwent surgery in any time (p < 0.001). Comparing patients with localized disease, median OS for patients treated with upfront surgery was 28 months, compared to 15 months in patients treated with neoadjuvant approach (p = 0.04). Most patients that did not undergo surgery have decline of performance status or disease progression on neoadjuvant treatment. On multivariable analysis in pancreatic cancer stages I and II, including age, sex, borderline or resectable disease, CA 19–9, positive lymph nodes and neoadjuvant treatment, the surgery was the only factor associated with improved overall survival (p = 0.04). Upfront surgery should still be considered a standard of care approach for resectable pancreatic cancer. Biomarker driven studies and randomized trials with combination therapies are necessary to address neoadjuvant chemotherapy and delaying surgery in purely resectable pancreatic cancer.

Impact of COVID-19 on the gastrointestinal surgical oncology patient population

“…We report an increase in negative resection margins for some cohorts in the COVID-19 period compared to pre-COVID-19, which could be a consequence of this increased utilization of neoadjuvant therapy. While a good strategy for managing system resources and combating the consequences of surgical delays for many cancers, some gastrointestinal tract cancers lack strong evidence for efficacy of neoadjuvant chemotherapy, which limits the utility of this approach for some patients [ 30 ].…”

Focus on Therapeutic Options for Surgically Resectable Pancreatic Adenocarcinoma Based on Novel Biomarkers

“…One potential approach for identifying pancreatic ductal adenocarcinoma (PDAC) patients who would likely benefit from neoadjuvant therapy (NAT) is through the selection of biomarkers, such as GATA6 expression [62,63]. Tumors expressing GATA6, classified as the classical subtype, tend to exhibit higher responses to FOLFIRINOX, while those with the basal-like subtype have low or no GATA6 expression, leading to worse outcomes [64].…”

CD74 Promotes a Pro-Inflammatory Tumor Microenvironment by Inducing S100A8 and S100A9 Secretion in Pancreatic Cancer

“…Pancreatic ductal adenocarcinoma (PDAC) is an aggressive cancer characterized by a poor prognosis and high mortality rates. Despite improvements in treatments, the incidence of pancreatic cancer is increasing, and it is ranked the seventh leading cause of cancer deaths worldwide [ 1 , 2 ]. Approximately 80–85% of pancreatic cancers are determined as unresectable at the time of diagnosis, contributing to the low patient survival rates [ 3 ].…”