Adjuvant and neoadjuvant approaches in pancreatic cancer.

Abstract

Pancreatic cancer treatment remains a challenging problem for surgeons and oncologists. This review aims to summarize the current advances on adjuvant and neoadjuvant treatment approaches for resectable pancreatic cancer. Recent phase III randomized trials of adjuvant therapy showed improvement of overall survival in both experimental and control groups. Effectiveness of adjuvant therapy in specific subgroups as elderly patients, intraductal papillary mucinous neoplasms, stage I, and DNA damage repair gene germline variants has been reported. Completion of all cycles of planned adjuvant chemotherapy is confirmed as an independent prognostic factor. Adjuvant chemotherapy remains underutilized, mainly because of early recurrence, prolonged recovery, or older age older than 75 years. So, neoadjuvant treatment is a logical approach to administer systemic treatment to more patients. Meta-analysis did not demonstrate an overall survival benefit of neoadjuvant treatments in resectable pancreatic cancer, and definitive conclusions cannot be drawn from available randomized controlled trials. Upfront surgery and adjuvant chemotherapy should still be considered a standard approach in resectable pancreatic cancer. Adjuvant chemotherapy with mFOLFIRINOX remains the standard of care in fit patients with resected pancreatic cancer, and limited high-level evidence support the use of neoadjuvant therapy in upfront resectable pancreatic cancer.