The Promise of Modern Radiotherapy in Resected Pancreatic Adenocarcinoma: A Response to Bekaii-Saab et al.

Abstract

Determining the optimal adjuvant management strategy for patients with resected pancreatic adenocarcinoma remains a controversial topic. In particular, defining the role for radiation continues to generate significant debate. As such, we welcome sustained investigation into whether radiation can improve oncologic outcomes after resection of pancreatic cancer. We therefore appreciate the work done by Bekaii-Saab et al. to review their institution’s experience with adjuvant chemoradiation for localized pancreatic cancer in which they find no benefit on overall survival or local control when comparing patients treated with chemoradiation versus chemotherapy alone. Despite their results, we disagree with the authors’ conclusion that there is ‘‘no benefit from chemoradiation over chemotherapy in the adjuvant treatment of pancreas cancer’’ and that ‘‘based on the available data and outside of a clinical trial, patients should be treated with chemotherapy alone following surgery.’’ Appreciation of the potential that modern radiotherapy may have for resected pancreatic cancer requires a historical understanding of early clinical trials that explored chemoradiation, some of which are referenced by the authors. Early institutional reports demonstrated poor local control after surgical resection of pancreatic cancer, with local failure rates of roughly 50 %. 1 As such, the Gastrointestinal Tumor Study Group (GITSG) undertook a clinical trial comparing 5-fluorouracil (5-FU)-based chemoradiation versus observation in patients undergoing Whipple resection. The chemoradiation arm experienced improved 2-year overall survival (42 vs. 15 %, p = 0.03), leading to widespread adoption of adjuvant chemoradiation in the United States. 2 However, this survival benefit could not be replicated in subsequent trials by the European Organization for Research and Treatment of Cancer (EORTC) and the European Study Group for Pancreatic Cancer (ESPAC), with the latter trial demonstrating the best outcomes in patients treated with chemotherapy alone. 3,4 The