Perioperative Chemotherapy for Pancreas Cancer: Quo Vadis?

Primary surgical resection alone offers the chance for cure in a small minority of patients with pancreatic ductal adenocarcinoma (PDAC), because it is an aggressive, systemic disease from the outset. The integration of multiagent cytotoxic therapies with surgical resection has become a foundational treatment paradigm. While the introduction of adjuvant chemotherapeutic regimens was the first to demonstrate significant improvements in survival, they are limited by the inability to treat systemic disease early. Importantly, up to 50% of patients do not receive adjuvant therapy because of early recurrence or intolerance following surgery. Neoadjuvant therapies, however, can treat systemic disease earlier, are perhaps better tolerated resulting in more total chemotherapy exposure, and better identify aggressive disease biology to avoid futile surgical interventions. However, this must be weighed against the need for biopsy-confirmed pathologic diagnosis, risk of delaying or missing the opportunity for curative resection, and potential for complications related to treatment. Thus, there is considerable interest in better defining neoadjuvant or perioperative chemotherapy strategies for those diagnosed with localized PDAC. …