What is the current role of neoadjuvant chemotherapy in pancreatic cancer and how do you see this possibly changing in the future?

FAQ Library published on December 11, 2017
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Alok A. Khorana, MD
Professor of Medicine
Cleveland Clinic Lerner College of Medicine
Case Western Reserve University
Cleveland, Ohio
What is the current role of neoadjuvant chemotherapy in pancreatic cancer and how do you see this possibly changing in the future?

Welcome to Partners in Pancreatic Cancer. My name is Dr. Alok Khorana. I am frequently asked, “What is the current role of neoadjuvant chemotherapy in pancreatic cancer and how do you see this possibly changing in the future?” Neoadjuvant approaches, which refer to systemic or systemic plus radiation therapy upfront before resection, are increasingly becoming more common in patients with resectable and potentially resectable or borderline resectable pancreatic cancer. In the past, the standard approach was, if we think the patient was resectable, let's go ahead and resect the patient and then worry about reducing risk of recurrence afterwards. What we have seen in the decades since Whipple surgeries and distal pancreatomies have been offered to patients, we have seen improvements in perioperative complication rates and perioperative mortality where patients are doing much better with the actual operation itself. But, we have not seen improvements in long-term mortality. We still see a very high rate of recurrence after a major pancreatic resection. Our approaches have changed from saying, let's go with a local treatment, which is surgery first, to saying, let's go with the systemic treatment, either systemic combination therapy or combination of chemotherapy with radiation therapy and just make sure that we are giving patients the benefit of the doubt in terms of controlling systemic disease first, before we offer them a local operation. Sometimes, these neoadjuvant approaches are formal in the form of a clinical trial. There is an ongoing SWOG study S1505 that offers upfront either FOLFIRINOX or gemcitabine and nab paclitaxel to patients who are potentially resectable. Sometimes the approaches are informal, so outside of the clinical trial where the surgeons and the multidisciplinary team feel that this is not a patient who would do well, or who would have a high probability of margin-positive disease or worse, and so, let's start with systemic therapy first, to see if we can downstage the patient. Let's make sure that we do not have occult systemic disease that is hiding somewhere and is not visible on scans, and once we get to the point where patients are doing well at that point, offer them resection. For most of our patients, I would say our approach is neoadjuvant first, generally for a period of 2 to 3 months; a small gap would be allowed then, to recover from the adjuvant therapy, and then resection followed by adjuvant therapy. Thank you for viewing this activity.

Last modified: October 19, 2017
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