If the locally advanced pancreatic cancer is unresectable, what other option does the patient has?
As clinical oncologist, it’s nice to have another arsenal against cancer; radiotherapy.
Pre-operative chemo-radiation is effective in locally advanced pancreatic cancer to convert it from borderline resectable/ unresectable to resectable.
- By giving chemotherapy and radiotherapy together, studies showed that up to 33% on initially borderline resectable/ unresectable cases was successfully converted to resectable tumor (Gillen S, 2010)
- Almost 80% of those tumor resected in initially borderline resectable/ unresectable cases was R0 resection, which means no cancer cells seen microscopically at the resection margin, perfect surgery!
- Treatment intention for complete resection is curative intent.
- Average survival was 20.5 months (1-yr survival rate 80%, 2-yr survival rate 50%) for those initially unresectable but was successfully converted to resectable tumor and underwent surgery.
You might ask, how can chemotherapy alone with FOLFORINOX managed to achieve average survival of 24 months while curative treatment with concurrent chemo-radiation also managed to achieve average survival roughly the same, if not lesser?!
One likely reason is high peri-operative mortality about 7% (7 out of 100 patients who underwent surgery died).
How to reduce peri-operative mortality?
- Patient selection must be refined based on through multidiscipline discussions
- Patient performance status/ fitness level must undergo rigorous testing.
- Surgery should also be performed in high volume centre.
- Better imaging modalities to prevent ‘open-and-close’ surgery
It’s better to spare patient going under the knife if it will cause more harm, even if chances of curative surgery is there; since palliative chemotherapy can also achieve similar average survival.
I can’t emphasise enough again the role of a good surgeon and good surgery to remove the tumor/ primary in totality if the cancer is resectable.
If surgery is attempted and is successful, it should be followed by additional/ adjuvant treatment (chemotherapy, radiotherapy, etc.) to deal with microscopic cancer cells that might be present and cannot be seen by surgeon during surgery.
Surgery removes the cancer, adjuvant/ additional treatment prevents cancer from coming back