Living Longer: Early Stage/ Resectable Pancreatic Cancer

At diagnosis, less than 20% patients with pancreatic cancer can be resected due to late presentations and advance nature of the disease.

However, even in early stages and resectable pancreatic cancer, the average survival is between 15 months – 24 months.

Standard of care was for immediate surgical resection if tumor is resectable. Aim is for RO resection margin, meaning microscopically margin-negative resection. Following surgical resection, adjuvant chemotherapy is recommended to improve survival (5-FU, gemcitabine).

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Median/ average survival according to stage I-IV

An abstract for PREOPANC-1 trial was presented at ASCO 2018. PREOPANC-1 trial investigates additional treatments (preoperative chemoradiation, surgery, adjuvant chemotherapy) with current standard of care (surgery, adjuvant chemotherapy) for resectable and borderline resectable (more challenging group of patients) pancreatic cancer.

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ASCO Immediate Release: PREOPANC-1 trial

The summaries of the above study:

  • The median/ average overall survival was 17.1 months with preoperative chemoradiotherapy (CRT) compared to 13.7 months with immediate surgery.
    • The chance of surviving longer than 2 years was higher with preoperative treatment than with immediate surgery (42% vs 30%).
    • PRODIGE 24 (mFOLFORINOX vs gemcitabine) did have longer survival without preoperative CRT but all their patients had resectable pancreatic cancer (no borderline resectable pancreatic cancer) 
  • Rate of R0 resection (tumor completely removed microscopically) was doubled in the preoperative treatment arm compared with the standard-of-care arm, 63% vs 31% respectively (huge difference!).
  • Among patients in whom the tumor was surgically removed successfully, the difference in median survival was even greater: 42.1 months with preoperative treatment vs 16.8 months with immediate surgery.
  • Patient selection is very important
    • Reflected by the 10% of patients who died in the treatment interval between initiation of preoperative chemoradiation and surgery
    • Making the overall survival improvement less impressive in this trial

Finally

Will it change my managements for resectable and borderline resectable pancreatic cancer?

For borderline resectable pancreatic cancer, I’ll definitely opt for preoperative CRT.

  • Doubling results of R0 (microscopically margin-negative resection) which leads to doubling of average survival for those patients >40 months is no small feat in oncology.

Surgeons should refer to an oncologist for consideration of preoperative chemoradiation, especially for those with borderline resectability.

Patients will benefit immensely from these treatments.

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