What is the role of adjuvant therapy in the treatment of pancreatic cancer?

Updated: Oct 02, 2020
  • Author: Tomislav Dragovich, MD, PhD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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Several studies (including the GITSG, ESPAC, CONKO) suggested the possibility that chemotherapy, with or without radiation therapy, would significantly improve median survivals following surgical resection of operable disease. [80, 81] These studies were not definitive and not widely accepted as justification for offering either modality for adjuvant therapy.

However, a large, retrospective study supported the use of adjuvant chemoradiotherapy. Yang et al analyzed a registry of 2,877 patients who underwent surgical resection with curative intent for pancreatic adenocarcinoma; approximately half received no adjuvant therapy, and approximately a quarter received postoperative chemoradiotherapy. A significant survival benefit was found for the chemoradiotherapy patients. [82] In 2011, the NCCN panel recommended the measurement of serum CA 19-9 levels after surgery and before adjuvant therapy. [2]

A study by Neuhaus et al in 368 patients with resected pancreatic cancer found that adjuvant gemcitabine prolongs survival when compared with surgery alone. [83] The 3-year survival rates were 36.5% and 19.5% for the gemcitabine and surgery-only arms of the study, respectively. The 5-year survival rates were 21% and 9% for the gemcitabine and surgery-only arms, respectively.

This trial was definitive and transformative. Adjuvant therapy with gemcitabine is now accepted as standard therapy for surgically resected pancreatic cancer. [7]  However, the superior survival demonstrated with modified FOLFIRINOX (mFOLFIRINOX) may well make that regimen the standard of care for nonmetastatic pancreatic ductal adenocarcinoma in patients who have undergone surgical resection and have a good performance status (see Chemotherapy). [9, 2]

A systematic review and meta-analysis by Wan et al found that adjuvant therapy with metformin signficantly reduced the risk of death in Asian patients with pancreatic cancer (hazard ratio [HR]=0.74]), but not in whites. Mortality risk was reduced in patients with stage I-II disease treated with metformin (HR=0.76, 95% CI=0.68-0.86) as well as in those with stage I-IV disease (HR=0.88, 95% CI=0.79-0.99), but not in those with stage III-IV disease. [84]

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