Resected pancreatic cancer

Pancreatic cancer is a systemic disease for most patients, and two-thirds of patients have locally advanced or metastatic disease at the time of diagnosis. For the subset of patients (20%) who present with potentially resectable tumors, the 5-year survival rate for those whose tumors are successfully resected is approximately 15-20% and lower for those with positive nodes or margins [1]. Patients usually succumb to metastatic disease or locoregional failure. As with other cancers, the rationale for postoperative therapy is to treat micrometastatic disease and improve survival in patients with resected cancer; unfortunately, despite more than two decades of research, there is no consensus on the best postoperative therapy for pancreatic adenocarcinoma. In a study reported in 1999, trends in disease stage, treatment patterns, and outcomes were analyzed for patients diagnosed with pancreatic adenocarcinoma between 1985 and 1995 [2]. Data were available for 100,313 patients. For the 9,044 patients who underwent pancreatectomy, the overall 5-year survival rate was 23.4%. Adjuvant treatment was used in 40% of cases and consisted of radiation therapy, chemotherapy, or both in 6.5%, 5.1%, and 28.3% of patients, respectively. The approach to adjuvant therapy also differs between high-volume centers in the USA and Europe. Some of the barriers to determining the best postoperative therapy include poor surgical recovery that complicates the use of chemotherapy and chemoradiation therapy, poor patient selection and inadequate staging studies for patients in postoperative trials, lack of standardized criteria for evaluating resection margins, and lack of chemotherapy with significant activity in pancreatic adenocarcinoma. More recently, preoperative or neoadjuvant treatments have been explored as an alternative to adjuvant therapy. In this chapter, we review the data for adjuvant and neoadjuvant strategies for the treatment of pancreatic cancer.