The Cost-Effectiveness of Neoadjuvant Chemoradiation is Superior to a Surgery-First Approach in the Treatment of Pancreatic Head Adenocarcinoma

Abbott, Daniel E.; Tzeng, Ching Wei D.; Merkow, Ryan P.; Cantor, Scott B.; Chang, George J.; Katz, Matthew H.; Bentrem, David J.; Bilimoria, Karl Y.; Crane, Christopher H.; Varadhachary, Gauri R.; Abbruzzese, James L.; Wolff, Robert A.; Lee, Jeffrey E.; Evans, Douglas B.; Fleming, Jason B.

doi:10.1245/s10434-013-2882-0

Cited by 63 publications

(33 citation statements)

References 32 publications

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“…The main potential advantages of neoadjuvant strategies are: i) increased resectability and likelihood of margin-negative resection, which is relevant, as patients with BRPAC or LAPAC exhibit a similar prognosis to those with immediately resectable PAC if R0 resection can be achieved (10); ii) increased likelihood of completion of multimodal treatment, which is possibly the most effective way to improve the outcome of patients with BRPAC or LAPAC; iii) prevention of unnecessary surgery in aggressive, treatment-resistant disease; iv) evaluation of chemo-sensitivity and increased patient's compliance (32); v) minimization of pancreatic leak without increase of postoperative complications (33-37); and vi) cost-effectiveness (38).…”

Section: Discussionmentioning

confidence: 99%

“…These studies are difficult to interpret, as they have used various definitions of BRPAC, different induction and post-resection regimens, and, if applied, incorporated varied radiation therapy plans (38)(39)(40)(41)(42). The most active regimens for advanced disease offer the best chance of achieving downstaging and systemic disease control.…”

Section: Discussionmentioning

confidence: 99%

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Neoadjuvant chemotherapy in borderline resectable pancreatic cancer: A case report

2017

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Abstract. Pancreatic cancer is the fourth leading cause of cancer mortality and is associated with a poor overall survival even when diagnosed early and considered resectable. Complete surgical removal with negative histological margins is an independent predictor of survival and remains the only potential curative treatment. In borderline resectable pancreatic adenocarcinoma (BRPAC), preoperative systemic therapy may increase resectability and margin-negative resection rate. There is no current consensus on the optimal chemotherapy regimen for BRPAC. The present case describes a patient with BRPAC who achieved a pathological complete response to neoadjuvant FOLFIRINOX (folinic acid, fluorouracil, irinotecan and oxaliplatin), but early relapse following a pancreaticoduodenectomy without vascular resection, with an uneventful postoperative course, except for a pulmonary embolism.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Neoadjuvant chemotherapy in borderline resectable pancreatic cancer: A case report

2017

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“…In addition, NT is cost-effective and allows to “selectin” patients with localized disease whom would benefit most from resection, and avoid the morbidity of PD in patients who will demonstrate radiographic evidence of metastatic disease during the course of NT 31–34 Currently, we lack the tools to accurately predict which patients are at risk for OAT and ER, and would therefore derive benefit from multimodality treatment upfront with NT; this is the strength of our study.…”

Section: Discussionmentioning

confidence: 99%

Early Recurrence and Omission of Adjuvant Therapy after Pancreaticoduodenectomy Argue against a Surgery-First Approach

et al. 2016

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Background Sequencing therapy for patients with periampullary malignancy is controversial. Clinical trial data report high rates of adjuvant therapy completion, though contemporary, real-world rates remain incomplete. We sought to identify patients who failed to receive adjuvant therapy and those at risk for early recurrence (ER) who might benefit most from neoadjuvant therapy (NT). Methods We retrospectively reviewed medical records of 201 patients who underwent pancreaticoduodenectomy for periampullary malignancies between 1999 and 2015; patients receiving NT were excluded. Univariate and multivariate analyses were performed to identify predictors of failure to receive adjuvant therapy and ER (within 6 months) as the primary end points. Results The median age at the time of surgery was 65.5 years (interquartile range 57–74 years). The majority of tumors were pancreatic ductal adenocarcinoma (76.6 %), and 71.6 % of patients received adjuvant therapy after resection. Univariate predictors of failure to undergo adjuvant therapy were advanced age, age-adjusted Charlson comorbidity index, operative transfusion, reoperation, length of stay, and 30- to 90-day readmissions (all p < 0.05). Advanced age, specifically among patients >70 years, persisted as a significant preoperative predictor on multivariate analysis (p < 0.01). Patients who failed to receive adjuvant therapy and/or developed ER had significantly worse overall survival rates compared to all other patients (27.8 vs. 9.7 months; p < 0.01). Conclusions Approximately one-third of surgery-first patients undergoing pancreaticoduodenectomy at our institution did not receive adjuvant therapy and/or demonstrated ER. This substantial subset of patients may particularly benefit from NT, ensuring completion of multimodal therapy and/or avoiding futile surgical intervention.

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“…Evaluation of the Surveillance, Epidemiology and End Results registry from 1994 to 2003 found that patients receiving neoadjuvant CRT have significantly higher rates of survival relative to non-neoadjuvant CRT (hazard ratio 0.55, 95% CI 0.38-0.79; p = 0.001) and adjuvant radiation therapy (hazard ratio 0.63, 95% CI 0.45-0.90; p = 0.03) [30]. Furthermore, neoadjuvant CRT is not only associated with improved survival, but also a significantly lower cost than surgery-first approaches [31]. …”

Section: Neoadjuvant Chemoradiationmentioning

confidence: 99%

Treatment of Locally Advanced Pancreatic Ductal Adenocarcinoma

Loehrer¹,

Ferrone²

2016

Dig Surg

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Pancreatic ductal adenocarcinoma (PDAC) is increasingly common and a leading cause of cancer-related mortality. Surgery remains the only possibility for cure. Upwards of 40% of patients present with locally advanced PDAC (LA-PDAC), where management strategies continue to evolve. In this review, we highlight current trends in neoadjuvant chemotherapy, surgical resection, and other multimodality approaches for patients with LA-PDAC. Despite promising early results, additional work is needed to more accurately and appropriately tailor treatment for patients with LA-PDAC.

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The Cost-Effectiveness of Neoadjuvant Chemoradiation is Superior to a Surgery-First Approach in the Treatment of Pancreatic Head Adenocarcinoma

Cited by 63 publications

References 32 publications

Neoadjuvant chemotherapy in borderline resectable pancreatic cancer: A case report

Neoadjuvant chemotherapy in borderline resectable pancreatic cancer: A case report

Early Recurrence and Omission of Adjuvant Therapy after Pancreaticoduodenectomy Argue against a Surgery-First Approach

Treatment of Locally Advanced Pancreatic Ductal Adenocarcinoma

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