Comparison the efficacy and safety of different neoadjuvant regimens for resectable and borderline resectable pancreatic cancer: a systematic review and network meta-analysis

Li, Xujia; Huang, Jinsheng; Jiang, Chang; Chen, Ping; Qi, Qi; Jiang, Qi; Li, Shengping; Guo, Guifang

doi:10.1007/s00228-022-03441-9

Cited by 6 publications

(13 citation statements)

References 44 publications

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“…An advantage in favor of neoadjuvant treatment was found in the overall analysis, confirmed in the subgroup of resectable patients (hazard ratio = 0.73, 95% CI 0.59–0.91). This has been confirmed by a more recent work including 12 randomized trials of neoadjuvant chemotherapy or chemoradiotherapy (5 including only resectable cancers, 5 borderline cancers, and 3 a mixture of both) [38 ▪ ]. The results are very consistent with an OS advantage in favor of neoadjuvant treatment for resectable cancer (hazard ratio = 0.69, 95% CI 0.54–0.87).…”

Section: Neoadjuvant Treatment In Resectable Pancreatic Cancersupporting

confidence: 60%

Adjuvant and neoadjuvant approaches in pancreatic cancer

Conroy

Lambert

Ducreux

2023

Current Opinion in Oncology

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Purpose of reviewPancreatic cancer treatment remains a challenging problem for surgeons and oncologists. This review aims to summarize the current advances on adjuvant and neoadjuvant treatment approaches for resectable pancreatic cancer. Recent findingsRecent phase III randomized trials of adjuvant therapy showed improvement of overall survival in both experimental and control groups. Effectiveness of adjuvant therapy in specific subgroups as elderly patients, intraductal papillary mucinous neoplasms, stage I, and DNA damage repair gene germline variants has been reported. Completion of all cycles of planned adjuvant chemotherapy is confirmed as an independent prognostic factor. Adjuvant chemotherapy remains underutilized, mainly because of early recurrence, prolonged recovery, or older age older than 75 years. So, neoadjuvant treatment is a logical approach to administer systemic treatment to more patients. Meta-analysis did not demonstrate an overall survival benefit of neoadjuvant treatments in resectable pancreatic cancer, and definitive conclusions cannot be drawn from available randomized controlled trials. Upfront surgery and adjuvant chemotherapy should still be considered a standard approach in resectable pancreatic cancer.

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Section: Neoadjuvant Treatment In Resectable Pancreatic Cancersupporting

confidence: 60%

Adjuvant and neoadjuvant approaches in pancreatic cancer

Conroy

Lambert

Ducreux

2023

Current Opinion in Oncology

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“…On the contrary, other meta-analyses have suggested that neoadjuvant chemoRT, when compared with up-front surgery, was not associated with improved OS. 52,77,78 In summary, the current data do not support the universal use of neoadjuvant chemoRT for patients with anatomically resectable PDAC (Table 1). total of 246 patients with anatomically resectable (54%) or BR (46%) PDAC were randomized to a neoadjuvant regimen of 3 cycles of gemcitabine combined with chemoRT (36 Gy/15 fractions) or to up-front surgery.…”

Section: Initially Resectable Diseasementioning

confidence: 74%

“…These results have been further corroborated by several cohort studies, matched-propensity analyses, systematic reviews, and meta-analyses comparing neoadjuvant therapy approaches to up-front surgical approaches, although the studies are limited due to variability in definitions of resectability and treatment regimens 38,41–61 . A meta-analysis of 27 studies and 63,151 patients, including 8461 who received neoadjuvant chemotherapy and 54,690 patients who received up-front surgery, demonstrated that neoadjuvant chemotherapy resulted in a better OS (hazard ratio [HR]: 0.72, 95% CI: 0.69-0.76) and improved R0 resection rate (HR: 0.62, 95% CI: 0.60-0.65) compared with up-front surgery 41 …”

Section: Summary Of Literature Reviewmentioning

confidence: 83%

“…For example, Cloyd et al 43 reported a meta-analysis of 6 randomized trials evaluating either neoadjuvant gemcitabine-based chemoRT or gemcitabine-based systemic therapy alone compared with up-front surgery and found that both neoadjuvant chemoRT or chemotherapy alone were associated with improved OS. On the contrary, other meta-analyses have suggested that neoadjuvant chemoRT, when compared with up-front surgery, was not associated with improved OS 52,77,78 …”

Section: Summary Of Literature Reviewmentioning

confidence: 96%

“…Multiple meta-analyses 43,50–52,77,78 and single or multi-institutional retrospective series have similarly suggested improved rates of R0 resection, 43,50,78,88–90 pathologically negative lymph nodes 43,91 locoregional control, 90 and OS 43,52,77,78,88–92 for patients treated with neoadjuvant chemoRT. In addition, single-arm phase 2 trials and retrospective series from high-volume centers, including patients predominantly treated with an initial systemic therapy strategy of FOLFIRINOX, gemcitabine, or GnP, followed by chemoRT 80,83,87,93–96 or stereotactic body radiotherapy (SBRT), 97–103 have demonstrated favorable rates of R0 resection (80% to 100%), locoregional control (80% to 94%), and median OS ranging from ~24 to 58 months.…”

Section: Summary Of Literature Reviewmentioning

confidence: 99%

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Executive Summary of the American Radium Society Appropriate Use Criteria for Neoadjuvant Therapy for Nonmetastatic Pancreatic Adenocarcinoma

Jethwa,

Kim,

Berlin

et al. 2023

American Journal of Clinical Oncology

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For patients with locoregionally confined pancreatic ductal adenocarcinoma (PDAC), margin-negative surgical resection is the only known curative treatment; however, the majority of patients are not operable candidates at initial diagnosis. Among patients with resectable disease who undergo surgery alone, the 5-year survival remains poor. Adjuvant therapies, including systemic therapy or chemoradiation, are utilized as they improve locoregional control and overall survival. There has been increasing interest in the use of neoadjuvant therapy to obtain early control of occult metastatic disease, allow local tumor response to facilitate margin-negative resection, and provide a test of time and biology to assist with the selection of candidates most likely to benefit from radical surgical resection. However, limited guidance exists regarding the relative effectiveness of treatment options. In this systematic review, the American Radium Society multidisciplinary gastrointestinal expert panel convened to develop Appropriate Use Criteria evaluating the evidence regarding neoadjuvant treatment for patients with PDAC, including surgery, systemic therapy, and radiotherapy, in terms of oncologic outcomes and quality of life. The evidence was assessed using the Population, Intervention, Comparator, Outcome, and Study (PICOS) design framework and “Preferred Reporting Items for Systematic Reviews and Meta-analyses” 2020 methodology. Eligible studies included phases 2 to 3 trials, meta-analyses, and retrospective analyses published between January 1, 2012 and December 30, 2022 in the Ovid Medline database. A summary of recommendations based on the available literature is outlined to guide practitioners in the management of patients with PDAC.

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