Neoadjuvant Therapy Followed by Resection Versus Upfront Resection for Resectable Pancreatic Cancer: A Propensity Score Matched Analysis

Abstract

Background and aim: To compare cancer-specific survival (CSS) between patients who received neoadjuvant radiation followed by resection (NRR) and those who received upfront resection (UR) for locally advanced pancreatic cancer (LAPC). Methods: A total of 772 LAPC patients who underwent curative-intent surgical resection with or without neoadjuvant radiation from 2004 to 2013 were identified from the Surveillance, Epidemiology, and End Result (SEER) database. Propensity score matching (PSM) was conducted to eliminate possible bias. Kaplan-Meier method was used to analyze long-term outcome. Independent risk factors of CSS were predicted by Cox proportional hazards model. Subgroup analyses were done according to 5 variables. Results: The propensity score model matched 196 patients from the whole cohort. Neoadjuvant radiation was an independent predictor of CSS no matter before or after PSM. After PSM, the 1-, 3-, 5-year CSS rates of NRR group were 82.7%, 39.2% and 17.1%, while 64.3%, 19.9% and 12.4% for UR group. The median CSS for NRR group was 25 months, while 17 months for UR group. In subgroup analyses, CSS rates or median CSS of NRR group were still superior to those of UR group in married, unmarried, pancreatic adenocarcinoma, G1+G2, G3+G4, N0 stage, N1 stage and M0 stage subgroups, but no differences were found in other histological types and M1 stage subgroups. Other predictors of CSS included histological type, tumor grade and marital status. Conclusions: Neoadjuvant radiation followed by resection has a significant survival benefit compared with upfront resection in LAPC patients. Therapeutic strategy for LAPC patients should be further explored.

Neoadjuvant Chemotherapy with Gemcitabine Plus Nab-paclitaxel Reduces the Number of Cancer-associated Fibroblasts Through Depletion of Pancreatic Stroma

“…NAC prior to resection is associated with a significant survival benefit compared with upfront resection in patients with early-stage, resected PDAC (29). Several randomized studies comparing various NAC regimens with upfront surgery are in progress around the world.…”

Onco-surgical Strategies in Pancreatic Ductal Adenocarcinoma

“…Furthermore, the proportion of patients with neadjuvant chemotherapy who were deemed resectable at laparotomy varies between 38% and 89% (32). Nevertheless, recently Mokdad and co-workers have shown that the use of neoadjuvant chemotherapy for localized, resectable PDAC has been associated with improved survivals (62). Conversely, a recent systematic review and meta-analysis has shown no potential benefit of neoadjuvant therapy for resectable PDAC (63).…”

When, What, and Why of Perioperative Treatment of Potentially Curable Pancreatic Adenocarcinoma

“…Use of neoadjuvant chemotherapy before surgical resection-an approach with growing utilization-is highlighted in the article by Mokdad and colleagues. 6,7 Postoperative chemotherapy improves survival in patients with resected pancreatic cancer, but adjuvant treatment can be limited by postoperative complications, poor tolerance, and early disease recurrence. To improve compliance with systemic therapy, address occult micrometastatic disease earlier in the treatment course, and better select patients for surgical resection, an alternative approach of delivering therapy before resection has been advocated.…”

“…The authors used propensity score matching to control for baseline differences in the two groups and demonstrated a modestly increased survival among patients who received neoadjuvant therapy. 6 Although these findings are a valuable addition to the literature, inherent limitations of the nonrandomized retrospective design temper their immediate applicability to practice and, at the same time, further support the need for well-designed randomized studies that evaluate the neoadjuvant treatment approach.…”