Survival outcomes between surgery with adjuvant therapy compared to neoadjuvant therapy with surgery in stage I pancreatic adenocarcinoma: Results from a large national cancer database.

Abstract

335 Background: There has been a paradigm shift in the treatment of stage 1 pancreatic adenocarcinoma (PAC) from surgery first followed by adjuvant therapy (AT) to Neoadjuvant therapy (NAT) first followed by surgery and this is reflected in the current NCCN guidelines as well. Data comparing these two modalities are limited. AIM: To compare long time survival between surgery vs Surgery + AT and NAT + Surgery in a large National Cancer Database. Methods: We identified patients with surgically resected AJCC clinical stage 1, 1A, and 1B PAC between 2004-2014. Patients were stratified into 3 groups to assess outcomes. Exclusion criteria: those with incomplete survival and sequence of therapy data. Hazard ratios (HR) were calculated for evaluation of survival, as well as for 30-Day and 90-Day Mortality between the 3 groups. Results were adjusted for age and Deyo-Charlson comorbidity index. Results: A total of 9684 pts with Clincal stage 1, 1A, 1B PAC between 2004-2014 were identified. Of these 2266 pts underwent surgery alone; 6222 had surgery followed by AT; and 1196 pts had neoadjuvant therapy followed by surgery. There was a HR of 0.995 (95% CI 0.935-1.058 p = 0.864) and 0.984 (95% CI 0.924-1.048, p = 0.617) for 30- and 90-Day mortality comparing upfront surgery to NAT, respectively. With AT as the reference group for survival, there was a HR of 1.362 (95% CI 1.286-1.443, p < 0.001) for surgery only and HR of 0.929 (95% CI 0.859-1.004, p = 0.064) for NAT. Conclusions: 1. Surgery alone had worse overall survival. 2. There was no significant difference in overall survival when comparing AT and NAT 3. A prospective randomized trial evaluating the differences in survival is needed.

Impact of Resection Margin Status in Patients with Pancreatic Cancer: a National Cohort Study

“…15 Neoadjuvant therapy can help with downstaging and treatment of occult metastasis which are present in 17% of patients with resectable disease, better patient compliance, and increase chance for margin negative resection. [18][19][20] Our analysis identified several factors that were predictors for positive margin following resection; in addition, we found that neoadjuvant treatment was an independent predictor that increased the likelihood for achieving R0 resection status. It is therefore important to consider neoadjuvant therapy for patients with resectable disease if they have known risk factors for a positive margin.…”

Response to Neoadjuvant Therapy and Prognosis in Patients with Resectable Pancreatic Cancer: A Propensity Score Matching Analysis

“…However, previous studies used clinical stage I and II disease as proxies for resectable disease as there is no direct way to assess resectability in their cancer registry. 14 , 18 , 19 Therefore, by definition, borderline resectable PDAC patients might have been enrolled in those studies. In real-world clinical practice, resectability is more important than tumor stage in determining the resection in pancreatic cancer.…”

Contemporary Reappraisal of Intraoperative Neck Margin Assessment During Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma

“…Neoadjuvant chemotherapy is well entrenched in the management of borderline resectable PDAC, and evolving paradigms advocate its application for resectable disease . The momentum for this approach is in part because of the advent of increasingly effective multiagent regimens (ie, mFOLFIRINOX and gemcitabine/nab-paclitaxel) with activity against PDAC.…”