The fact that the biology of pancreatic cancer is somewhat different from other cancers as is shown by dismal survival even after curative resection with or without adj chemo means that neo-adj treatment will not have the same benefit as in rectal cancer. Since the med oncologist outnumber the no of pancreatic surgeons and are far more enthusiastic, I am afraid they are going to take away patients for neo adj chemo from the surgeons denying them surgery the only potentially curative treatment. The main arguments favoring upfront Surgery are 1. Over 20% patients are lost during the first year in almost all studies of neo adj chemo. 2. No delay in the only definitive curative treatment that is surgery especially incase the disease is refractory to chemo. So the disease may progress during this period. 2. Adj chemo takes care of the growth of micro mets after surgery due to the spurt of growth factors in the post op period. 3. Nei adj treatment will require stent placement to relieve jaundice, so a higher rate of septic complications post op. 4. The benefit on median survival with Folfrinox in the Adj setting is significant ( >50 months). Besides neo- adj treatment so far has not produced better results , so the operable patients should not be denied the benefit of a potentially curative treatment. Finally it may be suggested that operable fit patients should have upfront surgery and others/ borderline resectable cases given pre-op therapy.
The fact of the matter is that starting from gemcitabine each new drug was thought by the medical oncologist to be the holy grail. I am afraid that the survival curves that presently look promising would ultimately join by five years ( actual survival) or soon thereafter.
The fact that the biology of pancreatic cancer is somewhat different from other cancers as is shown by dismal survival even after curative resection with or without adj chemo means that neo-adj treatment will not have the same benefit as in rectal cancer.
Since the med oncologist outnumber the no of pancreatic surgeons and are far more enthusiastic, I am afraid they are going to take away patients for neo adj chemo from the surgeons denying them surgery the only potentially curative treatment.
The main arguments favoring upfront Surgery are
1. Over 20% patients are lost during the first year in almost all studies of neo adj chemo.
2. No delay in the only definitive curative treatment that is surgery especially incase the disease is refractory to chemo. So the disease may progress during this period.
2. Adj chemo takes care of the growth of micro mets after surgery due to the spurt of growth factors in the post op period.
3. Nei adj treatment will require stent placement to relieve jaundice, so a higher rate of septic complications post op.
4. The benefit on median survival with Folfrinox in the Adj setting is significant ( >50 months). Besides neo- adj treatment so far has not produced better results , so the operable patients should not be denied the benefit of a potentially curative treatment.
Finally it may be suggested that operable fit patients should have upfront surgery and others/ borderline resectable cases given pre-op therapy.
The fact of the matter is that starting from gemcitabine each new drug was thought by the medical oncologist to be the holy grail. I am afraid that the survival curves that presently look promising would ultimately join by five years ( actual survival) or soon thereafter.