Background: Pancreatic ductal adenocarcinoma continues to be a devastating disease and only 15-20% of patients are resectable at diagnosis(1). For these patients, overall survival remains poor and up to 30% do not receive adjuvant chemotherapy due to surgical morbidity(2). The introduction of neoadjuvant chemotherapy (NAC) for this cohort has replaced upfront surgery (UFS) as the new standard of care around the world. Currently, there are no completed randomised controlled trials that support the use of either treatment pathway over the other. This retrospective cohort analysis was conducted to compare and contrast both treatment pathways.
Methods: Medical records from one large volume pancreatic cancer centre were reviewed to identify any patient that presented with upfront resectable pancreatic cancer from the years 2013-2019.
Results: One hundred and twenty-six patients were included in our analysis; 86 (68%) of patients were treated with UFS and 40 (32%) of patients were treated with NAC. A significantly longer median OS was observed in patients with upfront small-volume disease (stage 1a) who underwent UFS compared to NAC (24 vs 21 months, p=0.028). Complication rates (p=0.036) were significantly higher in the NAC group whilst R0 resections were similar in both groups (p=0.605).
Discussion: For all patients regardless of stage no difference in overall survival existed between patients in the NAC versus UFS groups. Planned subgroup analysis for early stage (1a) disease did demonstrate a survival benefit in patients in the UFS group. A prospective clinical trial in this cohort incorporating tumour biology is needed to substantiate these findings.