A new study led by researchers from the University of Colorado Department of Surgery shows that giving chemotherapy prior to surgery to patients with resectable pancreatic cancer located in the pancreatic body or tail results in better outcomes compared to immediate surgery.
Published in January in the journal Annals of Oncology, the international study uses patient data from 18 countries, including countries in North America, Europe, Asia, and Oceania.
Anatomy and biology
“We suspected that the benefit of this so called ‘neoadjuvant therapy’ would be especially pronounced in tumors located in the body or tail of the pancreas, as opposed to the pancreatic head,” says corresponding author Thomas Stoop, MD, a researcher from the University of Amsterdam who served as a visiting research fellow in the CU Department of Surgery in 2023.
“The theory is that often those tumors located in the pancreatic body and tail present later — patients get symptoms later, in comparison to tumors located in the pancreatic head,” says Stoop, also the co-author of a recently released JAMA Oncology study that studied the value of chemotherapy following pancreatic surgery in patients with pancreatic cancer who received chemotherapy prior to surgery. “This delay in disease presentation gives the disease more time to spread through the blood. Those patients might benefit from starting with chemotherapy and then going to surgery, instead of going immediately to surgery.”
Pancreatic cancer expert Marco Del Chiaro, MD, PhD, professor and division chief of surgical oncology at CU and one of the leading authors of the Annals of Oncology paper, says the study is the largest of its kind to suggest that patients with pancreatic body/tail cancer benefit from neoadjuvant chemotherapy instead of immediate surgery.
“If we really believe that pancreas cancer is a systemic disease, then chemo should be the first tool used in every patient, including those who are easiest to operate on,” he says. “If you give chemo first and treat the systemic disease before you take it out, that seems to be associated, even in these resectable tumors, with an advantage in survival.”
Stoop notes that the study has some limitations in that it only studies patients who made it to surgery and didn’t develop disease progression during the chemo process. Interestingly, he says, the international data from this study show that patients with larger tumors and higher tumor marker levels in their blood are the ones who benefit the most from neoadjuvant chemotherapy — information that can help surgeons determine who will benefit most from this neoadjuvant chemotherapy.
“We see that anatomy matters — where the tumor is located and its size — but also that biology matters,” he says. “That combination can help us decide how to treat patients and how to select for surgery.”
Changes in treatment
The Annals of Oncology study comes amid a changing treatment paradigm for pancreatic cancer, Del Chiaro says. Traditionally, pancreatic cancer was approached based on anatomical criteria of the tumor, including the presence and extent of vascular tumor involvement. Nowadays, due to the introduction of more adequate chemotherapy regimens, both anatomical, biological, and conditional factors are leading in the staging and treatment decision-making of pancreatic cancer, as shown in the current study published in Annals of Oncology.
Though a prospective randomized trial would need to be conducted to objectively prove that neoadjuvant chemotherapy is superior to upfront surgery in patients with resectable pancreatic body/tail cancer, Del Chiaro says, the study provides overwhelming data for those who are still contemplating which direction to take.
“This paper seems to at least suggest that neoadjuvant treatment for resectable cancer located in the body and tail of the pancreas is a strategy not inferior to upfront surgery,” he says. “Even if it seems to be logical that chemotherapy could offer an advantage as upfront treatment in a systemic disease, for the first time, we have data to support this theory.”
