Outcomes trial demonstrating a survival advantage of initial chemoradiotherapy for regional pancreatic adenocarcinoma (PCa)

Old and new drugs in systemic therapy of pancreatic cancer

BACKGROUND

The incidence of pancreatic cancer nearly equals its death rate (97%). Two-year survival is about 10%. Chemotherapy treatment is problematic because of the palliative and limited duration of response.

MATERIAL AND METHODS

The article analyzes the objective response and median survival time (MST) for old and new drugs in the treatment of pancreatic cancer.

RESULTS

The most encouraging results to date come from studies of 5-fluorouracil (5FU) as an adjuvant therapy and of gemcitabine in the advanced disease, which is one of the most active and best tolerated drugs in recent years. However, with the introduction of new drugs or with different old drug associations, interesting results are also becoming evident.

CONCLUSIONS

New approaches to CT treatment are necessary. Patient enrollment into rigorous and well conducted clinical trials, either at tumor diagnosis or after tumor recurrence, will generate new information regarding investigational therapies and it will offer improved therapies for patients with this disease.

Interventional endoscopy, neoadjuvant therapy and the gastroenterologist

With current treatment, survival of greater than 1 year should be anticipated for many patients with pancreatic cancer. Cure rates (5-year survival) of greater than 10% have been achieved even for unresectable disease. Obstructive jaundice is managed successfully with endoscopic placement of a plastic stent early in the evaluation of a patient with suspected regional pancreatic cancer, and a metal wall stent is reserved for patients with known 1997 AJCC stage IVB carcinoma or nonoperative patients. Relief of biliary obstruction allows improvement in liver function and more time to evaluate tumor stage accurately to determine initial treatment (see Fig. 1). A cost-effective algorithm to determine accurate stage and treatment can start with the size of the mass on initial imaging studies. EUS-guided FNA represents a significant improvement over CT scan-guided FNA to make a tissue diagnosis. Small pancreatic masses that would be resected regardless of whether an FNA is positive or negative require only an EUS evaluation to establish an early resectable stage. Tumors reliably staged as unresectable by nonoperative imaging methods including EUS are treated with chemotherapy with or without concurrent radiotherapy because median survival of these patients is 2 years in some series. Tumors can be resected after neoadjuvant chemoradiotherapy. For chronic pain or gastric outlet obstruction not responding or treatable by chemoradiotherapy, endoscopically guided celiac plexus nerve block and stenting improve the quality of life for patients with pancreatic cancer. A team approach is required to achieve the objectives of improved quality of life, prolonged survival, and possible cure for pancreatic cancer. The optimal combination and sequencing of staging methods, including EUS, specialized CT scan, MR imaging, intraoperative findings, and pathologic evaluations, would improve selection of patients for potential curative resection. Interpretations of disease stage based on each of these methods may overlap but are not identical and are operator dependent. Rather than reliance on any single standard, clinical judgment and communication among the team are paramount to providing optimal care for patients with a pancreatic neoplasm.