Posted: January 1, 2018

Until recently pancreatic cancer was viewed by all as almost totally incurable.  There was a air of deep pessimism about patients so afflicted.  Now comes from the American Society of Clinical Oncology (ASCO) pracitce guidelines that address the issue of how to maximize curative potential for selected patients.  By way of background ASCCO issues practice guidelines frequently to guide practicing oncologists who do not work at academic research centers and who in many cases do not have access to clinical trials.  These guidelines have become the de facto standard of care and are used by insurance companies in reimbursement decisions.   The authors of this position paper reviewed the results of recent clinical trials with special emphasis on the ESPAC-4 trial, which randomized patients who had undergone surgery with curative intent to postoperative chemotherapy with either gemcitabine or gem plus capecitabine, an oral 5FU derivative.  They randomized 730 patients to one therapy or the other and found a small difference in favor of the combination.  Based on this difference they recommended the combination.  Click here for the abstract; Dr  Stark can email you the full article if you request it on the form to the right.  Just to put some perspective on this study, many patients who are thought to be candidates for curative surgery receive pre-operative chemotherapy with or without radiation. They would not have been enrolled in this trial.   Furthermore, the patients in this study were a relatively poor-risk group: 60% of them had positive surgical margins (tumor at the edge of the specimen when analyzed by the pathologist after surgery, meaning that the surgeon probably left cancer behind); 80% had positive lymph nodes.  This group has such a bad prognosis that many surgeons won’t operate on them if they know in advance by scans that the nodes are positive.   The median survival in the better group was 28 months, which doesn’t seem like much, but represents a huge advance, in which most patients used to die within 12-15 months.

Dr. Stark comments:  This recommendation is a baby step in the progress made against this disease.  Chemo as an addition to surgery has probably reached its useful possibilities.  Look for immune checkpoint therapy or targeted therapy as the next big step.