Changing paradigms in locally advanced pancreatic cancer: Better defining the role of neoadjuvant radiation
*Roberto J Vidri1, *Anne O Vogt2, Dougald C Macgillivray2, *Ian J Bristol2, Timothy L Fitzgerald2
1Saint Mary's Medical Center, Lewiston, ME;2Tufts University Medical Center Maine Medical Center, Portland, ME
Objective:
To better define the role of preoperative radiation (RAD) in addition to multi-agent neoadjuvant therapy (NAT) in the treatment of borderline-resectable pancreatic cancer.
Design:
Retrospective cohort study using the National Cancer Database (2006-2014)
Setting:
Commission on Cancer-accredited facilities.
Patients:T3 and T4 pancreatic adenocarcinoma undergoing surgery
Interventions:
None
Main Outcome Measure:
Overall survival
Results
A total of 4091 patients were included; 3390 had T3 and 697 had T4 tumors. 1067 (26.1%) received RAD. Median follow-up was 22.3 months. Over the study period, there was increased use of NAT, but not RAD (Figure). Although RAD increased 30-day (2.47% vs. 0.86%, p<0.0001), and 90-day mortality (5.24% vs. 2.03%, p= 0.0152), individuals receiving RAD had improved overall survival on univariable (30.8 vs 23.4 months, p<0.0001), and multivariable analyses (HR 0.80 [CI 0.73 - 0.88] p<0.0001). Time to definitive surgery was also increased by RAD (203.8 vs 70.51 days, p<0.0001). Receiving RAD was associated with increased pathologic downstaging in T4 (89.1% vs 72.5%) (OR 1.92 [CI 1.15 - 3.20] p=0.013) and T3 tumors (32.8% vs. 8.4%)(OR 4.84 [CI 3.84 - 6.08] p<0.0001); complete pathologic response (5.5% vs. 0.8%) (OR 6.09 [CI 3.70 - 10.03] p<0.0001), and increased R0 resection rates (85.8% vs. 72.1%) (OR 2.24 [CI 1.84 - 2.73] p<0.0001).
Conclusions
The use of neoadjuvant therapy is increasing for the treatment of locally advanced pancreatic cancer. The addition of radiation to NAT, is associated with improved antineoplastic effectiveness (downstaging and complete pathologic response), surgical resection (R0 rates), and overall survival for this patient population.
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