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World J Gastroenterol. Nov 14, 2014; 20(42): 15564-15579
Published online Nov 14, 2014. doi: 10.3748/wjg.v20.i42.15564
Neoadjuvant therapy for pancreas cancer: Past lessons and future therapies
Jeffrey M Sutton, Daniel E Abbott
Jeffrey M Sutton, Daniel E Abbott, Department of Surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, Cincinnati, OH 45219, United States
Author contributions: Sutton JM and Abbott DE performed research, analyzed data, and wrote the manuscript.
Correspondence to: Daniel E Abbott, MD, Division of Surgical Oncology, Department of Surgery, University of Cincinnati Medical Center, 234 Goodman Street, ML 0772, Cincinnati, OH 45219, United States.
Telephone: +1-513-5848900 Fax: +1-513-5840459
Received: December 9, 2013
Revised: January 21, 2014
Accepted: May 28, 2014
Published online: November 14, 2014

Pancreatic adenocarcinoma remains a most deadly malignancy, with an overall 5-year survival of 5%. A subset of patients will be diagnosed with potentially resectable disease, and while complete surgical resection provides the only chance at cure, data from trials of postoperative chemoradiation and/or chemotherapy demonstrate a modest survival advantage over those patients who undergo resection alone. As such, most practitioners believe that completion of multimodality therapy is the optimal treatment. However, the sequence of surgery, chemotherapy and radiation therapy is frequently debated, as patients may benefit from a neoadjuvant approach by initiating chemotherapy and/or chemoradiation prior to resection. Here we review the rationale for neoadjuvant therapy, which includes a higher rate of completion of multimodality therapy, minimizing the risk of unnecessary surgical resection for patients who develop early metastatic disease, improved surgical outcomes and the potential for longer overall survival. However, there are no prospective, randomized studies of the neoadjuvant approach compared to a surgery-first strategy; the established and ongoing investigations of neoadjuvant therapy for pancreatic cancer are discussed in detail. Lastly, as the future of therapeutic regimens is likely to entail patient-specific genetic and molecular analyses, and the treatment that is best applied based on those data, a review of clinically relevant biomarkers in pancreatic cancer is also presented.

Keywords: Pancreatic cancer, Neoadjuvant therapy, Chemotherapy, Chemoradiation, Biomarkers

Core tip: The sequence of multi-modality therapy for pancreatic cancer continues to be debated, though many pancreatic cancer specialists are increasingly utilizing neoadjuvant chemoradiation prior to surgical resection. This manuscript details the rationale for neoadjuvant therapy, the data that supports its use, and the potential of biomarker use for personalizing care in pancreatic cancer.