Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 21, 2015; 21(11): 3157-3165
Published online Mar 21, 2015. doi: 10.3748/wjg.v21.i11.3157
Update on the management of pancreatic cancer: Surgery is not enough
Daniel Ansari, Adam Gustafsson, Roland Andersson
Daniel Ansari, Adam Gustafsson, Roland Andersson, Department of Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, SE-221 85 Lund, Sweden
Author contributions: Ansari D and Gustafsson A performed the literature search; Andersson R designed the study and revised the manuscript; all authors were involved in manuscript writing and read and approved the final manuscript.
Conflict-of-interest: The authors declare no conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Roland Andersson, MD, PhD, Department of Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Getingevägen 4, SE-221 85 Lund, Sweden. roland.andersson@med.lu.se
Telephone: +46-46-172359
Received: November 12, 2014
Peer-review started: November 15, 2014
First decision: December 11, 2014
Revised: December 19, 2014
Accepted: February 5, 2015
Article in press: February 5, 2015
Published online: March 21, 2015

Pancreatic ductal adenocarcinoma (PDAC) represents the fourth cause of death in cancer and has a 5-year survival of < 5%. Only about 15% of the patients present with a resectable PDAC with potential to undergo “curative” surgery. After surgery, local and systemic recurrence, is though very common. The median survival of resected patients with adjuvant chemotherapy after surgery is only 20-23 mo. This underscores the significant need to improve PDAC management strategies. Increased survival rate is dependent on new breakthroughs in our understanding of not at least tumor biology. The aim of this review is to update and comment on recent knowledge concerning PDAC biology and new diagnostics and treatment modalities. One fundamental approach to improve survival rates is by earlier and improved diagnosis of the disease. In recent years, novel blood-based biomarkers have emerged based on genetic, epigenetic and protein changes in PDAC with very promising results. For biomarkers to enter clinical practice they need to have been developed using adequate control groups and provide high sensitivity and specificity and by this identify patients at risk already in a pre-symptomatic stage. Another way to improve outcomes, is by employing neoadjuvant treatments thereby increasing the number of resectable cases. Novel systemic treatment regimes like FOLFIRINOX and nab-paclitaxel have demonstrated improvements in prolonging survival in advanced cases, but long-term survival is still scarce. The future improved understanding of PDAC biology will inevitably render new treatment options directed against both the cancer cells and the surrounding microenvironment.

Keywords: Pancreatic cancer, Diagnosis, Genetics, Epigenetics, Proteomics, Surgery, Prognostic models, Chemotherapy, Stroma

Core tip: This review updates the current progress in the management of pancreatic cancer with focus on novel modes of diagnosis and treatment. New blood-based biomarkers for early detection based on genetic, epigenetic and protein changes in pancreatic cancer are discussed and new treatment strategies such as stromal depletion are highlighted. Pancreatic cancer is a systemic disease already at diagnosis and demands multimodal managements strategies in order to improve outcomes.