Neoadjuvant therapy for resectable pancreatic cancer

Table 2 Summary of the benefits and drawbacks of neo-adjuvant and adjuvant therapies for the treatment of patients with resectable pancreatic cancer

Neo-adjuvant therapy		Adjuvant therapy
Advantages	Disadvantages	Advantages	Disadvantages
In comparison to the strategy of adjuvant chemotherapy or chemoradiation therapy where up to 50% of patients who undergo surgery cannot complete their therapy due to complications or decline of their function, neoadjuvant strategy has been shown to be well tolerated by the majority of patients and therefore a greater proportion receive systemic therapy	Neoadjuvant therapy requires the placement of biliary stents to decompress the biliary obstruction prior to surgery of patients with jaundice. The placement of biliary stents before surgery increases the risk of infections in the perioperative period	One of the advantages of surgery first approach is that patients have a short period of time between when they are diagnosed and when they undergo resections of their tumor. This might have some benefits on patients’ and their families’ anxiety	About 20%-50% of patients will not be able to complete their postoperative therapy due to surgical complications or overall decline of their performance status
The use of neo-adjuvant therapy might sterilize the presence of small metastatic disease and reduce the size of the primary tumor. Downsizing the primary tumor might increase the likelihood of negative resection margins	Pre-operative therapy delays surgery and increases the risk of progression of the disease to the point of becoming unresectable	Since patients undergo surgery as soon as possible after their diagnosis, their risk of tumor progression is smaller than patients who wait a longer time before being operated on	One of the risk of undergoing surgery first for pancreatic cancer is that, some patients will undergo a major operation without the benefit of being cured as they might already have micrometastases
Treating patients before surgery, gives physicians some time to identify the tumors with poor prognosis that do not respond to the therapy. The identification of those patients who are likely to experience early metastases is very important because prevents them to undergo unnecessary surgery	The use of neoadjuvant therapies might increase the risk of perioperative morbidity and mortality due to the side effects of chemotherapy or chemoradiation	Patients who undergo surgery first do not routinely need the placement of biliary stents to release their jaundice before undergoing resection	Patients who undergo surgery first have a higher risk of positive resection margins
One of the advantages of using chemotherapy or chemoradiation therapy before surgery is that the blood supply to the pancreatic tumor is not compromised by the ligation of vessels. Therefore, chemotherapy agents can be delivered to the pancreatic tumor in higher concentrations