The experience of neoadjuvant chemotherapy versus upfront surgery in resectable pancreatic cancer: a cross sectional study

Abstract

Background: Upfront resection (UR) followed by adjuvant chemotherapy remains the standard treatment for resectable pancreatic cancer. There is increasing evidence suggesting favourable outcomes toward neoadjuvant chemotherapy (NAC) followed by surgery.

Methods: All clinical staging with resectable pancreatic cancer patients treated at a tertiary medical centre from 2013 to 2020 were identified. The baseline characteristics, treatment course, surgery outcome and survival results of UR or NAC were compared.

Results: Finally, in 159 resectable patients, 46 patients (29%) underwent NAC and 113 patients (71%) received UR. In NAC, 11 patients (24%) did not receive resection, 4 (36.4%) for comorbidity, 2 (18.2%) for patient refusal and 2 (18.2%) for disease progression. In UR, 13 patients (12%) were unresectable intraoperatively; 6 (46.2%) for locally advanced and 5 (38.5%) for distant metastasis. Overall, 97% of patients in NAC and 58% of patients in UR completed adjuvant chemotherapy. As of data cut-off, 24 patients (69%) in NAC and 42 patients (29%) in UR were still tumour free. The median recurrence-free survival in NAC, UR with adjuvant chemotherapy and without adjuvant chemotherapy were 31.3 months (95% CI, 14.4-not estimable), 10.6 months (95% CI, 9.0-14.3) and 8.5 months (95% CI, 5.8-11.8), P =0.036; and the median overall survival in each group were not reached (95% CI, 29.7-not estimable), 25.9 months (95% CI, 21.1-40.5) and 21.7 months (12.0-32.8), P =0.0053. Based on initial clinical staging, the median overall survival of NAC was not significantly different from UR with a tumour less than or equal to 2 cm, P =0.29. NAC patients had a higher R0 resection rate (83% versus 53%), lower recurrence rate (31% versus 71%) and harvested median number lymph node (23 versus 15).

Conclusion: This study demonstrates that NAC is superior to UR in resectable pancreatic cancer with better survival.

Trial registration: ClinicalTrials.gov NCT05700188.

Figure 1

The flow chart of pancreatic cancer patients treated at a tertiary medical centre. PDAC, Pancreatic ductal adenocarcinoma.

Figure 2

The Kaplan–Meier curve of progression-free survival (A) and overall survival (B) of the intention-to-treatment population in NAC and UR groups, and further stratified by tumour size (C, D). NAC, neoadjuvant chemotherapy; UR, upfront resection.

Figure 3

Recurrence-free survival (A) and overall survival (B) in resected patients in NAC and UR groups. (C) Recurrence-free survival in the NAC group stratified by tumour response grade. (D) The change of clinical staging and pathological staging. Recurrence-free survival (E) and overall survival (F) in resectable pancreatic cancer patients based on the pathology staging. NAC, neoadjuvant chemotherapy; TRG, tumour response grade; UR, upfront resection.

Figure 4

Treatment outcome after covariates adjustment. Progression-free survival (A) and overall survival (B) of upfront resection and neoadjuvant chemotherapy group after propensity score matching. (C) Forest plot of the Cox proportional hazard model of progression-free survival and overall survival. Blue dots represented hazard ratio (HR) and the grey line indicated a 95% CI. The grey dot indicated the reference group.