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New Study Reveals Improved Survival in Pancreatic Cancer with Preoperative Therapy

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Pancreatic cancer, one of the most challenging cancers to treat, has seen significant advancements in preoperative treatment strategies, potentially improving patient outcomes.

This news is grounded in a comprehensive review article published in Nature Reviews Gastroenterology & Hepatology, which focuses on the combined use of chemotherapy, radiotherapy, and surgical decision-making in cases of borderline resectable and locally advanced pancreatic cancer.

The global incidence of pancreatic ductal adenocarcinoma is on the rise, with limited survival improvements over the past decades. Historically, pancreatic cancer has been divided into primary resectable, borderline resectable, and locally advanced categories, largely based on vascular involvement. Traditional treatment involves surgery combined with systemic chemotherapy. However, for borderline resectable and locally advanced stages, an upfront surgical approach has shown suboptimal results, necessitating a change in treatment protocols.

Recent years have seen a paradigm shift in treating borderline resectable and locally advanced pancreatic cancer. The introduction of preoperative multi-agent chemotherapy regimens, such as folfirinox and gemcitabine plus nab-paclitaxel, aims for local and systemic control and better patient selection for surgery. These regimens, termed neoadjuvant therapy for borderline resectable and induction therapy for locally advanced cases, have shown promise in improving survival rates. However, the decision to employ these therapies is influenced by anatomical, biological, and conditional factors of the patient.

Disease staging plays a crucial role in treatment selection. New staging classifications, incorporating more nuanced definitions of borderline resectable and locally advanced stages, aim to improve clinical decision-making and allow for more personalised treatment approaches. These classifications consider not just anatomical factors but also biological markers like serum CA19-9 levels and patient-related factors, such as performance status.

Several randomised trials have compared the outcomes of neoadjuvant chemotherapy or chemoradiotherapy with upfront surgery. While these trials show varied results, they generally indicate improved survival rates with neoadjuvant treatment. However, more trials assessing modern multi-agent chemotherapy and radiotherapy are needed for a definitive understanding.

One of the significant challenges in treating pancreatic cancer is response evaluation after preoperative therapy. Conventional cross-sectional imaging often underestimates tumor response. Hence, additional methods like serum tumor markers (notably CA19-9), more accurate imaging techniques, and histopathological examination are advised for a comprehensive evaluation.

Surgery following preoperative therapy in these patients requires specialised expertise. Surgical risks, alternative local therapies, and the extent of surgery are critical considerations. Moreover, shared decision-making with patients about the potential outcomes and risks is crucial.

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