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Advanced-stage pancreatic cancer: therapy options

Abstract

Pancreatic ductal adenocarcinoma is one of the most aggressive cancers, and surgical resection is a requirement for a potential cure. However, the majority of patients are diagnosed with advanced-stage disease, either metastatic (50%) or locally advanced cancer (30%). Although palliative chemotherapy is the standard of care for patients with metastatic disease, management of locally advanced adenocarcinoma is controversial. Several treatment options, including extended surgical resections, neoadjuvant therapy with subsequent resections, as well as palliative radiotherapy and/or chemotherapy, should be considered. However, there is little evidence available to support treatment options for locally advanced disease. As valid predictive biomarkers for stratification of therapy are not available today, future trials need to define the role of the different treatment options. This Review summarizes the current evidence and discusses available treatment options for both locally advanced and metastatic pancreatic adenocarcinoma.

Key Points

  • Surgical resection of pancreatic cancer is a requirement for potential cure; the 5-year-survival after resection plus adjuvant chemotherapy is over 20%

  • Locally advanced primarily irresectable pancreatic carcinomas should be treated with neoadjuvant treatment (chemoradiotherapy in most cases) to down-stage or even down-size the tumour to obtain the chance of secondary resection

  • Borderline resectable pancreatic cancers can be treated by extended surgery and adjuvant chemotherapy; neoadjuvant treatment regimens to achieve better tumour control before surgery are an alternative in these patients

  • The FOLFIRINOX protocol and nab-paclitaxel are new therapy options that improve survival for patients with metastatic disease and a good performance status

  • Recent advances in understanding the molecular pathogenesis of the disease raise the hope that a more-personalized therapy will be possible in the near future

  • Centralization of the treatment of pancreatic cancer in high-volume hospitals reduces perioperative morbidity and mortality, and improves long-term oncological outcome

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Figure 1: Patient with locally advanced pancreatic cancer.
Figure 2: CT scan of borderline resectable disease.

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J. Werner, S. E. Combs, C. Springfeld, W. Hartwig and T. Hackert researched data for the article, J. Werner, S. E. Combs, C. Springfeld and M. W. Büchler made a substantial contribution to discussion of the content, all authors wrote the article, and J. Werner and M. W. Büchler edited the manuscript prior to submission.

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Correspondence to Markus W. Büchler.

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C. Springfeld has received honoraria for serving on an advisory board of Celgene. The other authors declare no competing interests.

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Werner, J., Combs, S., Springfeld, C. et al. Advanced-stage pancreatic cancer: therapy options. Nat Rev Clin Oncol 10, 323–333 (2013). https://doi.org/10.1038/nrclinonc.2013.66

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