Adjuvant treatment following curative resection for pancreatic cancer is now well established. Historically, the role of adjuvant therapy post resection was uncertain, as was the best form of adjuvant, the choices lying between adjuvant chemotherapy, chemoradiation or a combination of these. The landmark randomized controlled European Study Group for Pancreatic Cancer (ESPAC)-1 trial, provided the strongest evidence for the benefit of adjuvant therapy. ESPAC-1 showed a strong survival advantage for chemotherapy comprising 5-fluorouracil (5-FU) with folinic acid (FA), but no support for the use of chemoradiation. The CONKO-001 trial showed that gemcitabine was also superior to surgery alone. The ESPAC-3 trial showed no superiority for gemcitabine over 5-FU/FA although gemcitabine was less toxic. The effects of adding biological agents or combining agents within regimens are being investigated as well as neo-adjuvant therapies being compared with adjuvant therapy. A network meta-analysis has confirmed reduced survival and increased toxicity with adjuvant chemoradiotherapy. Adjuvant systemic chemotherapy with either gemcitabine or 5-FU/FA following curative resection for pancreatic adenocarcinoma continues as the mainstay of treatment. The five-year survival rates are around 25% with chemotherapy compared to resection alone, with a significant survival benefit also shown for patients with R1 positive resection margins.

Adjuvant treatment following on from curative resection for pancreatic cancer has been in use for nearly thirty years and is still hotly debated. The treatments discussed in this review are centered on adjuvant chemoradiotherapy, combinations of biological agents with chemotherapy and combination chemotherapy with chemoradiotherapy.

Clinical studies from the 1970s and 1980s indicated that the survival rates increased in locally advanced pancreatic cancer when treated with external beam radiotherapy (EBRT) with a radiation sensitizer. This led to the Gastrointestinal Tumor Study Group Trial 9173 trial in which patients who had had resection were randomized to either chemoradiotherapy, comprising 40 Gy EBRT with 5-fluorouracil (5-FU) and follow on 5-FU for six months, or no adjuvant treatment. This trial planned to recruit 150 patients, but closed after 8 years, having only recruited 43 patients. The analysis showed an apparent improved survival in the treatment group compared to the control group (Table 1). A similar survival was seen in another 30 non-randomized patients registered to the treatment group. Several subsequent studies showed that post-operative chemoradiation was feasible but the true survival benefit remained uncertain because none were randomized 

With Regards,
Sara Giselle
Associate Managing Editor
Global Journal of Digestive Diseases