Adjuvant chemotherapy—the standard after resection for pancreatic cancer

Pancreatic cancer is one of the major causes of cancer death. Most patients present with advanced disease, and only 10% to 15% can undergo resection. Survival after curative surgery is poor, as recurrences occur either locally or in the liver. Adjuvant treatment has been employed to improve the poor prognosis. There is a clear-cut survival advantage with 5-fluorouracil (5-FU)/folinic acid or gemcitabine compared with observation, based on the results from the European Study Group for Pancreatic Cancer (ESPAC) 1 and Neuhaus studies. The survival advantage associated with chemotherapy is supported by an individual patient data meta-analysis. In contrast, there is no justification for the use of adjuvant chemoradiation based on the European Organization for Research and Treatment of Cancer (EORTC) and ESPAC-1 trial results. The use of chemoradiation followed by chemotherapy, as shown in the 1987 Gastrointestinal Tumor Study Group (GITSG) study and the recent Radiation Therapy Oncology Group (RTOG) 9704 combination study, has not proved to be superior to chemotherapy alone based on the results of the underpowered study. The standard of care for adjuvant therapy based on level I evidence is postoperative chemotherapy using 5-FU with folinic acid, providing a best estimate of 29% 5-year survival rate.