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COMMENTARY ON THE IZMIR STUDY
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Year : 2020  |  Volume : 57  |  Issue : 2  |  Page : 164--165

Commentary on adjuvant therapy in operated pancreatic carcinoma by the Izmir group

Rushabh Kothari 
 Department of Medical Oncology, Narayana Multispeciality Hospital, Ahmedabad, Gujarat, India

Correspondence Address:
Rushabh Kothari
Department of Medical Oncology, Narayana Multispeciality Hospital, Ahmedabad, Gujarat
India




How to cite this article:
Kothari R. Commentary on adjuvant therapy in operated pancreatic carcinoma by the Izmir group.Indian J Cancer 2020;57:164-165


How to cite this URL:
Kothari R. Commentary on adjuvant therapy in operated pancreatic carcinoma by the Izmir group. Indian J Cancer [serial online] 2020 [cited 2021 Mar 3 ];57:164-165
Available from: https://www.indianjcancer.com/text.asp?2020/57/2/164/284479


Full Text



Pancreatic adenocarcinoma is among the most difficult malignancies to treat. Surgical resection with a negative margin is a must for cure. Unfortunately, only 15% of patients are able to undergo the same.[1],[2] Even those who undergo resection majority will have local (about 15%) or distant recurrence (about 65%).[3] Thus, various strategies have been tried in adjuvant treatment like chemotherapy, radiotherapy, chemoradiotherapy, etc.

There is a consensus among all expert groups regarding the need for adjuvant treatment in all stages of operated pancreatic cancer. Across continents, there is a difference in practice regarding adjuvant treatment. Chemotherapy alone is generally practiced across Europe while chemoradiotherapy plus chemotherapy is practiced across America.[4],[5]

The current standard of care as adjuvant chemotherapy is modified FOLFIRINOX in a fit patient.[6] Gemcitabine with/without capecitabine is another option for not so fit patients.[7] Adding platinum is beneficial in BRCA-positive patients.[8]

The role of adjuvant radiotherapy or chemoradiotherapy is controversial. Margin-positive and node-positive patients may get more benefit from this strategy. We have conflicting data on the role of chemoradiotherapy from various trials. Europeans and Japanese practice chemotherapy alone based on CONKO-001, EORTC, and ESPAC1 trial data. In EORTC, the benefit of radiotherapy in addition to chemotherapy was minimal, while it was detrimental in ESPAC 1. Contrary to this based on GITSG, EORTC, and flaws in ESPAC-1 data, Americans do add radiotherapy, especially in node-positive and margin-positive patients. Even a meta-analysis to decide on appropriate adjuvant treatment has failed to answer the question.[2]

The article by Izmir oncology group is a nice attempt to show real-world practice pattern in operated pancreatic cancers.[9] Practical issues like high R1 resection rates, poor prognosis of operated pancreatic adenocarcinoma, high morbidity of surgery, the possibility of post-surgical mortality, variation in adjuvant treatments, and poor survival pattern has been conveyed appropriately in the article. Also, consistency in survival pattern as per stage and nodal status has been well elucidated. The importance of adjuvant treatment in pancreatic adenocarcinoma patients is highlighted well.

This study has some drawbacks. Here, the decision of adjuvant treatment was not uniform or protocol driven. It was left to the physician's discretion. Also, there was no uniformity on chemotherapy regimen chosen. Also, patients in different subgroups were not similar in respect to other confounding factors like performance status, margin status, etc., Groups which are compared are of small and unequal size. All these make comparing different groups among each other futile. I take this data as a reflection of community practice rather than data guiding us in the decision to offer adjuvant therapy.

I will agree with the need for adjuvant chemotherapy in pancreatic adenocarcinoma. Role of radiotherapy as adjuvant treatment currently is limited to a subset of margin-positive patients. We need a randomized study to compare and conclude on best adjuvant approach for this difficult to treat disease. While planning such a study, only patients fit for adjuvant therapy must be enrolled and randomized to various groups of adjuvant treatment.

References

1Ryan DP, Hong TS, Bardeesy N. Pancreatic adenocarcinoma. N Engl J Med 2014;371:1039-49.
2Liao WC, Chien KL, Lin YL, Wu MS, Lin JT, Wang HP, et al. Adjuvant treatments for resected pancreatic adenocarcinoma: A systematic review and network meta-analysis. Lancet Oncol 2013;14:1095-103.
3Iacobuzio-Donahue CA, Fu B, Yachida S, Luo M, Abe H, Henderson CM, et al. DPC4 Gene status of the primary carcinoma correlates with patterns of failure in patients with pancreatic cancer. J Clin Oncol 2009;27:1806-13.
4Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, et al. Potentially curable pancreatic cancer: American Society of Clinical Oncology Clinical Practice Guideline update. J Clin Oncol 2017;35:2324-28.
5nccn.org [Internet]. National Comprehensive Cancer Network. Available from https://www.nccn.org/professionals/physician_gls/pancreatic adenocarcinoma. [Last Updated on 2019 Jul 02; Cited on 2019 Jul 16].
6Conroy T, Hammel P, Hebbar M, Abdelghani MB, Wei AC, Raoul JL, et al. FOLFIRINOX or gemcitabine as adjuvant therapy for pancreatic cancer. N Engl J Med 2018;379:2395-406.
7Oettle H, Post S, Neuhaus P, Gellert K, Langrehr J, Ridwelski K, et al. Adjuvant chemotherapy with gemcitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer: A randomized controlled trial. JAMA 2007;297:267-77.
8Yu S, Agarwal P, Mamtani R, Symecko H, Spielman K, O'Hara M, et al. Retrospective survival analysis of patients with resected pancreatic ductal adenocarcinoma and a germline BRCA or PALB2 mutation. JCO Precis Oncol 2019;3:1-11.
9Varol U, Uzum Y, Sengul A, Korkmaz UB, Parvizi M, Akyol M, et al. An analysis of adjuvant treatment strategies in operated pancreatic cancer patients. An Izmir oncology group study. Indian J Cancer 2020;57:158-63.