Editing Pancreatic cancer (section)

== '''Neoadjuvant therapy''' ==

* Rationale
** '''PREOPANC trial 2019''' - RCT - median survival for borderline resectable tumours was different by a meaningful amount with neoadjuvant CTx, and R0 resections were much higher. Additionally, this was with gemcitabine CRT, not FOLFIRINOX, which is thought to have superseded gemcitabine CRT. 5-year OS was 20% with vs 6% with up-front surgery. Few hundred patients total. Also showed benefit to neoadjuvant CTx for 'resectable' patients.
** 25% of patients never receive adjuvant CTX, because of refusal, complications, or inability to recover from surgery
** Maximise therapy to an intact gland with intact blood supply
** Response to therapy can be assessed more readily - avoid surgery for patients that progress on CTX
** Physiological stress test to establish who can recover from surgery
** For borderline resectable cases, improved overall survival and R0 resections
** Foreseeable that eventually standard of care will be neoadjuvant chemotherapy for all
* Preparation
** Need tissue
** Need biliary drainage with SEMS
* Regime
** FOLFIRINOX is most common - aggressive therapy requiring good performance status
** Gemcitabine-based chemoradiotherapy is an alternative, but used less often
* Defining response to treatment
*# Presence or absence of clinical benefit
*# CT findings to suggest stable or improving disease (cross-sectional diameter)
*# Serum CA 19-9
* ERCP and short metal stent if necessary (gets blocked less than plastic stents)