For resectable pancreatic cancer, (RPC) or borderline resectable pancreatic cancer (BRPC) the standard treatment is surgery followed by adjuvant chemotherapy. There is a worldwide ongoing discussion on the benefit of neoadjuvant treatment instead of adjuvant treatment for these patients. Interpretation and comparison of studies is hard because of a difference in patient selection between studies about these two strategies. Reporting by intention to treat and randomised clinical trials are essential.

In the first decade of the 21st century, many studies and reviews suggested superiority of the neoadjuvant approach in RPC and BRPC for patients with resected pancreatic cancer. Several reviews also suggested an advantage by intention to treat. The first two randomised trials failed due to lack of accrual, and the third discontinued because of changed standard regimens. Since 2018, two randomised trials were published and one presented. A meta-analysis of these six RCTs, four of which with neoadjuvant chemoradiotherapy, and all with gemcitabine based regimens, revealed that with neoadjuvant treatment overall survival improved compared to upfront surgery for both RPC and BRPC. Since local control and pathological factors such as pN classification and R0 resection rate are invariably better after neoadjuvant treatment, radiotherapy probably plays an important role.

Currently, more effective treatments are available, in particular FOLFIRINOX and gemcitabine + nab-paclitaxel are considered the best available chemotherapeutic schedules and stereotactic body radiotherapy (SBRT) is superior to conventional radiotherapy. Future studies should investigate the role of FOLFIRINOX or gemcitabine plus nab-paclitaxel combined with SBRT.

BELG J MED ONCOL 2021;15(3):117-22