Matthew H.G. Katz, MD, FACS, associate professor, Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, discusses the benefit of neoadjuvant chemotherapy in patients with pancreatic cancer.

One of the underlying rationales for giving preoperative therapy to patients with pancreatic cancer is to select those with rapidly progressive disease, particularly those who are not anticipated to benefit from an operation, prior to undergoing what would otherwise be a complex and potentially morbid operation, says Katz.

Chemotherapy, and potentially radiation therapy, is given prior to surgery and a certain number of those patients will progress during the administration of therapy, typically systemically, and those patients will then not then undergo an operation, explains Katz. Arguably, those patients are likely those who would develop metastases relatively soon after an operation had that been performed de novo, concludes Katz.

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Matthew H.G. Katz, MD, FACS, discusses the benefit of neoadjuvant chemotherapy in patients with pancreatic cancer.

Dr. Katz on Neoadjuvant Chemotherapy in Pancreatic Cancer

Matthew H.G. Katz, MD, FACS, associate professor, Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, discusses the eligibility criteria for up-front surgery in patients with pancreatic cancer.

There has never been a study that randomized patients with optimal characteristics to receive either neoadjuvant or adjuvant therapy, says Katz. Currently, however, a study through the Alliance for Clinical Trials in Oncology is in development and will randomize patients to treatment arms of postoperative FOLFIRINOX versus perioperative FOLFIRINOX.

There is a role for neoadjuvant systemic therapy, even for patients who otherwise appear to be eligible for surgery. In those situations, patients have the option of receiving surgery up front. For patients to receive up-front surgery, they must have a resectable tumor, a normal CA19-9 level, and be overall healthy; however, patients with pancreatic cancer do not often meet all 3 of those criteria, concludes Katz.

Matthew H.G. Katz, MD, FACS, discusses the eligibility criteria for up-front surgery in patients with pancreatic cancer.

Dr. Katz on Eligibility Criteria for Up-front Surgery in Pancreatic Cancer

Matthew H.G. Katz, MD, FACS, associate professor, Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, discusses the utility of preoperative chemotherapy for patients with resectable pancreatic cancer.

Surgical resection followed by 6 months of systemic chemotherapy has been the mainstay of treatment for patients with resectable pancreatic cancer for many years, says Katz. Currently, the standard of care for these patients is pancreaticoduodenectomy or distal pancreatectomy followed by FOLFIRNOX.

However, current ASCO guidelines recommend the administration of preoperative systemic chemotherapy for patients who have large or anatomically advanced tumors, patients with poor performance status that renders them ineligible for upfront surgery, and patients with occult metastatic disease detected with imaging or elevated CA 19-9 levels, concludes Katz.

While preoperative chemotherapy has not been adopted as the standard of care in this patient population, it can be considered in the right patient, explains Katz. Preoperative radiation therapy may provide additional benefit for these patients, concludes Katz.

Matthew H.G. Katz, MD, FACS, discusses the utility of preoperative chemotherapy for patients with resectable pancreatic cancer.

Dr. Katz on Preoperative Chemotherapy in Resectable Pancreatic Cancer

Matthew H.G. Katz, MD, FACS, associate professor, Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, discusses the role of preoperative chemoradiation for the treatment of patients with localized pancreatic cancer.

Chemotherapy has long been a mainstay of treatment in this space, but what investigators are still trying to understand is if there is a role for radiation therapy in these patients—particularly if these modalities can be given concurrently. Katz says he believes radiation has a place either preoperatively or postoperatively, but the definitive data are still out there.

There was a study that suggested the benefit of radiation in the preoperative setting, but this trial did not randomize patients to receive either radiation or chemotherapy; it randomized them to radiation or surgery alone. As such, it does not definitively show that radiation has a true benefit, Katz notes.

Chemoradiation seems to be beneficial before surgery, but phase III trials still need to confirm that. In general, physicians are more comfortable giving chemotherapy alone in the preoperative setting. For example, Katz says, he would not give chemoradiation to a patient at risk for subclinical metastatic disease or if their CA 19-9 level was astronomically high.

Matthew H.G. Katz, MD, FACS, associate professor, Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, discusses preoperative chemoradiation for the treatment of patients with localized pancreatic cancer.

Matthew H.G. Katz, MD, FACS

Articles

Dr. Katz on Neoadjuvant Chemotherapy in Pancreatic Cancer

Dr. Katz on Eligibility Criteria for Up-front Surgery in Pancreatic Cancer

Dr. Katz on Preoperative Chemotherapy in Resectable Pancreatic Cancer

Dr. Katz on Preoperative Chemoradiation in Localized Pancreatic Cancer