Controversies in the adjuvant treatment of pancreatic adenocarcinoma.

There is no universally accepted standard approach to treat patients with pancreatic cancer in the adjuvant setting. This controversy derives from several studies, each fraught with its own limitations. Standards of care also vary depending on which side of the Atlantic you are on: chemo-radiotherapy followed by chemotherapy is considered the optimal therapy in North America (GITSG, RTOG) while chemotherapy alone is the current standard in Europe (ESPAC-1, CONKO). Whether gemcitabine is superior to 5-FU remains to be learnt from the ESPAC-3 study currently on-going in Europe. A number of important questions have yet to be fully addressed: What is the absolute value of radiotherapy in this setting? How should radiotherapy be delivered, if at all? What should be the time to deliver of either or both therapeutic modalities in the adjuvant setting? Are there any patients who can benefit from the combined modality? What is the most appropriate chemotherapeutic agent(s) to administer in the adjuvant setting? Is there any role of integrating the novel/targeted agents, albeit the negative studies in the metastatic setting? What are the new developments (such as vaccines, pancreas cancer stem cells, etc.) in this area? The author summarizes the evolution of adjuvant therapy for resected pancreatic cancer and highlights the controversies that originate from several studies, each fraught with its own limitations.