Pancreatic Adenocarcinoma: Update on Neoadjuvant and Adjuvant Treatment
Follow-Up and Surveillance
Case Conclusion
After recovery from surgery, the patient is offered and completes 4 cycles of adjuvant chemotherapy with gemcitabine plus capecitabine. He is started on surveillance at 3 and 6 months, and he maintains an excellent performance status. He develops clinical evidence of pancreatic enzyme insufficiency and is placed on oral replacement therapy. He has no other complaints, and there is no evidence of recurrence on MRI and CA 19-9 levels.
- What is the recommended duration of surveillance following curative resection?
Surveillance after curative resection of pancreatic adenocarcinoma is recommended by NCCN guidelines.26 However, pancreatic adenocarcinoma has a poor prognosis, and surveillance after curative surgical resection with or without perioperative therapy has not been shown to impact survival. Most recurrences will occur within 2 years after treatment. Surveillance recommendations differ among expert groups.26,28,29 NCCN guidelines recommend evaluating patients by history and physical examination every 3 to 6 months for the first 2 years, then every 6 to 12 months for 3 years. CA 19-9 level and CT scan should be obtained every 3 to 6 months for 2 years and then every 6 to 12 months for 3 years. Follow-up with CA 19-9 levels and CT scans after 5 years is not routinely performed unless guided by signs, symptoms, or laboratory findings that raise suspicion for recurrence. Follow-up visits should also include evaluation of treatment-related toxicities, symptom management, nutrition support of pancreatic insufficiency, and psychosocial support.
Conclusion
Pancreatic cancer is a leading cause of cancer-related death that frequently presents with locally advanced or metastatic disease due to nonspecific symptoms and lack of a screening modality. Histological tissue biopsy confirmation and accurate resectability staging guide treatment planning and prognosis. The only potentially curative therapy is surgical resection plus adjuvant therapy for those with resectable disease. Surgical candidates with borderline resectable and unresectable disease can be offered induction preoperative chemotherapy followed by consolidation chemoradiation, based on clinical consensus practice. Enrollment in clinical trials should be encouraged for all patients, as evidence from clinical trials is essential to making progress in pancreatic cancer treatment.
