Adjuvant Pancreatic Cancer Management: Towards New Perspectives in 2021

SIMPLE SUMMARY: In operated pancreatic cancer patients who are able to begin treatment within 3 months after surgery, adjuvant chemotherapy is currently used to limit disease recurrence but questions remain for the clinician. Recently, modified FOLFIRINOX has become the standard-of-care in the non-Asian population, nevertheless there is still a risk of toxicity and feasibility may be limited in heavily pre-treated patients. Gemcitabine-Nabpaclitaxel, Gemcitabine alone in non-Asian patients are alternatives to be discussed. In Asia, S1-based chemotherapy remains the standard. The aim of this review is to summarize adjuvant management of resected pancreatic cancer and to raise current and future concerns, especially the need for biomarkers and the best holistic care for patients. ABSTRACT: Adjuvant chemotherapy is currently used in all patients with resected pancreatic cancer who are able to begin treatment within 3 months after surgery. Since the recent publication of the PRODIGE 24 trial results, modified FOLFIRINOX has become the standard-of-care in the non-Asian population with localized pancreatic adenocarcinoma following surgery. Nevertheless, there is still a risk of toxicity, and feasibility may be limited in heavily pre-treated patients. In more frail patients, gemcitabine-based chemotherapy remains a suitable option, for example gemcitabine or 5FU in monotherapy. In Asia, although S1-based chemotherapy is the standard of care it is not readily available outside Asia and data are lacking in non-Asiatic patients. In patients in whom resection is not initially possible, intensified schemes such as FOLFIRINOX or gemcitabine-nabpaclitaxel have been confirmed as options to enhance the response rate and resectability, promoting research in adjuvant therapy. In particular, should oncologists prescribe adjuvant treatment after a long sequence of chemotherapy +/– chemoradiotherapy and surgery? Should oncologists consider the response rate, the R0 resection rate alone, or the initial chemotherapy regimen? And finally, should they take into consideration the duration of the entire sequence, or the presence of limited toxicities of induction treatment? The aim of this review is to summarize adjuvant management of resected pancreatic cancer and to raise current and future concerns, especially the need for biomarkers and the best holistic care for patients.