BUFFALO, NYRecent advances in adjuvant therapies have begun to
improve survival outcomes and quality of life for patients with
gastrointestinal tumors such as pancreatic carcinomas and colorectal
cancers metastatic to the liver. But the role of the surgeon remains critical.
Adjuvant chemotherapy helps patients who can be resected. But
the skill of the surgeon in removing the tumor, while minimizing
complications, is the first step toward offering patients an
opportunity to receive adjuvant therapy and possibly survive their
cancer, Lawrence Wagman, MD, chair, Division of Surgery, City
of Hope National Medical Center, said at the Surgical Oncology
Symposium hosted by Roswell Park Cancer Institute.
Citing three recent clinical trials that have addressed the role of
adjuvant therapy in hepatic cancer, he said that all three have
shown that adjuvant chemotherapy works, whether delivered by the
hepatic artery or portal vein.
Although additional adjuvant studies are needed, he said, we
have shown enough benefit from adjuvant therapy that I do not believe
we need to compare it to a surgery-only control group. The initial
evidence supports the adjuvant treatment of all patients who have
colorectal cancer metastases that have been completely resected. All
hepatic carcinoma patients should be treated with adjuvant therapy.
At City of Hope, patients are generally treated with floxuridine, 0.3
mg/kg/day for 14 days, via the portal vein to perfuse
micrometastases. We have found that the portal vein offers
easier access and lower toxicity for our patients, and may increase
the total amount of drug delivered, Dr. Wagman said.
In pancreatic cancer, there has been discussion over which surgical
techniques commonly used today offer the best chance for overall
survival. In a comparison of the classic Whipple technique and the
pyloric-preserving Whipple (PPW), there appears to be little
difference in survival and quality of life for cancer patients,
although PPW does improve quality of life for patients who require
the procedure due to trauma, said John Daly, MD, chair, Department of
General Surgery, New York Hospital, Cornell University Medical Center.
In addition to surgeon skill and adjuvant therapy, it has been
shown that mortality and morbidity are higher at institutions that
perform fewer pancreatic resections, Dr. Daly said. Data
from the New York State Department of Health (see Table)
suggest that encouraging patients to be treated by the hospitals
with the most experience will improve mortality, he said.
There may be a benefit in regionalization of surgical treatment.
A strong survival benefit has also been shown for the use of adjuvant
chemotherapy and radiation after pancreatic cancer surgery. In a
Gastrointestinal Study Group trial, patients who did not receive
adjuvant therapy after surgery had significantly reduced survival,
compared with those who received adjuvant chemotherapy and radiation therapy.
Pancreatic cancer is a terrible disease with terrible
outcomes. We have made strides, but there is enormous opportunity for
improvement, Dr. Daly concluded.