BUFFALO, NY—Recent 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.

Pancreatic Cancer

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.