Robert A. Wolff, MD

After 2 decades of disappointing phase III trials and years of single-agent gemcitabine therapy, the pancreatic cancer community is relieved to expand the front-line armamentarium in patients with mPAC. Here we evaluate the current landscape and ask some provocative questions about response rate, dosing, and predictive markers.

In this issue of ONCOLOGY, the case and discussion provided by Dasari and colleagues highlight a significant problem for many patients with potentially resectable pancreatic cancer (PC)-the rapid emergence of preexisting metastatic disease. The authors describe the case of a 57-year-old woman with a resectable tumor after staging evaluation and management which included an endoscopic ultrasound (EUS), CT imaging, and endoscopic retrograde cholangiopancreatography (ERCP) with insertion of an endobiliary stent. Although the results from EUS are not detailed in the report, there were apparently no preoperative features to suggest more advanced disease, and she underwent surgery. Four weeks later, she presented with advanced disease manifested by an elevated CA 19-9, bilobar liver metastases, and possible local recurrence. This case illustrates some important considerations in the management of PC as we discuss here.

The CONKO-001 trial presents a mix of good news and bad news, said Dr. Wolff of the M.D. Anderson Cancer Center.

Although in centers where pancreatectomy is performed frequently,associated morbidity and mortality rates have improved, long-term outcomesin pancreatic adenocarcinoma patients remain poor when surgeryis the sole therapeutic modality. The impact of adjuvant chemotherapyon survival in patients with localized pancreatic cancer remainsincompletely defined. The European Study Group for Pancreatic Cancer(ESPAC)-1 trial has suggested that overall survival rates are superiorwhen chemotherapy is added to surgery, even when regimens believedto be relatively ineffective in the treatment of advanced diseaseare used. The role of radiotherapy given with chemotherapy is alsounresolved, but chemoradiation continues to receive consideration inthe multimodality approach to localized pancreatic cancer. Enhancedcollaboration and increased involvement by pancreatic surgeons havehelped in the recruitment of pancreatic cancer patients for large-scalerandomized clinical trials in Europe and the United States. Many newerchemotherapeutic agents with efficacy in gastrointestinal cancers haveyet to be investigated in the adjuvant and neoadjuvant settings.

Surgery has evolved to become the standard of care for a defined subset of patients with hepatic colorectal metastases. Hepatic resections are now well-controlled procedures, with several centers reporting very low perioperative mortality rates.

Recent prospective and retrospective data suggest that the use of multimodality therapy combining pancreaticoduodenectomy with postoperative adjuvant chemotherapy (fluorouracil) and external-beam radiation

This year, approximately 40% of the 28,300 patients diagnosed with pancreatic carcinoma in the United States will present with locally advanced disease. Radiotherapeutic approaches are often employed, as these patients