Evidences and opinions for adjuvant therapy in pancreatic cancer

Pancreatic adenocarcinoma is a rare tumor with a very poor outcome. Even with surgery, 5-year overall survival is less than 10%, due to the propensity of the disease for local and systemic recurrence. Adjuvant chemoradiotherapy and systemic chemotherapy were assessed in prospective trials in order to improve disease control and patients' prognosis. However, due to the difficulty of performing prospective trials in a rare disease; to the progress in surgical and radiotherapic techniques; and to the availability of novel anti-cancer agents, the existing information on the best possible management of patients with resectable disease is limited and becomes rapidly obsolete. Accordingly and also due to some contradictory findings from randomized trials, the topic of optimal adjuvant therapy for this disease encompasses several areas of controversy. The present review reports the main opinions on the role of adjuvant chemoradiotherapy, adjuvant chemotherapy, best single agent, and combination chemotherapy. Data from randomized trials are presented and critically analyzed to identify the available evidence supporting the different therapeutic choices and the main methodological drawbacks hampering the proper interpretation of results. Single agent chemotherapy yields a clinically significant, albeit modest, improvement in overall survival and may represent a standard option. The role of combination chemotherapy warrants further investigation and the impact of adjuvant chemoradiation both on local control and on the final outcome is uncertain. The need for more active and effective systemic treatments, for a better knowledge of the disease biology, for new therapeutic agents and predictors of pattern of recurrence is evident.