Neoadjuvant Therapy for Localized Pancreatic Cancer

Pancreatic ductal adenocarcinoma is an aggressive malignancy with poor long-term survival. While surgical resection followed by adjuvant chemotherapy remains the standard of care for resectable disease, a substantial proportion of patients fail to receive postoperative therapy. Neoadjuvant treatment has emerged as an alternative strategy aimed at improving delivery of systemic therapy, increasing margin-negative resections, and better assessing tumor biology. This review summarizes major clinical trials evaluating neoadjuvant approaches in resectable and borderline resectable pancreatic cancer.

A narrative review of published randomized and phase II-III clinical trials was performed, focusing on studies comparing neoadjuvant therapy with upfront surgery, trials comparing different neoadjuvant chemotherapy regimens, and studies evaluating the addition of neoadjuvant radiation therapy. Ongoing phase III trials were also reviewed.

Multiple trials demonstrated improved rates of chemotherapy delivery and higher R0 resection rates with neoadjuvant therapy. Some studies showed survival benefits (mOS ranging from 15.7 to 37 months), particularly in borderline resectable disease. While others failed to demonstrate an overall survival advantage compared with upfront surgery, especially in resectable disease. Trials comparing different neoadjuvant regimens and those evaluating the addition of radiation have yielded largely comparable outcomes, highlighting variability in treatment response and study design.

Current evidence supports the feasibility and safety of neoadjuvant therapy in localized pancreatic cancer; however, survival benefits remain inconsistent, especially in resectable disease. Results underscore the need for well-powered randomized trials especially in Western populations, improved patient selection, and biologic stratification to better define the optimal role of neoadjuvant therapy.