Chemotherapy Completion as a Quality Metric in Resected Pancreatic Ductal Adenocarcinoma

Background: Over 60,000 patients are diagnosed annually with pancreatic cancer in the United States, most with pancreatic ductal adenocarcinoma (PDAC). Despite multimodality treatment, prognosis remains poor, underscoring the need to better define factors associated with improved survival in resectable disease. The aim of this study was to propose "completeness of therapy" in resectable PDAC based on chemotherapy type, relative dose intensity (RDI), duration, and timing of initiation, and to evaluate their association with overall survival (OS). Methods: A systematic review of PubMed identified 34 studies. Hazard ratios (HRs) were extracted and synthesized in forest plots. Outcomes focused on OS in relation to chemotherapy completion (cumulative cycles), time to adjuvant chemotherapy initiation (TTA), RDI, and regimen type. The goal was to conceptualize an evidence-based completeness-of-therapy framework for resected PDAC. Results: Completion of chemotherapy was associated with a 42% reduction in the hazard of death compared with incomplete therapy (HR = 0.58, 95% CI 0.47-0.71, p < 0.01). No significant OS difference was observed for longer TTA within a ≤12-week window after surgery (HR = 1.22, 95% CI 0.95-1.56, p = 0.10). Higher RDI demonstrated a large but non-significant trend toward improved OS (HR = 0.51, p = 0.24). Non-significant trends favoring gemcitabine-based regimens (HR = 0.87, p = 0.26) and FOLFIRINOX (HR = 0.79, p = 0.26) were observed, with FOLFIRINOX suggesting a 21% relative reduction in mortality. Conclusions: Chemotherapy completion is strongly associated with improved OS in resectable PDAC. Initiation of adjuvant therapy within 12 weeks appears sufficient, allowing recovery from surgery. Higher RDI and specific chemotherapy regimens demonstrated numerically favorable hazard ratios; however, these associations were not statistically significant and should be interpreted cautiously.