Neoadjuvant radiotherapy for pancreatic cancer: rationale and outcomes

Pancreatic cancer is an aggressive disease with median survival in localized resectable cases measured by months. Surgery is necessary for cure, but remains only part of the treatment paradigm; the ideal treatment is multimodal. After undergoing surgery alone for pancreatic cancer, most patients will recur and the use of neoadjuvant chemoradiation therapy is an attractive, more novel treatment approach for several reasons: to facilitate down staging in borderline or locally advanced patients so that surgical resection is feasible; to increase the rate of R0 resections while sterilizing there section field; to expedite the delivery of adjuvant therapy, which may be delayed or infeasible postoperatively because of complications in therapy; to allow time preoperatively for the natural process of the disease to present itself while undergoing therapy for prognostic value; and to decrease toxicity owing to smaller radiation fields and less radiation to the small bowel. Although there have been no phase III multicenter randomized controlled trials for this patient population, there have been multiple single-institution reports published, and clinical trials are on the horizon.