The most common type of pancreatic cancer, pancreatic ductal adenocarcinoma (PDAC) has limited treatment options and a low survival rate. Traditionally, patients whose disease is resectable—able to be removed by surgery—have been treated with a post-operative adjuvant approach, consisting of surgery followed by chemotherapy or radiation. In recent years, however, there has been a heightened interest in perioperative treatment, in which patients receive chemotherapy or radiation both before and after surgery.
In their study now published in Annals of Surgical Oncology, Alice C. Wei, MD, MSc, and colleagues conducted a phase 2 trial to evaluate the safety and efficacy of gemcitabine in combination with erlotinib followed by pancreaticoduodenectomy—a procedure to remove tumors from the head of the pancreas, also known as the Whipple procedure—in patients with resectable PDAC. In this interview with i3 Health, Dr. Wei discusses the potential that perioperative chemotherapy has to offer for patients with this disease.
What are some of the most challenging aspects of treating patients with resectable PDAC?
Alice C. Wei, MD, MSc: These are very complex patients who have a lot of symptoms at the time of their diagnosis. In order to provide optimal care, we need to confirm a diagnosis, relieve their symptoms, and simultaneously plan for the optimal sequence of surgery and chemotherapy or radiation. This can be challenging and has to be tailored for every individual patient.
Can you comment on the significance of your research on perioperative gemcitabine in combination with erlotinib for patients with resectable PDAC?
Dr. Wei: There have been a tremendous number of developments for the treatment of pancreatic cancer over the last decade. Prior to that, it was a very lethal cancer, and it still remains a very challenging disease to treat. However, a number of more active regimens have become available to patients over the last decade, and as a result, there has been a lot of interest in understanding which treatment is best to give to individual patients.
Classically, we used to recommend post-operative adjuvant treatment, which involves performing the surgery first and then administering chemotherapy and/or radiation. Now, there is much more interest in perioperative treatment, which consists of giving chemotherapy first, performing the surgery, and then following with more chemotherapy afterwards. This paradigm of giving patients chemotherapy first while planning for surgery is something that physicians in many other cancers are also starting to do. One of the most significant things about our trial is that it was one of the earliest cooperative group studies to test the strategy of administering chemotherapy first for patients who have resectable pancreatic cancer.
How do you foresee the treatment of resectable PDAC evolving?
Dr. Wei: The concept of giving chemotherapy first, even for patients who are planning to have surgery, is a large part of the evolution of thinking about individual patients and how to best treat them.
Do you have any words of advice for oncologists treating patients with resectable PDAC?
Dr. Wei: Given the rapid changes in the treatment of pancreatic cancer, I think that one of the most important pieces of advice is to further explore the idea of perioperative chemotherapy. The types of patients to whom we are able to offer surgery has also evolved; for patients whose disease might have been considered unresectable a decade ago, we may now be able to design surgery in combination with strategies like perioperative chemotherapy and radiation therapy.
It's a new age for pancreatic cancer treatment. Perioperative approaches like the gemcitabine plus erlotinib regimen are being tested in different scenarios to provide a better idea of whether they should be the approach for every patient. The perioperative approach for resectable pancreatic cancer is not yet the standard, but it may be one day; other trials have followed ours with new regimens that are currently being tested. In the next few years, we will have a much better idea of whether perioperative chemotherapy or radiation will become the new standard. This is a very exciting time for the treatment of resectable PDAC.
About Dr. Wei
Alice C. Wei, MD, MSc, is an Associate Attending Surgeon in the Hepatopancreatobiliary Service at Memorial Sloan Kettering Cancer Center (MSKCC) and the Co-Director of Surgical Initiatives at the David M. Rubenstein Center for Pancreatic Cancer Research at MSKCC.She specializes in treating diseases of the liver, bile ducts, gallbladder, and pancreas with minimally invasive methods such as laparoscopic surgery, robotic surgery, and ablation therapy. Her research focuses on increasing the efficacy of cancer surgery and enhancing the quality of post-operative care.
For More Information
Wei AC, Ou FS, Shi Q, et al (2019). Perioperative gemcitabine plus erlotinib plus pancreaticoduodenectomy for resectable pancreatic adenocarcinoma: ACOSOG Z5041 (Alliance) phase II trial. Annals of Surgical Oncology. [Epub ahead of print] DOI:10.1245/s10434-019-07685-1
Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily represent those of i3 Health.