ESPAC5: immediate surgery versus short-course neoadjuvant chemotherapy or chemoradiotherapy for borderline resectable pancreatic cancer
In this four-arm British trial, two months of chemotherapy before surgery for borderline resectable pancreatic cancer doubled the share of patients alive at one year compared with operating straight away, even though the same proportion got to an operation.
Overview
Multicentre randomised phase 2 trial of the European Study Group for Pancreatic Cancer in 90 patients with borderline resectable pancreatic ductal adenocarcinoma, randomised to immediate surgery or to one of three short-course neoadjuvant treatments (gemcitabine plus capecitabine, FOLFIRINOX, or capecitabine-based chemoradiotherapy) followed by surgery, with adjuvant chemotherapy in all arms.
Resection rates were similar between immediate surgery and the pooled neoadjuvant arms, but one-year overall survival was 39 percent after immediate surgery and 77 percent after neoadjuvant treatment (hazard ratio 0.27). The chemotherapy arms did better than chemoradiotherapy, and FOLFIRINOX did best.
- One-year overall survival 39 percent with immediate surgery versus 77 percent with neoadjuvant treatment, hazard ratio 0.27.
- Resection rates were similar (about 62 versus 55 percent), so the survival gain did not come from more operations.
- Neoadjuvant chemotherapy, especially FOLFIRINOX, outperformed chemoradiotherapy.
ESPAC5 supports neoadjuvant chemotherapy over immediate surgery in borderline resectable disease and points to FOLFIRINOX as the regimen to build on.
- A phase 2 feasibility trial with 90 patients across four arms; the survival comparison was a secondary endpoint.
- Only two months of neoadjuvant treatment were given, shorter than most current protocols.
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