Top Line: So when do we use radiation for pancreatic cancer again..?
The Study: The randomized phase 2 Alliance A021501 trial randomized 110 patients with borderline resectable pancreatic cancer to either neoadjuvant mFOLFIRINOX then surgery or neoadjuvant mFOLFIRINOX then 5-fraction radiation then surgery. Spoiler alert: the radiation arm was closed to accrual early after the first analysis demonstrated a significant increase in margin-negative resection rate in the chemo alone arm. Final analysis after a further 16 patients were enrolled on the chemo alone arm (n=126) revealed an almost doubling of median survival among those getting neoadjuvant chemo alone (30 months) versus neoadjuvant chemo then radiation (17 months). Now this is interesting for a couple of reasons. First, it separates the chemo from the radiation, unlike PREOPANC and this Mass Gen trial. And, in fact, the survival after neoadjuvant chemo then radiation is consistent with these previous data. Second, the median survival achieved after neoadjuvant chemo alone is unprecedented for borderline resectable pancreatic cancer, making for another blockbuster hit for mFOLFIRINOX.
TBL: Med oncs authoring the accompanying editorial don’t mince words: “With the continued lack of observed survival benefit across more than two decades of clinical trials in pancreas cancer, to our knowledge, the role of radiotherapy remains unproven.” | Katz, JAMA Oncol 2022