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Neoadjuvant Therapy and Surgery Offer a Promising Treatment Option for Patients with Borderline Resectable Pancreatic Cancer

Advance With MUSC Health
February 19, 2021
Dr. Katherine Morgan in surgery.

Pancreatic cancer is deadly and often not diagnosed until it has reached an advanced stage. Moreover, as the population ages and the incidence of obesity, diabetes and pancreatitis rises, pancreatic cancer is predicted to increase. "It's definitely increasing in incidence and is currently the third leading cause of cancer death in the United States;' says Dr. Katherine Morgan, an MUSC Health oncology and gastroenterology surgeon. "It spreads systemically very early and often it's not diagnosed until it has advanced to stage IV. That's what makes it so challenging to treat."

Yet a significant number of patients who present with borderline resectable pancreatic cancer - before the tumor has become widespread -- can benefit from multimodal treatments available at MUSC Hollings Cancer Center, one of 71 National Cancer Institute-designated cancer centers in the nation.

In borderline resectable pancreatic cancer, the tumor is locally advanced and involves some of the main blood vessels in the area. Although the tumor is technically removable, the surgery poses a high risk for having positive margins and leaving microscopic tumor.

To optimize the surgical outcome, Dr. Morgan treats patients with neoadjuvant therapy to shrink the tumor before surgery. "This helps ensure we can take out all the tumor, including not only what we see, but what is microscopic,” she says.

Neoadjuvant therapy consists of chemotherapy, which is sometimes followed by external radiation or brachytherapy. Neoadjuvant therapy may be beneficial in all stages of localized pancreas cancer, but is particularly valuable in patients with borderline resectable pancreatic cancer.

Based on the patient's demographic and underlying medical conditions, oncologists utilize a chemotherapy regimen consisting of two agents or four agents.

"A short course of neoadjuvant treatment lasts only a couple of months and then we do early reevaluation with CT scans to make sure the patient is responding to the chemotherapy," she says. "If the response is good, we may extend the treatment time with chemotherapy or proceed with surgery. If we've maximized the chemotherapy, we may add radiation treatment to help optimize local control of the tumor."

Neoadjuvant therapy typically lasts from four to six months.

"Patients who have multimodal treatment, completing chemotherapy with or without chemoradiation and having surgery with negative margins, have the most favorable outcomes,” she says. "In borderline resectable pancreatic cancer, despite the neoadjuvant treatment, we often have to resect the portal vein or a major artery and perform vascular reconstruction to be sure we get all of the tumor."

Dr. Morgan is encouraged by the results.

"Of patients undergoing neoadjuvant treatment for borderline resectable pancreatic cancer, approximately one-third have good tumor response to chemotherapy, and one-third do not improve radiographically but still become candidates for resection,” she says.

Dr. Morgan is optimistic about treatments for these patients, as well as a national clinical trial underway at MUSC, including one that is testing the efficacy of delivering chemotherapy directly to the tumor via a special catheter.

The median overall survival rate for patients who have completed multimodal therapy, including chemotherapy and surgery, is upwards of four years, she says.

Patients come to MUSC, home to the National Cancer Institute-designated Hollings Cancer Center, from across the Southeast for advanced, personalized treatment and participation in clinical trials.

"We have amazing multidisciplinary experts in all the different disciplines pathology, radiology, gastroenterology, oncology, surgical and gastroenterology oncology, and we work together as a team," she says.

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Keywords: Cancer, Surgery, For Providers