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Total Neoadjuvant Therapy: The New Standard for Pancreatic Cancer?

Pancreatic cancer has long been treated with surgery followed by chemotherapy or radiation. However, reversing the order of those treatments—a process known as total neoadjuvant therapy—could lead to better outcomes for patients.

Total neoadjuvant therapy is a newer approach to treating pancreatic cancer in which a patient receives radiation therapy or chemotherapy to shrink their tumor before undergoing surgery to remove it. Many experts believe that sequencing of treatments in this order can lead to better outcomes.

“There’s more and more science showing that this is the right way to treat pancreatic cancer,” explained Sanjay S. Reddy, MD, FACS, a surgical oncologist at Fox Chase Cancer Center.

The benefits of total neoadjuvant therapy

Surgery to remove the tumor is typically considered the main treatment for pancreatic cancer, if the cancer has not spread beyond the pancreas. This procedure is not a small operation, and it’s not always possible to remove every bit of cancer.

Some pancreatic tumors are attached to or wrapped around blood vessels, making them harder to remove. However, even when a tumor isn’t touching a blood vessel, many patients have microscopic pancreatic cancer cells in other areas that can’t be detected.

Giving chemotherapy or radiation before surgery can help shrink large tumors that are on or near blood vessels so they’re easier to operate on. It can also help kill those undetectable cancer cells in other parts of the body.

“I think of these tumors as a large plant, and surrounding this are weeds which we can’t see,” Reddy explained. “Surgery can address the plant, but chemotherapy is the best way to address the weeds.”

Is total neoadjuvant therapy right for everyone?

Total neoadjuvant therapy is often recommended for pancreatic cancer patients whose tumors are too big to be removed by surgery at the time of their diagnosis, or if the tumor involves major blood vessels. “However, if the tumor is completely away from any blood vessels, surgery is still considered standard. Although there is growing support in sequencing these patients with systemic chemotherapy first,” Reddy said.

Still, experts like Reddy are convinced that total neoadjuvant therapy could play a valuable role in treating many pancreatic cancer cases.

“The microscopic cancer cells that we can’t see, the so-called weeds and seeds, can’t be addressed through surgery. We hope that chemotherapy can control those cells,” Reddy said. “So, the combo of the two, I feel, holds the most promise.”

That’s why even for patients with small, early-stage pancreatic tumors, seeing a medical oncologist to discuss systemic treatments before definitive resection could prove beneficial.

“This disease is one that involves a true team approach,” Reddy said. “Meeting with a surgical, medical, and radiation oncologist helps the patient understand all the available options, including clinical trials, so that they can make a better informed decision regarding their care.”

Learn more about pancreatic cancer treatment at Fox Chase Cancer Center.