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Invited Critique
January 2010

Is the Debate Finally Over?Comment on “Survival Effects of Adjuvant Chemoradiation Following Chemoradiotherapy After Resection for Pancreatic Carcinoma”

Arch Surg. 2010;145(1):56. doi:10.1001/archsurg.2009.241

In this study, Yang et al use data from a large population-based registry to show a significant survival advantage with adjuvant chemoradiotherapy after pancreatic cancer resection. Moreover, they explore the effects of variables such as HVCs and teaching status that have been previously shown to affect outcomes in pancreatic cancer survival. The authors nicely confirm that patients treated at HVCs and TFs indeed have improved survival but also show that all patients benefit from adjuvant chemoradiotherapy after resection. However, like most studies generated using these large databases, there are several weaknesses to this study. There is missing information on cancer stage in more than 50% of the patients, the margin status is not known (R0 or R1), and there is no information on the type or duration of chemoradiotherapy, all of which limit the potential utility of such studies. Nevertheless, such studies can be hypothesis generating and can also point to large societal trends. The present study shows that pancreatic cancer surgery still happens at LVCs despite the large volume of data showing better outcomes at HVCs. Importantly, the majority of patients receive no adjuvant therapy, likely reflecting the morbidity of the operation and that most patients do not recover their performance status to receive adjuvant therapy. In this context, the finding on univariate analysis by the authors of a potential survival benefit of neoadjuvant therapy is intriguing and warrants further investigation.

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