Prognostic Factors Following Curative Resection for Pancreatic Adenocarcinoma

The conclusion of this study isdrawn from a population-based analysisof 396 patients. The inclusion was basedupon the code for operation radical pan-creaticoduodenectomy or Whipple pro-cedure, which also included total pan-createctomy, proximal pancreatectomy,partial pancreatectomy and distal pan-createctomy. This means that it includesa wide range of pancreatic cancers. Inaddition, there is no information aboutthe specific kind of the tumor in case ofa process in the pancreatic head region,which in every series of Whipple resec-tion will include a substantial number ofampullary carcinomas and distal bileduct carcinomas. Furthermore, a centralpathologist should specifically look forneuroendocrine tumors. Lacking this in-formation and considering the variationin the types of tumor, it is impossible tocome to a valid conclusion. This is sup-ported by the fact that the survival rate isextremely high. The 5-year survival rateis depicted in the figures above 30%,median survival time is nearly 18months, which has to mean that tumorslike distal bile duct cancer and ampul-lary cancer are included in the series andmay be also endocrine tumors.As I have said above, this alsomeans that conclusions about the prog-nostic factors cannot be made. The titleof the article is misleading, for it sug-gests that prognostic factors be given forpancreatic adenocarcinoma, which usu-ally means carcinoma of the head of thepancreas instead of a variation of can-cers. We know that the prognosis ofcancer in corpus or tail of the pancreas isworse. On the other hand the prognosisof cyst adenocarcinoma is better. Wealso know that the prognosis of distalbile duct and peri-ampullary cancer ismuch better. Thus, conclusions aboutprognostic factors cannot be made fromthis study.One of the most significant find-ings was the adjuvant combined chemo-radiotherapy as a prognostic factor. Thisis in contradiction with the evidence thatexists in the literature. We live in the eraof evidence-based medicine. Evidenceshould nowadays be based upon level Ior level II studies and there are only 2large prospective randomized studiesthat can be taken into account, which arethe studies of Klinkenbijl et al (AnnSurg 1999; 230:776-782) and Neoptolo-mos et al (Lancet, November 2001).These 2 large randomized studiesclearly indicate that there is no signifi-cant effect of chemo-radiotherapy inpancreatic cancer. The study in the Lan-cet is not even mentioned in the article!To my surprise these 2 studies aremisinterpreted by the authors. Theywrite that: “two prospective randomizedclinical trials are in progress,” “althoughpreliminary data from the EORTCshowed no significant benefit of adju-vant-radiotherapy or chemotherapy on2-year survival, additional data from thisongoing as well as those from the ES-PAC-1 trial, should go a long way to-ward elucidating the role of adjuvantchemo-radiotherapy in the treatment ifpancreatic cancer patients.” This is aserious misinterpretation, these trials arenot ongoing trials and provide a firmstatement with good statistical evidence.Both trials are closed and finished.The studies that are mentioned bythe authors that are consistent with theirfindings are all retrospective analysis, ex-cept for the historic GITSG-trial, whichhad a insufficient, very small number ofpatients.