Recovery to Intended Oncologic Therapy After Upfront Pancreatectomy for Pancreatic Ductal Adenocarcinoma

Background Upfront resection with adjuvant chemotherapy remains standard for resectable pancreatic ductal adenocarcinoma (PDAC), but a quarter or more of patients never start adjuvant therapy. We assessed readiness for adjuvant therapy within 12 weeks of upfront pancreatectomy, its correlates, and how often ready patients went untreated. Methods We reviewed 114 consecutive upfront pancreatectomies for PDAC at a high-volume centre (2017-2023). The primary endpoint was clinician-documented readiness for adjuvant chemotherapy within 12 weeks; initiation was secondary. The same oncologist usually documented both, so they are not independent. A burden score counted five adverse recovery events by day 30. Results Of 107 assessed patients, 89 (83.2%, 95% CI 74.7-89.7) were ready within 12 weeks (87.3% excluding 5 who died or had metastatic disease). Readiness was 94.6% with no adverse event, 82.4% with one, and 68.8% with two or more (non-readiness vs none: OR 7.1, 95% CI 2.1-30.5). Clinically relevant pancreatic fistula alone showed no association (OR 1.15, 95% CI 0.36-3.33; 5 events), but a clinically important effect could not be excluded. The burden score had an internally estimated AUC of 0.73 (95% CI 0.59-0.85). Only 54 (50.5%) started chemotherapy within 12 weeks, including 53 of 88 ready patients. Discussion Most patients were ready for adjuvant therapy within 12 weeks, and failure to recover tracked cumulative postoperative burden by day 30. Over a third of ready patients had no documented chemotherapy start, although readiness and initiation were not independently assessed. These hypothesis-generating findings require external validation and do not compare treatment sequencing.