Meta-analysis comparing upfront surgery with neoadjuvant treatment in patients with resectable or borderline resectable pancreatic cancer

BackgroundStudies comparing upfront surgery with neoadjuvant treatment in pancreatic cancer may report only patients who underwent resection and so survival will be skewed. The aim of this study was to report survival by intention to treat in a comparison of upfront surgery versus neoadjuvant treatment in resectable or borderline resectable pancreatic cancer. MethodsMEDLINE, Embase and the Cochrane Library were searched for studies reporting median overall survival by intention to treat in patients with resectable or borderline resectable pancreatic cancer treated with or without neoadjuvant treatment. Secondary outcomes included overall and R0 resection rate, pathological lymph node rate, reasons for unresectability and toxicity of neoadjuvant treatment. ResultsIn total, 38 studies were included with 3484 patients, of whom 1738 (499 per cent) had neoadjuvant treatment. The weighted median overall survival by intention to treat was 188months for neoadjuvant treatment and 148months for upfront surgery; the difference was larger among patients whose tumours were resected (261 versus 150months respectively). The overall resection rate was lower with neoadjuvant treatment than with upfront surgery (660 versus 813 per cent; P<0001), but the R0 rate was higher (868 (95 per cent c.i. 846 to 887) versus 669 (642 to 696) per cent; P<0001). Reported by intention to treat, the R0 rates were 580 and 549 per cent respectively (P=0088). The pathological lymph node rate was 438 per cent after neoadjuvant therapy and 648 per cent in the upfront surgery group (P<0001). Toxicity of at least grade III was reported in up to 64 per cent of the patients. ConclusionNeoadjuvant treatment appears to improve overall survival by intention to treat, despite lower overall resection rates for resectable or borderline resectable pancreatic cancer. PROSPERO registration number: CRD42016049374. Improved survival with neoadjuvant treatment