A commentary on ‘The experience of neoadjuvant chemotherapy versus upfront surgery in resectable pancreatic cancer: a cross sectional study’

Dear Editor,

We read with great interest the study entitled ‘The experience of neoadjuvant chemotherapy versus upfront surgery in resectable pancreatic cancer. a cross sectional study’¹, which indicated that patients receiving neoadjuvant chemotherapy (NAC) followed by surgery benefited more than those receiving upfront resection (UR) followed by adjuvant chemotherapy. However, despite of the significant value of the result for clinical guidance, there are several concerns that we would like to discuss.

First, this study demonstrated that the prognosis of patients in the NAC group was significantly better than those in the UR group. Notably, only 37 of 46 patients in the NAC group proceeded to surgery, and 100 of 113 patients in the UR group underwent complete tumor resection. Nevertheless, when patients’ survival analysis was performed, all 46 patients in the NAC group and 113 patients in the UR group were included. However, we tend to believe that patients who do not successfully undergo surgery should be excluded from the analysis. Considering the persistence and progression of the tumor in the body, this will seriously affect the survival time of the patient, and thus lead to a certain bias in the results.

Second, 42 of the 100 resected patients in the UR group did not receive postoperative chemotherapy, which was unacceptable to some extent. According to National Comprehensive Cancer Network (NCCN) Guidelines², postoperative adjuvant chemotherapy is recommended for all patients with pathologically diagnosed pancreatic ductal adenocarcinoma. In this study, the author should further explain the reason why the patients did not receive postoperative chemotherapy, whether it was a poor general condition or the patients’ refusal, etc. If the reason is a poor general condition of the postoperative patients, considering that almost all patients in the NAC group receive postoperative chemotherapy, then it is possible that patients in the UR group possess a worse postoperative systemic status, which leads to a poorer prognosis. This point needs further clarification to avoid the influence of multiple uncorrelated factors on the conclusions.

Third, given that the follow-up period of patients includes 2020–2021, which is during the COVID-19 (coronavirus disease 2019) pandemic, the postoperative survival time of patients may be affected to some extent. Studies have reported the adverse effects of COVID-19 on the prognosis of postoperative patients³. In this paper, it mainly be reflected in the sharp increase in the mortality of follow-up patients during the period of 2020–2021, which may require further attention. In addition, the baseline information and surgery-related information of the patients need to be further detailed, including the patient’s underlying disease history, duration of surgery, and postoperative complications.

Overall, this study provides another strong evidence for the application of NAC followed by surgery in resectable pancreatic cancer. However, this study is a single-center cross-sectional study, and the effectiveness of its conclusions needs to be confirmed in a larger multicenter study. In addition, according to the experience of our center, although NAC followed by surgery has proven its effectiveness, there are still some patients in this process who will miss the opportunity for surgery due to tumor progression, and how to accurately identify this part of patients is one of the keys to the large-scale promotion of this strategy in the future.

Ethical approval

Not applicable for this study.

Consent

Not applicable.

Sources of funding

This study was supported by the CAMS Innovation Fund for Medical Sciences (2021, 2021-1-I2M-002) and National Nature Science Foundation of China (2021, 82102810).

Author contribution

Y.C.: study concept and writing; C.W. and Y.Z.: critical revision of the manuscript; C.W. and Y.Z.: obtained funding.

Conflicts of interests disclosure

No potential competing interests were disclosed by the authors.

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Guarantor

Yuan Chen.

Data availability statement

Not applicable.

Provenance and peer review

Our paper was not invited.