In this podcast, Dr Jeroen Dekervel, gastrointestinal oncologist at UZ Leuven (Belgium), moderates a discussion between Dr Nina Sanford, radiation oncologist at UT Southwestern, Dallas (USA), and Dr Bas Groot Koerkamp, surgical oncologist at Erasmus MC, Rotterdam (The Netherlands), on the role of radiotherapy in borderline resectable pancreatic ductal adenocarcinoma (PDAC).
The discussion begins with a clinical case, setting the stage for an exploration of whether and when radiotherapy should be part of neoadjuvant treatment. Both experts agree on the importance of systemic therapy in all patients with borderline resectable PDAC. Dr Groot Koerkamp outlines his preference for neoadjuvant 5-FU, irinotecan and oxaliplatin (FOLFIRINOX) without radiotherapy, emphasizing that current evidence has not demonstrated a clear survival benefit of adding radiotherapy in this setting. He acknowledges that radiotherapy can increase R0 resection rates but underscores the lack of robust data supporting improvements in hard endpoints like overall survival. Dr Sanford highlights the selective role radiation may play after systemic therapy, especially in cases with persistent arterial involvement or in patients who are not immediate surgical candidates. She points to the potential of stereotactic body radiotherapy to deliver ablative doses with a shorter treatment course and improved tolerability.
The experts review trial data, including PREOPANC-1, PREOPANC-2 and ALLIANCE A021501. While the evidence remains inconclusive, both speakers agree that future studies will be essential to refine patient selection and identify those who may benefit most from radiotherapy. Both experts see a potential role for radiotherapy in the locally advanced setting or in patients unfit for surgery or prolonged chemotherapy, as being explored in ongoing trials like LAPSTAR and PANCOSAR as well as NRG GI-011.
The episode concludes with a shared call for high-quality, randomized trials with clinically meaningful endpoints to better guide treatment decisions in this complex and evolving field.
Acknowledgments
Funding
None declared.
Disclosure
JD received consulting fees and/or speaker honoraria from Amgen, AstraZeneca, Bayer, BMS, Eisai, Need Inc., Ipsen, Lilly, MediMix, Merck, MSD, Novartis, Roche and Servier. BGK received an in-kind contribution of Tricumed (pumps) for clinical trials with intra-arterial chemotherapy. NS has declared no conflicts of interest.