To the Editor:
Klinkenbijl et al. in their article, “Adjuvant radiotherapy and 5-fluorouracil after curative resection of cancer of the pancreas and periampullary region: Phase III trial of the EORTC Gastrointestinal Tract Cancer Cooperative Group” (Ann Surg 230:776–784), conclude in both the Conclusions section of their abstract and in the Discussion section of the manuscript that “routine use of adjuvant chemoradiotherapy is not warranted as standard treatment in cancer of the head of the pancreas or periampullary region.” Subset analysis of patients with pancreatic head adenocarcinoma and periampullary adenocarcinoma was performed because these diseases have different natural histories and patterns of treatment failure. For patients with adenocarcinoma of the pancreas, median survival was 17.1 months for the 60 patients who received adjuvant chemoradiation, and 12.6 months for the 54 patients who received surgery alone (RR = 0.7, 95% CI = 0.5–1.1, P = .099). On page 780 in the Results section of the manuscript, the authors acknowledge that follow-up duration and patient numbers were insufficient to draw conclusions about the potential benefit of postoperative adjuvant therapy for patients with adenocarcinoma of pancreatic origin. In fact, a trend in favor of adjuvant therapy was shown (RR = 0.7). Further, the confidence intervals (95% CI = 0.5–1.1) include clinically relevant values (e.g., RR = 0.5) indicating that the data do not exclude the possibility that a meaningful survival benefit may be associated with adjuvant chemoradiation.
The Conclusion section of the abstract and the final paragraph of the manuscript clearly convey to the reader that there is no indication for adjuvant 5-FU–based chemoradiation after pancreatectomy for patients with adenocarcinoma of the pancreas. This is not supported by data in the manuscript (as acknowledged by the authors in a much less visible part of the manuscript), is clearly misleading, and may negatively impact the care of patients with pancreatic cancer due to the wide readership of this journal.
Douglas B. Evans MD
Robert A. Wolff MD
Kenneth R. Hess MD