DÄ internationalArchive38/2008Pancreatic Cancer – Low Survival Rates: Gemcitabine More Useful

Correspondence

Pancreatic Cancer – Low Survival Rates: Gemcitabine More Useful

Dtsch Arztebl Int 2008; 105(38): 655. DOI: 10.3238/arztebl.2008.0655

Geißler, M

LNSLNS From the point of view of the "DKG-S3 Guideline Committee for Exocrine Pancreatic Carcinoma", the following points should be discussed which were neglected in the review of Beger et al..

In the paragraph on adjuvant chemotherapy (Cx), the authors imply that the 5-fluorouracil bolus protocol, as used in the ESPAC-1 study, is the standard adjuvant chemotherapy after R0-resection. However, the S3 guideline (3) recommends that the 5-fluorouracil bolus protocol should not be used. On the contrary, the guideline unambiguously recommends adjuvant Cx with gemcitabine, because disease-free survival and overall survival were improved by gencitabine in the CONK0-001 study (2). Even though it was expected that bolus 5-fluorouracil and gemcitabine would be equipotent in the ESPAC-III study, gemcitabine would still be preferable as Cx, as the tolerability is better and the handling simpler.

The authors' sentence "Some data, however, demonstrate that adjuvant palliative chemoradiotherapy can improve the prognosis for the R1/R2 resected patient" is likewise inconsistent with the S3 guideline.

Based on the subgroup analysis of the CONK0-001 study, this advocates additive palliative Cx with gemcitabine. Although a metaanalysis (4) found a trend towards benefit with adjuvant radiochemotherapy in comparison with resection alone, there are no data comparing this with chemotherapy alone. Because of the markedly higher toxicity and stress to the patient in comparison to gemcitabine for what is usually palliative treatment, the guideline regards this procedure as only an option for the individual patient. The guideline recommends that radiochemotherapy after R1 resection should, if at all possible, be performed in the form of randomized controlled study protocols. We are urgently awaiting the results of prospective randomized studies to clarify this important question.
DOI: 10.3238/arztebl.2008.0655


Prof. Dr. Michael Geißler
Klinik für Onkologie, Gastroenterologie und Allgemeine Innere Medizin
Klinikum Esslingen
Postfach 10 07 53
73707 Esslingen, Germany
m.geissler@klinikum-esslingen.de

Conflict of interest statement
The author acts as an adviser to Lilly and receives honoraria for presentations.
1.
Neoptolemos JP, Stocken DD, Firess H et al.: A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer. N Engl J Med 2004; 350: 1200–10. MEDLINE
2.
Oettle H, Post S, Neuhaus P, Gelldorf K et al.: Adjuvant chemotherapy with Gemzitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer. JAMA 2007; 297: 267–77. Update ASCO 2008. MEDLINE
3.
Adler G, Seufferlein T, Bischoff SC et al.: S3-Leitlinien „Exokrines Pankreaskarzinom“ 2007. Ergebnis einer evidenzbasierten Konsensuskonferenz. Gastroenterologie 2007; 6: 487–523. MEDLINE
4.
Stocken DD, Büchler MW, Dervenis C et al.: Pancreatic cancer Meta-analysis Group. Meta-analysis of randomized adjuvant therapy trials for pancreatic cancer. BJC 2005; 92: 1372–81. MEDLINE
1. Neoptolemos JP, Stocken DD, Firess H et al.: A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer. N Engl J Med 2004; 350: 1200–10. MEDLINE
2. Oettle H, Post S, Neuhaus P, Gelldorf K et al.: Adjuvant chemotherapy with Gemzitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer. JAMA 2007; 297: 267–77. Update ASCO 2008. MEDLINE
3. Adler G, Seufferlein T, Bischoff SC et al.: S3-Leitlinien „Exokrines Pankreaskarzinom“ 2007. Ergebnis einer evidenzbasierten Konsensuskonferenz. Gastroenterologie 2007; 6: 487–523. MEDLINE
4. Stocken DD, Büchler MW, Dervenis C et al.: Pancreatic cancer Meta-analysis Group. Meta-analysis of randomized adjuvant therapy trials for pancreatic cancer. BJC 2005; 92: 1372–81. MEDLINE