New implications from long-term outcomes of perioperative therapy in resectable pancreatic cancer.

This publication is a focused review of contemporary evidence guiding multimodality treatment in potentially curable pancreatic cancer, using recent randomized trials to clarify when and how to use chemotherapy and radiotherapy around surgery.

Key points:

• • Foundation of improved survival

  The major survival gains in pancreatic cancer come from combining surgical resection with effective systemic chemotherapy. The article emphasizes that systemic therapy—not local intensification alone—is the core driver of outcome improvement.

• • Chemotherapy vs chemoradiotherapy in the adjuvant setting

  Recent data, including the RTOG 0848 trial (adjuvant chemotherapy ± chemoradiation), are highlighted to refine the role of postoperative chemoradiotherapy. These results help define which patients may benefit from added radiation versus chemotherapy alone, reducing prior uncertainty.

• • Neoadjuvant vs adjuvant strategies for “resectable” disease

  The review discusses the challenge of deciding between neoadjuvant therapy and upfront surgery in patients deemed resectable. The NORPACT‑1 trial (neoadjuvant FOLFIRINOX vs upfront surgery) is used to illustrate how randomized data are reshaping views on the necessity and value of routine neoadjuvant treatment in clearly resectable tumors.

• • Limitations of current resectability classifications

  The distinction between “resectable,” “borderline resectable,” and “unresectable” is criticized as unreliable and inconsistently applied. The authors stress that:

  • • Analyses restricted only to patients who actually undergo resection (“resected”) produce a biased, more favorable subset.
  • • Some argue for de‑emphasizing these categories in favor of upfront chemotherapy for nearly all patients, rather than basing strategy solely on imaging-defined resectability.

• • Choice and duration of adjuvant chemotherapy

  Long‑term follow‑up from major trials—PRODIGE 24 (FOLFIRINOX vs gemcitabine) and ESPAC‑4 (gemcitabine‑capecitabine vs gemcitabine)—confirms:

  • • Superiority of combination regimens over gemcitabine monotherapy.
  • • Durable benefit and broader applicability of adjuvant chemotherapy in fit, resected patients.

  The article also underscores that FOLFIRINOX and gemcitabine‑capecitabine are not the only possible systemic backbones, leaving room for individualization based on patient fitness, comorbidity, and local practice.

• • Overall message for practice

  The review integrates these trial results to:

  • • Support adjuvant combination chemotherapy as standard for suitable patients after resection.
  • • Narrow the indications for routine adjuvant chemoradiation.
  • • Urge caution in overreliance on resectability labels and selective reporting of only resected patients.
  • • Encourage a more universal and earlier use of systemic therapy, while recognizing the need to tailor regimen choice rather than defaulting to the most intensive option for all.