Benefits of Neoadjuvant Therapy

The ability to deliver systemic therapy to all patients: critically important as systemic therapies become more effective and tumor/patient profiling allow for individualized, personalized medicine

Following neoadjuvant therapy, post-treatment preoperative staging allows for the identification of patients with aggressive tumor biology, who manifest with disease progression and are unresponsive to available therapies. These patients are spared the toxicity of surgery

Increased efficacy of radiation therapy if it is incorporated into the treatment program; free radical production in a well oxygenated environment

Decreased radiation induced toxicity to adjacent normal tissue as the radiated field is resected at the time of pancreatectomy

Decreased rate of positive resection margins; SMA margin in particular

Decreased rate of pancreatic fistula formation

Potential for the downstaging of borderline resectable tumors to facilitate surgical resection

Disadvantages of Neoadjuvant Therapy

Potential for complications from pre-treatment endoscopic procedures; endoscopic ultrasound-guided fine-needle aspiration biopsy and endoscopic stent placement

Biliary stent occlusion which may occur during neoadjuvant therapy

Disease progression obviating resectability; loss of a “window” of resectability which rarely occurs in the borderline resectable patient Physicians have to work together during the preoperative phase; discrete handoff from surgeon to medical oncologist to radiation oncologist, as occurs with adjuvant therapy, is not possible in the neoadjuvant setting

As employees of health systems, surgeons may be incentivized to operate frequently in an effort to meet defined productivity (work RVU) requirements which impact compensation