Supportive care considerations during concurrent chemoradiotherapy for pancreatic adenocarcinoma: lessons learned from clinical experience.

Concurrent chemotherapy and radiotherapy (chemoradiotherapy) for the management of pancreatic adenocarcinoma in either adjuvant or locally regional advanced settings produces predictable acute toxicities that are proportional in severity to the intensity and type of systemic therapy and to the parameters of radiotherapy. In addition, relevant to the adjuvant setting, surgery for pancreatic cancer often produces physiologic alterations that may impact a patient's ability to tolerate chemoradiotherapy. Failures to anticipate, monitor, and proactively manage the effects of surgery and toxicities of chemoradiotherapy can result in the need for unplanned treatment interruptions and/or inability to complete all planned therapy. In this review, complications of pancreatic cancer itself and of pancreatic resection as well as toxicities of chemoradiotherapy are delineated, and approaches to their management before, during, and after chemoradiotherapy are presented. Planning for the treatment of side effects before the anticancer therapy begins facilitates therapy administration and improves patient tolerance.

The Virginia Mason approach to localized pancreatic cancer.

This article describes the approaches presently employed at Virginia Mason Medical Center for treatment of localized pancreatic cancer, including preoperative staging, operative intervention, incorporation of adjuvant therapy, and supportive care.

Interferon-based adjuvant chemoradiation therapy after pancreaticoduodenectomy for pancreatic adenocarcinoma.

BACKGROUND: Patients with cancer who undergo pancreaticoduodenectomy (PD) followed by radiation and 5-fluorouracil (5-FU) therapy have experienced median overall survival from 18 to 24 months and an actuarial 2-year overall survival from 34% to 48%. We previously reported an 84% 2-year survival using a novel adjuvant chemoradiation protocol that included alpha interferon. This report describes the continued observations regarding this methodology with longer follow-up and more than twice the number of patients as the original report. METHODS: From July 1995 to May 2002, 43 patients with adenocarcinomas in the pancreatic head underwent PD at our institution. The mean age was 62 years (range 29 to 77) and 60% were men. Final pathologic findings were stage I (2%), II (12%), III (72%), and IVa (14%) while 84% had positive lymph nodes (average number of nodes positive was 3.2 nodes, (range 0 to 13). Tumor extended through the capsule of the surgical specimen in 70%. These patients then received our investigational protocol consisting of external-beam irradiation at a dose of 4,500 to 5,400 cGy (25 fractions over 5 weeks) and three-drug chemotherapy: continuous infusion 5-FU (200 mg/m(2) daily, days 1 to 35), weekly intravenous bolus cisplatin (30 mg/m(2) daily, days 1,8,15,22,29), and subcutaneous alpha, interferon (3 x 10(6) units, days 1 to 35). This chemoradiation was followed by continuous infusion 5-FU (200 mg/m(2) daily, weeks 9 to 14 and 17 to 22). Chemoradiation was generally initiated between 6 and 8 weeks after surgery. RESULTS: All patients completed radiation therapy. There were no deaths due to chemoradiation but 42% were hospitalized during chemoradiation, virtually all due to gastrointestinal toxicity. With a mean follow-up time of 31.9 months, 67% of the patients are alive. Therefore, the median survivorship has not been reached. Actuarial overall survival for the 1-, 2-, and 5-year periods was 95% (confidence interval [CI] = 91% to 98%), 64% (CI = 56% to 72%), and 55% (CI = 46% to 65%), respectively. CONCLUSIONS: This follow-up report further suggests overall survival may be improved for patients with adenocarcinoma in the pancreatic head using an adjuvant interferon-based chemoradiation protocol. These results are obtained despite a high incidence of node involvement and advanced tumor stage. From this limited patient series, the actuarial 2-year and 5-year overall survival rates suggest a potential for improved long-term survival. Further study of this regimen in a multiinstitutional setting is needed.