title: A comparison of three treatment strategies for locally advanced and borderline resectable pancreatic cancer.
abstract: BACKGROUND
  The optimal treatment strategy for locally advanced and borderline resectable pancreatic cancer is not known. We compared overall survival (OS), local control (LC), metastasis free survival (MFS), and percent of patients who were able to undergo successful surgical resection for three treatment strategies.
  
  
  METHODS
  We retrospectively reviewed 115 sequentially treated cases of locally advanced (T4) or borderline resectable (T3 but unresectable) pancreatic cancer. Patients were treated with either chemotherapy alone (C), concurrent chemoradiation therapy (CRT), or chemotherapy followed by chemoradiation therapy (CCRT). We compared survival between groups using Kaplan-Meier analysis and Cox-proportional hazards models.
  
  
  RESULTS
  Median follow-up was 18.7 months. Fifty-six (49%) patients had locally advanced disease. Of the patients who received chemotherapy up-front, 82/92 (89%) received gemcitabine-based chemotherapy. Of the patients receiving C alone, 11/65 (17%) were diagnosed with distant metastases or died before 3 months. The rate of successful surgical resection was 6/50 (12%) in patients treated with radiation therapy (CRT or CCRT). Median survival times for patients undergoing C, CRT, and CCRT were 13.9, 12.5, and 21.5 months respectively. Patients treated with CCRT experienced statistically significant improved OS and MFS compared to C alone (P=0.003 and P=0.012 respectively). There was no difference in LC between treatment groups. On multivariable analysis younger age (P=0.009), borderline resectable disease (P=0.035), successful surgery (P=0.002), and receiving chemotherapy followed by chemoradiation therapy (P=0.035) were all associated with improved OS.
  
  
  CONCLUSIONS
  Treatment with CCRT is associated with improved median OS and MFS compared with C alone. This strategy may select for patients who are less likely to develop early metastases and therefore have a better prognosis.
authors.affiliation: Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA.
authors.forename: Shane
authors.initials: S
authors.lastname: Lloyd
authors.forename: Bryan W
authors.initials: BW
authors.lastname: Chang