title: Neoadjuvant therapy versus upfront surgical strategies in resectable pancreatic cancer: A Markov decision analysis.
abstract: BACKGROUND
  Neoadjuvant therapy is gaining acceptance as a valid treatment option for borderline resectable pancreatic cancer; however, its value for clearly resectable pancreatic cancer remains controversial. The aim of this study was to use a Markov decision analysis model, in the absence of adequately powered randomized trials, to compare the life expectancy (LE) and quality-adjusted life expectancy (QALE) of neoadjuvant therapy to conventional upfront surgical strategies in resectable pancreatic cancer patients.
  
  
  METHODS
  A Markov decision model was created to compare two strategies: attempted pancreatic resection followed by adjuvant chemoradiotherapy and neoadjuvant chemoradiotherapy followed by restaging with, if appropriate, attempted pancreatic resection. Data obtained through a comprehensive systematic search in PUBMED of the literature from 2000 to 2015 were used to estimate the probabilities used in the model. Deterministic and probabilistic sensitivity analyses were performed.
  
  
  RESULTS
  Of the 786 potentially eligible studies identified, 22 studies met the inclusion criteria and were used to extract the probabilities used in the model. Base case analyses of the model showed a higher LE (32.2 vs. 26.7 months) and QALE (25.5 vs. 20.8 quality-adjusted life months) for patients in the neoadjuvant therapy arm compared to upfront surgery. Probabilistic sensitivity analyses for LE and QALE revealed that neoadjuvant therapy is favorable in 59% and 60% of the cases respectively.
  
  
  CONCLUSIONS
  Although conceptual, these data suggest that neoadjuvant therapy offers substantial benefit in LE and QALE for resectable pancreatic cancer patients. These findings highlight the value of further prospective randomized trials comparing neoadjuvant therapy to conventional upfront surgical strategies.
authors: Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Surgery, 330 Brookline Avenue, Boston, MA 02215, USA. Electronic address: S.W.L.de_geus@lumc.nl.
authors: S W L
authors: SW
authors: de Geus
authors: Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA. Electronic address: devans@mcw.edu.
authors: D B
authors: DB
authors: Evans
authors: Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Surgery, 330 Brookline Avenue, Boston, MA 02215, USA. Electronic address: lindsay.bliss@gmail.com.
authors: L A
authors: LA
authors: Bliss
authors: Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Surgery, 330 Brookline Avenue, Boston, MA 02215, USA. Electronic address: meskande@bidmc.harvard.edu.
authors: M F
authors: MF
authors: Eskander
authors: Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Surgery, 330 Brookline Avenue, Boston, MA 02215, USA. Electronic address: jkennedysmith@gmail.com.
authors: J K
authors: JK
authors: Smith
authors: Department of Gastrointestinal Oncology, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA. Electronic address: rwolff@mdanderson.org.
authors: R A
authors: RA
authors: Wolff
authors: Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Surgery, 330 Brookline Avenue, Boston, MA 02215, USA. Electronic address: rmiksad@bidmc.harvard.edu.
authors: R A
authors: RA
authors: Miksad
authors: Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA. Electronic address: mcw@hsph.harvard.edu.
authors: M C
authors: MC
authors: Weinstein
authors: Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Surgery, 330 Brookline Avenue, Boston, MA 02215, USA. Electronic address: jftseng@bidmc.harvard.edu.
authors: J F
authors: JF
authors: Tseng
mesh_terms: D059186:Chemoradiotherapy, Adjuvant; D003661:Decision Support Techniques; D006801:Humans; D008017:Life Expectancy; D008390:Markov Chains; D020360:Neoadjuvant Therapy; D010190:Pancreatic Neoplasms / Q000601:surgery*
keywords: Decision support techniques; Markov process; Neoadjuvant therapy; Pancreatic neoplasms; Surgical procedure