Radiotherapy in locally advanced pancreatic cancer

Abstract

While radiotherapy was considered an important treatment modality in locally advanced pancreatic cancer for several decades, the presentation of the LAP 07 trial results have impressed a concept that radiotherapy provides no benefit in this patient group. Further analysis however, revealed that the use of radiotherapy in the LAP 07 trial was associated with better local control and a greater chemotherapy-free interval, both meaningful palliation benefits. Further, the initiation of radiation was delayed by a four month period of induction treatment that employed a drug with only an 8% response rate, and progression free survival control of 3.1 months. A detailed review of the literature to date demonstrates that modern radiotherapy in locally advanced pancreatic cancer has a significant local effect, is well tolerated and associated with improved quality of life through providing durable local control, and in a subset population, resulting in long-term survival. Perhaps the most important conclusion of the LAP 07 study, which was very well conducted, is that delaying a local therapy for four months is not an effective sequencing strategy when the induction treatment is of borderline efficacy in a cancer with a rapid progression characteristic. While newer agents are improving survival, the outlook remains dismal. Optimising the integration of radiation needs to be a priority to define how this modality can assist the modest gains that have come about from a very large number of chemotherapy sequencing studies.