Adenocarcinoma of the pancreas continues to have an extremely poor prognosis. At present, surgical resection remains the only instrument for cure. Despite attempts at curative resection, time to recurrence is often brief, with recurrence presenting as both local and distant failure. The addition of postoperative chemoradiation therapy has offered a marginal benefit; therefore other strategies for the treatment of this disease have been aggressively pursued. Initially, the delivery of chemoradiation in the preoperative setting was a strategy theoretically thought to provide an improved resection rate with less toxicity, resulting in superior outcomes including improved recurrence-free and overall survival. After more than a decade of experience, the authors have not substantiated these theoretical advantages. Neither disease-free nor overall survival has been shown to be superior with the delivery of chemoradiation in the preoperative period. Although they had more advanced disease, most patients receiving preoperative therapy and subsequently undergoing potentially curative resection had median disease-free and overall survivals equivalent to those of patients receiving no preoperative therapy. This result suggests a potential superiority of chemoradiation given in the preoperative setting. In addition, a greater number of patients are able to receive a full course of chemoradiation therapy in a more timely fashion, and the effect of this therapy can be more accurately characterized. In addition, it has been shown that patient selection is improved by increasing the latency period before resection for the manifestation of metastatic disease. Improved patient selection minimizes unnecessary surgery. The treatment of pancreatic cancer remains elusive. Current strategies for the treatment of this disease are suboptimal despite persistent efforts to improve outcomes. The benefits of chemoradiation therapy delivered in the preoperative period may potentially provide patients with superior outcomes, although phase III trials have not been performed. The discovery of more effective agents and improved delivery strategies, in addition to a concerted effort by the medical and scientific'community to promote multi-institutional controlled, prospective trials, may render this modality superior to the authors' current treatment regimens.
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