A commentary on ‘The experience of neoadjuvant chemotherapy versus upfront surgery in resectable pancreatic cancer. A cross sectional study’ – a correspondence
Authors: Xue-Lei Li, Zhi-Peng Liu, Hai-Su Dai, Xian-Yu Yin, Zhi-Yu Chen
Journal: International Journal of Surgery (2023)

Dear Editor, With great interest, we read the article by Su et al.1. This article is a single-center cross-sectional study involving an analysis of the prognosis of neoadjuvant chemotherapy versus upfront surgical treatment for resectable pancreatic ductal adenocarcinoma. The authors collected clinical data of patients with stage I and stage II pancreatic ductal adenocarcinoma who received treatment from a tertiary hospital from 2013 to 2020, and a total of 159 patients were eligible after exclusion, including 46 patients (29%) in the neoadjuvant chemotherapy (NAC) group and 113 patients (71%) in the upfront resection (UR) group. They found that NAC is superior to UR in resectable pancreatic cancer with better survival. This is a great finding; however, after carefully reading the article, we would like to raise the following questions regarding some details. First, we noted that nearly all patients (34/35) in the NAC group received postoperative adjuvant therapy, while only approximately half (58/100) in the UR group received postoperative adjuvant therapy. In clinical practice, patients with pancreatic cancer who receive postoperative adjuvant therapy after surgery can significantly extend their survival time2,3. However, the authors seem to have overlooked this important factor when comparing the two groups. Specifically, because the differences between the two groups in receiving postoperative adjuvant therapy were too large, the current result could not prove whether receiving postoperative adjuvant therapy led to better survival in the NAC group or whether preoperative NAC led to better survival in the NAC group. If the authors want to further confirm the advantages of NAC, they need to maintain consistency between the two groups; that is, it would be better to exclude patients who did not receive postoperative adjuvant therapy in both groups. Second, we noted that R0 resection rates were significantly higher in the NAC group than in the UR group. Similarly, R0 resection has a significant impact on the survival time of patients with pancreatic cancer after resection4-6. Comparing the survival time, the difference in this important factor between the two groups should not be ignored. This current result raises the question of whether NAC leads to higher R0 resection rates and thus longer survival or whether the drug effects of NAC give patients a longer survival time. We suggest that if the authors added R0 resection into the propensity score matching process, it may solve this question. Finally, I would like to thank Su et al. for their study on the prognosis of neoadjuvant chemotherapy and upfront resection for resectable pancreatic ductal adenocarcinoma, which will undoubtedly promote the development of neoadjuvant therapy for pancreatic malignant tumors. We believe that neoadjuvant chemotherapy will play an important role in the treatment of patients with malignant tumors. Ethical approach Not available. Sources of funding Chongqing Technology Innovation and Application Development Special Key Project (No. CSTC2021jscx-gksb-N0009). Conflicts of interest disclosure The authors declare that they have no conflicts of interest. Author contribution X.-L.L.: writing – original draft; Z.-P.L. and X.-Y.Y.: writing – review and editing; H.-S.D.: conceptualization and supervision; Z.-Y.C.: conceptualization, funding acquisition, and writing – review and editing. Research registration unique identifying number (UIN) Name of the registry: not available. Unique identifying number or registration ID: not available. Hyperlink to your specific registration (must be publicly accessible and will be checked): not available. Guarantor Zhi-Yu Chen. Data availability statement Not available for this manuscript.