Neoadjuvant Therapy vs. Straight to Surgery

Patients with a surgically resectable pancreatic cancer often ask the question, “should I get chemotherapy before my surgery or should I go straight to surgery?”  Chemotherapy before surgery is called “neoadjuvant” therapy, and for a number of years it seemed the best way to go.  This conclusion was larger based on work from a research team at the MD Anderson Cancer Center (see references #1 and #2 below).  Indeed, several studies reported that both life expectancy (LE) and quality-adjusted life expectancy (QALE) was better for patients who underwent neoadjuvant therapy than it was for patients who underwent surgery first, followed by chemotherapy after surgery (see reference #2 below). 

A recent paper presented at the 2023 American Society of Clinical Oncology Meeting II (Short-course neoadjuvant FOLFIRINOX versus upfront surgery for resectable pancreatic head cancer: A multicenter randomized phase-II trial (NORPACT-1). | Journal of Clinical Oncology ( questions the impact of neoadjuvant therapy.  In this paper, a team from Europe, reported the results of a randomized phase II trial conducted from 2017 to 2021.In the trial, called NORPACT-1, 140 patients were randomly assigned to either receive neoadjuvant FOLFIRINOX, or to undergo surgery first (upfront surgery).  Surprisingly, the average overall survival was lower in the patients who received neoadjuvant therapy (25.1 months) than it was in the patients who underwent upfront surgery (38.5 months). 

From these results, the authors concluded “Neoadjuvant FOLFIRINOX did not improve OS compared with upfront surgery in resectable pancreatic head cancer. Our results do not support neoadjuvant chemotherapy as standard of care for these patients.”

Where does this leave us?  Unfortunately, as happens all too often in medicine, the data aren’t clear.  Although many studies support the use of adjuvant therapy in patients with resectable pancreatic cancer, some studies, such as this one, do not.  This means the decision of whether or not to go with neoadjuvant therapy or have upfront surgery, should very much be a personal decision based on thoughtful discussions between the patient and their health care provider.  Some patients may “want their cancer out” and prefer upfront surgery.  Others may wish to see how their cancer responds to chemotherapy before having surgery.  Simply put, every patient should be fully informed, and should have a voice in their treatment. 


  1. Raut CP, Evans DB, Crane CH, Pisters PW, Wolff RA. Neoadjuvant therapy for resectable pancreatic cancer. Surg Oncol Clin N Am. 2004 Oct;13(4):639-61
  2. de Geus SW, Evans DB, Bliss LA, Eskander MF, Smith JK, Wolff RA, Miksad RA, Weinstein MC, Tseng JF. Neoadjuvant therapy versus upfront surgical strategies in resectable pancreatic cancer: A Markov decision analysis. Eur J Surg Oncol. 2016 Oct;42(10):1552-60. doi: 10.1016/j.ejso.2016.07.016.