Es baaaaack.

Top Line: ESPAC-4 established that gemcitabine + capecitabine as combo adjuvant therapy for resected pancreatic cancer improves survival over the previous standard of gem monotherapy.

The Study: As a reminder, 730 patients with grossly-resected pancreatic cancer were randomized to one of the two adjuvant therapy arms, and those receiving the combo achieved an improvement in median survival from 26 → 28 months. That’s good and all, but tbh it’s been pretty swiftly forgotten in the wake of FOLFIRINOX. Well, ESPAC es back with a secondary analysis focusing on patterns of recurrence. First, for what it’s worth, with longer follow-up of over 40 months, the survival advantage with combo therapy remained, now from 28 → 30 months. By now, two-thirds of enrollees have a documented recurrence: 50% local only, 40% distant only, and 10% both. Distant recurrences tended to occur sooner (9 months) after therapy than local recurrences (12 months), but median survival after recurrence was around 9 months either way. Another interesting tidbit was the strong association of N2 disease with subsequent declaration of distant disease, supporting new staging. Finally, combo adjuvant therapy not only reduced risk of recurrence (including local) but also reduced risk of death following recurrence.

TBL: However you label a pancreatic cancer recurrence, the prognosis is bad—and considering it was probably there at the time of surgery, optimizing adjuvant systemic therapies remains paramount. | Jones, JAMA Surg 2019