A decade of progress: a before and after study on improved survival in pancreatic cancer through evolving multimodal therapy.

BACKGROUND: Pancreatic cancer remains one of the deadliest malignancies with poor survival outcomes. This study investigated the influence of evolving multimodal strategies, particularly the increased use of neoadjuvant chemotherapy (NAC) and extended surgical resection, on patient outcomes over the last decade. METHODS: This before-and-after study included patients with pancreatic cancer who received curative surgery at a tertiary medical center from 2011 to 2022. The patients were divided into two treatment periods: Period A (2011-2017, n = 154) and Period B (2018-2022, n = 251). Patients were evaluated based on their clinical stage, resectability, treatment strategy, surgical approach, and survival outcomes. The primary endpoints were overall survival (OS) and progression-free survival (PFS). Sensitivity analysis was conducted by propensity score matching to minimize the differences in clinical demographics. RESULTS: NAC use increased significantly from 22.1% in period A to 74.9% in period B (P < 0.001), along with an increase in the use of extended pancreatectomies (31%-58%, P < 0.001). Extended resections provided survival benefits yet were associated with higher major morbidity (20% vs 11%) and 30-day mortality rates (2.1% vs 0.5%). Median OS and PFS improved markedly from A to B for resectable/borderline resectable cases (OS: 19.2-35.5 months; PFS: 8.3-18.6 months; both P < 0.001). Improvements in OS from period A to period B were also observed for patients with locally advanced/metastatic disease (12.3-19.7 months, P < 0.001). Multivariate analysis identified period B, lower CA19-9 levels before surgery, early pathological stage, and adjuvant chemotherapy as independent predictors of survival. Similar results were determined after propensity score matching. CONCLUSION: The shift toward a multimodal approach significantly improved survival in patients with pancreatic cancer, especially those with resectable and borderline resectable tumors. Although extended pancreatectomy increases surgical risk, the survival benefits support its selective use. Continued refinement of the treatment selection and perioperative care is warranted.