Top Line: Radiotherapy has had a tough time establishing its incremental value when added to modern neoadjuvant chemotherapy for resectable pancreatic cancer.
The Study: A large propensity-matched retrospective cohort (n=452) suggests adding radiation to FOLFIRINOX or gemcitabine/nab-paclitaxel substantially improves pathologic response, maximizing ypN0 (34%→62%) and R0 resections (52%→85%), without ultimately improving overall survival or even reduced recurrences. That’s because, as always, ~70% of patients in both groups developed distant recurrence as their first site of failure. Radiation here was mostly 50.4 Gy in 25–28 fractions with concurrent chemo (57%), 25–30 Gy in 5–10 fractions with concurrent chemo (32%), or 5 fractions of ≥5 Gy (11%). Though one could guess, it is impossible to know if more contemporary approaches of dose-escalated radiation with inclusion of elective nodes could have impacted distant failure rate.
TBL: These findings reinforce that better locoregional control has limited impact when pancreatic adenocarcinoma remains dominated by early systemic relapse. | de Stefano, JAMA Surg 2026
The Study: A large propensity-matched retrospective cohort (n=452) suggests adding radiation to FOLFIRINOX or gemcitabine/nab-paclitaxel substantially improves pathologic response, maximizing ypN0 (34%→62%) and R0 resections (52%→85%), without ultimately improving overall survival or even reduced recurrences. That’s because, as always, ~70% of patients in both groups developed distant recurrence as their first site of failure. Radiation here was mostly 50.4 Gy in 25–28 fractions with concurrent chemo (57%), 25–30 Gy in 5–10 fractions with concurrent chemo (32%), or 5 fractions of ≥5 Gy (11%). Though one could guess, it is impossible to know if more contemporary approaches of dose-escalated radiation with inclusion of elective nodes could have impacted distant failure rate.
TBL: These findings reinforce that better locoregional control has limited impact when pancreatic adenocarcinoma remains dominated by early systemic relapse. | de Stefano, JAMA Surg 2026