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Page 2 of 14 Pereira et al. J Cancer Metastasis Treat 2018;4:30 I http://dx.doi.org/10.20517/2394-4722.2018.13

Pancreatic cancer is more common in elderly persons (between 60 and 80 years) and some studies have
shown an increased incidence among diabetes or chronic pancreatitis patients [2,9,10] . Both environmental
[7,8]
and inherited factors can contribute to the development of this disease and the most common risk factors
[11]
associated to this type of cancer are smoking [12,13] and overweight obesity .
[14]
The adenocarcinoma is the most common pancreatic cancer, representing 85% of all cases . Furthermore,
[15]
the pancreatic adenocarcinoma remains one of the most challenging malignancies with limited therapeutic
options and poor prognosis because it is usually diagnosed at an advanced stage . This aspect partially can
[3]
[16]
be explained by the fact that early stages of pancreatic cancer often present none or nonspecific symptoms,
which can be translated in diagnosis challenges .
[12]
Normally, advanced pancreatic cancer patients can present symptoms like nausea, vomiting, bloating,
unexplained weight loss, jaundice, abdominal pain, dyspepsia and sometimes pancreatitis . Moreover, 70%
[9]
of patients present diabetes mellitus, usually with a diabetes history of less than 2 years . The poor prognosis
[17]
is also attributed to the high incidence of metastasis, leading to an aggressive disease course combined with
the limited efficacy of systemic treatments .
[5]
Surgery procedures are considered the most effective treatment and the only curative intervention but only
20% of patients are fit for it based on disease staging and up to 80% of these patients relapse. When compared
[4]
to other resected solid tumors, the poorest outcomes are observed in patients with resected pancreatic cancer.
After surgery, those resected patients are selected for adjuvant therapy with chemoradiation or chemotherapy
alone and they present a median survival post-surgery combined with adjuvant therapy averaging 2 years ,
[14]
with only 20% of patients reaching 5-year survival rate . Regarding that, there are some studies with
[18]
neoadjuvant chemotherapy administered in patients with resectable, borderline resectable or locally advanced
disease aiming to increase resectability by achieving higher margin-negative resections and conversion rates .
[19]
According to the American Cancer Society, the 5-year relative survival of pancreatic cancer patients is 29%
for localized stage at diagnose period, 11% for regional stage and only 3% for distant stage [20,21] . These statistical
data indicate that there is an increased need for development of efficient and well-tolerated treatment options.
This work intends to summarize the approved adjuvant chemotherapy approaches [Table 1] for advanced
pancreatic cancer and some immunotherapy treatment trends for this aggressive and devastating disease.

TREATMENT OPTIONS
Treatment of pancreatic cancer is multimodal, and most patients will receive more than one type. The
primary and only curative intervention is surgery. In sequence, it includes adjuvant (treatment given after
primary treatment) chemotherapy and/or radiation therapy, or palliative care depending on the stage of
cancer, according to the staging system developed by American Joint Committee on Cancer, which is
now in the 8th edition. Based on the cancer stage the patient will be directed to a kind of treatment. This
staging system takes into account the TNM status which means: T - primary tumor size; N - lymph node
involvement; M - distant metastasis [Table 2] .
[18]
As mentioned, different treatment guidelines are used for each stage. Frequently, stage II (resected lesions)
is treated by surgery and adjuvant chemotherapy, sometimes including chemoradiation; Stage III (locally
advanced) chemotherapy with or without chemoradiation and stage IV (metastatic) with chemotherapy .
[22]

SURGERY
Pancreatic cancer patients are subdivided into four groups: resectable, borderline resectable, locally advanced
nonresectable, and metastatic. Cancer that is confined to the pancreas without significant involvement of nearby