LAUSR

Reply: We are thankful to Dr. Zhang and his colleagues for their interest in our work and for their thoughtful comments. The relative efficacy of preoperative and postoperative therapy for localized pancreatic cancer is unknown, and the optimal multimodal composition, sequence, and duration of therapies that should be administered to each patient are unclear. Nonetheless, a strong rationale exists for the administration of chemotherapy and/or (chemo)radiation prior to pancreatectomy for pancreatic cancer, and multiple anecdotal series and trials of patients given treatment in this manner have had favorable outcomes. Therefore, prior to pancreatectomy, multidisciplinary teams increasingly administer treatment to patients with resectable or borderline resectable cancer using a variety of modalities and regimens for variable durations, guided as much by conscious and unconscious bias regarding the utility of preoperative therapy as by high-level data. Within this context, we conducted a retrospective study of a heterogenous group of 245 patients with pancreatic cancer given preoperative therapy at our institution to begin to answer the following question: does systemic chemotherapy improve the survival of patients who received therapy prior to pancreatectomy? Although existing guidelines recommend that a total of 6 months of perioperative chemotherapy be delivered to such patients, this weak recommendation is based entirely on consensus and extrapolation—which may or may not be appropriate—of data generated in trials of patients undergoing a somewhat arbitrary therapy duration of 6 months following primary resection. Whereas it stands to reason that some patients might benefit from chemotherapy following preoperative therapy and pancreatectomy, the opposite is certainly possible.