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  • br Survival analysis br Patients who started salvage


    Survival analysis
    Patients who started salvage treatment only based on rising CA19-9 levels had a significantly longer median DFS than patients with treatment changes based on radiological examinations (23.6 months vs. 12.1 months, P < 0.001) (Fig. 1A). Compared with the A and B group, the interval from CA19-9 elevation to radiological confirmation was also significantly prolonged in patients with tu-mor marker guided salvage treatment (13.2 months vs. 3.5 months, P < 0.001) (Fig. 1B). Apart from the longer DFS, the median OS was prolonged in the intervention group (28.1 months vs. 20.7 months, P ΒΌ 0.049) (Fig. 1C).
    According to the ASCO guidelines, rising CA19-9 levels usually precede the radiographic appearance of a recurrent disease, but the present data are insufficient to recommend the routine use of CA19-9 alone for monitoring responses to therapy without radio-graphic confirmation [25]. However, many studies have shown that there is a correlation between the patient's clinical benefits and tumor marker CA19-9 levels decline during chemotherapy for advanced pancreatic cancer, which means rising CA19-9 levels may serve as a negative predictive marker [14,26,27]. A recent study found that the time from CA19-9 elevation to radiographic recur-rence ranged from 6 to 18 months [21]. No matter the type of cancer, the primary goal of surveillance after curative treatment is to detect the local or distant recurrence as early as possible and
    doctors can intervene to prolong the survival of patients. Therefore, rising CA19-9 levels during adjuvant chemotherapy might be helpful to consider salvage therapy, especially when the radio-graphic evidence of tumor recurrence is absent. However, there is still not enough evidence to support the apparent common practice that regular follow-up after surgery to identify earlier recurrence can improve the survival of patients [28e32]. Although the role of surveillance in patients with resected pancreatic adenocarcinoma is limited, CA19-9 measurement and follow-up CT scans with Z-Guggulsterone every 3e6 months for 2 years after surgical resection are still category 2B recommendations according to NCCN guidelines.
    Our current study suggested that CA19-9 can preceded the radiological appearance by about 3 months and tumor marker-guided early salvage therapy can delay disease progression and prolong overall survival of patients receiving resection. In patients who started their salvage treatment early, the median DFS and OS were prolonged compared with those patients who were treated only after recurrence was ascertained by radiological examinations. Approximately 80% of the recurrences of pancreatic cancer occur within two years after potentially curative treatment. When pa-tients are informed about recurrence, they have a quite limited survival. This active adjuvant chemotherapy can slow down the disease progression and benefit patients with advanced pancreatic cancer, which deserves to improve the frequency of tumor marker assay in follow-up strategy because one CA19-9 assay costs only about 15 dollars in China.
    Before this study, there was a heavily debated issue among doctors in the field of oncology; that is, whether salvage treatment based only on tumor marker should be carried out or not if the clinical characteristics of the patient are good and a CT scan is negative [33]. In addition to pancreatic cancer, tumor marker-guided treatment for other cancers has been reported. In breast cancer patients, CEAeTPAeCA15.3 tumor marker-guided salvage treatment can significantly prolong the DFS and OS in relapsing responsive patients [34,35]. Similarly, a longer OS of gastric cancer patients based on symptoms or tumor markers rather than CT was also reported [36]. However, some study showed that CEA com-bined with CT was not significantly different from regular CT in follow up of colorectal cancer [37]. A meta-analysis indicated that there was no survival benefit for patients with intensive follow-up after colorectal cancer resection, although more patients were treated with salvage treatment in intensive follow-up group [38]. In addition, when to initiate salvage therapy for prostate cancer pa-tients with a prostate-specific antigen recurrence is controversial. Early hormonal treatment can only benefit patients with aggressive prostate cancer and a fast rising prostate-specific antigen, whereas in others heterogametic sex may be more harmful [39].