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Chances, risks and limitations of neoadjuvant therapy in surgical oncology.

ABSTRACT: Over the last decades, neoadjuvant treatment has been established as a standard of care for a variety of tumor types in visceral oncology. Neoadjuvant treatment is recommended in locally advanced esophageal and gastric cancer as well as in rectal cancer. In borderline resectable pancreatic cancer, neoadjuvant therapy is an emerging treatment concept, whereas in resectable colorectal liver metastases, neoadjuvant treatment is often used, although the evidence for improvement of survival outcomes is rather weak. What makes neoadjuvant treatment attractive from a surgical oncology viewpoint is its ability to shrink tumors to a smaller size and to increase the chances for complete resection with clear surgical margins, which is a prerequisite for cure. Studies suggest that local tumor control is increased in some visceral tumor types, especially with neoadjuvant chemoradiotherapy. In some other studies, a better control of systemic disease has contributed to significantly improved survival rates. Additionally, delaying surgery offers the chance to bring the patient into a better general condition for major surgery, but it also confers the risk of progression. Although it is a relatively rare event, cancers may progress locally during neoadjuvant treatment or distant metastases may occur, jeopardizing a curative surgical treatment approach. Although this is seen as risk of neoadjuvant treatment, it can also be seen as a chance to select only those patients for surgery who have a better control of systemic disease. Some studies showed increased perioperative morbidity in patients who underwent neoadjuvant treatment, which is another potential disadvantage. Optimal multidisciplinary teamwork is key to controlling that risk. Meanwhile, the neoadjuvant treatment period is also used as a "window of opportunity" for studying the activity of novel drugs and for investigating predictive and prognostic biomarkers of chemoradiotherapy and radiochemotherapy. Although the benefits of neoadjuvant treatment have been clearly established, the risk of overtreatment of cancers with an unfavorable prognosis remains an issue. All indications for neoadjuvant treatment are based on clinical staging. Even if staging is done meticulously, making use of all recommended diagnostic modalities, the risk of overstaging and understaging remains considerable and may lead to false indications for neoadjuvant treatment. Finally, despite all developments and emerging concepts in medical oncology, many cancers remain resistant to the currently available drugs and radiation. This may in part be due to specific molecular resistance mechanisms that are marginally understood thus far. Neoadjuvant treatment has been one of the major advances in multidisciplinary oncology in the last decades, requiring a dedicated treatment team and an optimal infrastructure for complex oncology care. This article discusses the goals and novel directions as well as limitations in neoadjuvant treatment of visceral cancers.

SUBMITTER: Lordick F

PROVIDER: S-EPMC6753981 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Background and objectiveEsophageal cancer is one of the common malignant tumors in China. Previous studies have shown that surgery alone is less effective. Neoadjuvant therapy refers to preoperative chemoradiotherapy, which is the standard treatment for locally advanced and operable esophageal cancer. Selection of appropriate surgical methods and timing after neoadjuvant therapy is of great significance for improving the prognosis of patients and reducing postoperative complications.MethodsAn online electronic search of all eligible literature through PubMed, Google Scholar, and the Cochrane Library database was conducted using a combination of the following keywords: esophageal cancer, neoadjuvant therapy, neoadjuvant chemotherapy, chemoradiotherapy, immunotherapy, targeting, surgery, complications. With a focus on the use of surgery after neoadjuvant therapy, Eligible articles were identified by one or both authors.Key content and findingsNeoadjuvant chemoradiotherapy combined with radical surgical resection remains the current standard of care for resectable esophageal cancer, significantly improving survival and pathologic complete response (PCR) compared with preoperative chemotherapy Recently, studies have also found that immunotherapy combined with chemotherapy has a more advantageous pathological response in patients with locally advanced disease. Although the emergence of targeted drugs has led to a change in treatment mode from traditional chemoradiotherapy to precision therapy, the postoperative progression-free survival (PFS) and overall survival (OS) need to be explored as well as how surgery-related risks caused by treatment can be reduced. Traditionally, surgery is performed 4-6 weeks after neoadjuvant therapy, and optimal timing for surgery after treatment is still being explored as research progresses, the surgical method also should be determined according to the specific situation of the patient. Postoperative complications should be dealt with in a timely manner, and of course, active preoperative intervention is equally important.ConclusionsNeoadjuvant therapy combined with surgery is the gold standard for resectable esophageal cancer. However, optimal timing of surgery after preoperative treatment remains unclear. Minimally invasive thoracoscopic surgery (including robotic surgery) has gradually replaced traditional open surgery. Active prevention before operation, accurate and meticulous operation during operation, and timely treatment after operation can minimize the incidence of adverse events.

Project description:The COVID-19 pandemic has dramatically affected everyone's daily life in one way or another, requiring a re-negotiation of existing strategies for work-life integration, not only for individuals but also within families and partnerships. To contribute to existing knowledge on work-life integration during COVID-19 in Germany, we look at gender and parenthood differences in the experiences of work-to-family (WFC) and family-to-work (FWC) conflicts. By accounting for employees' previous conflict experiences, we were able to reveal the extent to which the current conditions contributed to differences in these conflicts. Moreover, we explored the relevance of demands and resources in the family and work spheres as a way to explain different levels of WFC and FWC across gender and parenthood. Our analyses are based on a sample of 660 employees from a German linked employer-employee panel study and a COVID-19 follow-up survey conducted in late 2020. Results revealed that work-family conflict experiences before the pandemic play an important role in current conflict perceptions. Whereas WFC were more likely to be accentuated during the pandemic, prior FWC experiences may have helped to mitigate conflicts under these new conditions. Work-family conflicts in general have increased during the COVID-19 pandemic, but this finding applied only to conflicts in the family-to-work direction. Although such increases were not limited to parents, they were particularly high in this group. Overall, gender differences in work-family conflicts were absent, but differences were found between mothers and fathers. The need to compensate for a lack of external childcare, as well as having to work from home, increased FWC, especially among fathers. This study suggests that FWC in particular became more important during the pandemic; however, parents were not the only ones who were disadvantaged when it came to work-life integration; childless individuals likewise struggled to balance the demands of work and private life.

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Chances, risks and limitations of neoadjuvant therapy in surgical oncology.

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