ADENOCARCINOMA of pancreatic ductal cells is almost always fatal. Despite many thousands of pancreatoduodenectomies during the last 40 years, fewer than 100 cured patients are known. The past 20 years have produced only about 50 five-year survivors among 1,250 patients treated for cure (4% rate), and many of those have later died of recurrent cancer. To the contrary, some patients counted as cures have only been explored, not resected.
Thus, the traditional logic of oncological surgery—resecting local disease and the pathways of its local spread and nodal metastases—dictates ineffective treatment of pancreatic cancer because the disease is usually systemic by the time of diagnosis. Progress requires (1) identifying the causes of pancreatic cancer so as to minimize them, (2) detecting the cancer while it is localized, (3) devising effective nonsurgical therapy for residual local disease and suppression of metastases, and (4) ensuring valid assessments of surgical and nonsurgical treatments by