Is “postoperative adjuvant chemotherapy” needed for small bowel adenocarcinoma after surgical resection?

DEAR EDITOR, The article by Li et al1 piqued our interest to show the prognostic factors involving with survival in patients with small bowel adenocarcinoma after surgical resection. Based on their results, we believe that high postoperative prognostic nutritional index (PNI), absence of lymphovascular space invasion (LVSI), and administration of postoperative adjuvant oxaliplatin-based chemotherapy (CT) were associated with favorable overall survival (OS) of patients with small bowel adenocarcinoma after complete surgical resection.1 Moreover, because these factors have been identified by “multivariate analysis,” it suggested that all three factors are independent. As shown by Li et al,1 more than three-quarters of patients (77.3%, 34/44) had received adjuvant oxaliplatin-based CT, and this therapy adhered to the treatment guideline of National Comprehensive Cancer Network (NCCN). In our limited knowledge, we believe that these 34 patients may be really beneficial for adjuvant oxaliplatin-based CT to the disease control and subsequently take advantages of survival, because NCCN guideline has already recommended this therapeutic choice. However, there is uncertainty about the remaining 10 patients without postoperative adjuvant oxaliplatin-based CT in Dr. Li’s study. According to the findings by Dr. Li et al,1 postoperative adjuvant CT provides a very significant and powerful protection to prevent the patients from dying of their diseases. The hazard ratio (HR) was 0.055, suggesting that patients without postoperative adjuvant CT had an at least 18-fold increase of risk to die of diseases. If we compared other prognostic factors, such as presence of LVSI (an 8-fold increase) and postoperative PNI <45.2 (an 11-fold increase) as shown by authors, the value of adding postoperative adjuvant CT to the patients with small bowel adenocarcinoma after surgical resection is much apparent and dominant, hinting us to reconsider whether all patients in their study had better be treated with postoperative adjuvant CT. For many types of cancers needing surgical treatment, CT, either administered before or after definite surgery has already played an essential component of multi-modality strategy, particularly for those patients at locally- or far-advanced cancers or accompanied with worse prognostic factors.2–5 However, not all patients need. Regarding the need of adjuvant therapy, clinical guides are often based on benefits/risks of this approach and also considered cost-effectiveness globally.5 Either overtreatment or undertreatment is not a standard of care for these patients.5 Additionally, nobody will be in doubt that “stage,” particularly for surgery-based cancers, which are always the most important and independent parameter associated with both progression-free survival (PFS) and OS.3–5 However, in Dr. Li’s study, the “stage” seemed not to play any role for either PFS or OS in patients with small bowel adenocarcinoma after surgical resection. Our comment would not like to argue the authors’ contribution to offer us an important issue “the benefits and essential role of adequate postoperative nutrition,” which is often under-investigated in cancer patients’ care. We believe that “real-world” data are really worthy of our attention, because they may test the reproducibility of recommendations from “guideline” or “routine clinical practice.” Continuously updating new information by challenging old concepts may offer the better care to cancer patients because fighting cancer is still unsuccessful.