Treatment and survival in 13,560 patients with pancreatic cancer, and incidence of the disease, in the West Midlands: an epidemiological study

A phase II pilot trial of 13-cis retinoic acid and interferon-alpha in patients with advanced pancreatic carcinoma

BACKGROUND

Advanced unresectable pancreatic adenocarcinoma has a dismal prognosis. The authors previously have shown that retinoic acid (RA) and interferon-alpha (IFN-alpha) inhibit growth and induce differentiation in human pancreatic carcinoma cells in vitro and in vivo. The purpose of this trial was to examine the feasibility and tolerability of a combination therapy of 13-cis RA and IFN-alpha in patients with advanced unresectable pancreatic carcinoma.

METHODS

Twenty-two patients (median age, 62 years) with histologically confirmed, unresectable pancreatic adenocarcinoma classified as International Union Against Cancer Stage III (5 patients) or IV (17 patients) were included. Patients received 1 mg/kg body weight 13-cis RA orally and 6 million IU IFN-alpha subcutaneously daily. Restaging by ultrasound, computed tomography scan, and chest X-ray was performed every 2 months.

RESULTS

No complete remission and 1 partial remission (PR) (4.5%) were observed. Fourteen patients (63.6%) demonstrated stable disease with a median duration of 5.0 months (range, 2.3-17.7+ months). Toxicity mainly was related to IFN-alpha and predominantly was hematologic (no toxicity was World Health Organization [WHO] Grade 4 and 13.6% were WHO Grade 3). Nonhematologic toxicities did not exceed Grade 2 (skin and oral mucosa) and mainly were related to 13-cis RA. The median survival of the patients with Stage III disease was 8.7 months (range, 6.8-23.9+ months) and was 7.4 months for patients with Stage IV disease (range, 0.9-19.2+ months), resulting in a median overall survival of 7.7 months (range, 0.9-23.9+ months).

CONCLUSIONS

Combination therapy with 13-cis RA and IFN-alpha is feasible and well tolerated in patients with advanced pancreatic carcinoma. Based on the median survival rates observed in this study this combination should be investigated further in Phase III trials.

[Comparison of color Doppler ultrasonography and endoscopic ultrasonography for preoperative evaluation of the mesenteric-portal axis in pancreatic lesions]

AIM OF THE STUDY

This prospective study was undertaken to evaluate the accuracy of ultrasonography combined with colour Doppler and endoscopic ultrasonography for predicting superior mesenteric and portal vein involvement in pancreatic diseases.

MATERIAL AND METHODS

The study was prospective. Forty-four patients were included. Ultrasonography with colour Doppler was performed in 30 patients, endoscopic ultrasonography in 43. Prediction of superior mesenteric vein or portal vein involvement was blindly assessed by physicians without knowledge of results of other imaging methods. Resectability or potential resectability (n = 34) and irresectability (n = 10) were assessed in all patients by surgery. Thirty patients underwent a pancreaticoduodenectomy.

RESULTS

For endoscopic ultrasonography the sensitivity (0.90), the specificity (0.88), the positive predictive value (0.69) and the negative predictive value (0.97) were better than those observed with ultrasonography and Doppler (050, 0.88, 0.69, 0.97, respectively). The specificity of computed tomography (0.96) was better than that of endoscopic ultrasonography but predictive negative values were similar.

CONCLUSIONS

Imaging methods to predict superior mesenteric or portal vein involvement in pancreatic diseases are becoming increasingly numerous, complex, and expensive. Endoscopic ultrasonography has a better diagnostic value for correctly predicting resectability than ultrasonography with Doppler. However, for decision making, usefulness of these methods seems to be limited.

Transmembrane 4 superfamily as a prognostic factor in pancreatic cancer

Several members of the transmembrane 4 superfamily (TM4SF) have been reported to be related to tumor progression and metastasis. The aims of our study were to clarify the relationship between TM4SF and pancreatic cancer and to determine the prognostic significance of TM4SF in human pancreatic cancer. The mRNA levels for MRP-1/CD9, KAI1/CD82 and ME491/CD63, which belong to the TM4SF gene family, were evaluated in 40 resectable pancreatic adenocarcinomas using reverse transcriptase-PCR. MRP-1/CD9 gene expression was associated with lymph node status, and with pathological status. Moreover, MRP-1/CD9 expression was inversely associated with histo-pathological grading. KAI1/CD82 gene expression was inversely associated with tumor status. ME491/CD63 gene expression, however, was conserved in all pancreatic cancers. The overall survival rate for the 22 patients whose tumors had decreased MRP-1/CD9 gene expression was strikingly lower than that for the 18 patients with MRP-1/CD9-positive tumors. The overall survival rate of the 15 patients who were KAI1/CD82-positive was significantly higher than that of the 25 patients with decreased KAI1/CD82 gene expression. In a multivariate analysis using the Cox proportional hazards model, MRP-1/CD9 and KAI1/CD82 status was found to be the most significant.

Review article: current treatment and optimal patient management in pancreatic cancer

This review analyses the current state of knowledge and understanding concerning the optimum treatment and therapeutic management of patients who suffer from pancreatic cancer. It outlines recent advances in scientific understanding and assesses their potential future value to clinicians in confronting this disease. Despite a significant expansion in scientific knowledge relating to factors underlying the early development of pancreatic carcinoma, the clinician continues to be restricted to a severely limited therapeutic armoury for this disease. Local therapies (surgery and radiation) are inevitably of limited value in the face of a disease that is normally encountered at a stage where metastasis is already highly developed. Despite such limitations, however, surgery performed in specialist units may be of value for 10-20% of patients, with a 5-year survival rate in such units of between 10 and 24%. This may be improved even further by appropriate use of adjuvant treatment. The advanced stage of the disease when normally encountered emphasizes the potential value of systemic treatment in this therapeutic area. Unfortunately systemic treatment (chemotherapy) has been found to be ineffective to date in significantly extending survival, with a low rate and duration of remission being identified in most trials. The challenge for both the health service and the pharmaceutical industry is to harness recent and future developments in scientific knowledge to the practical benefit of clinicians. Where cure is possible it should be vigorously pursued; where it is not, in this field above all others, clinicians have a duty of care. To achieve this it is necessary to abandon the therapeutic nihilism that has characterized the attitudes of clinicians towards this disease in the past. It is time that such nihilism was replaced by a recognition of the challenges and the opportunities available to clinicians in enhancing the quantity and quality of life available to patients. The dictum of 'curing whenever possible but caring always' should be the future therapeutic philosophy used to guide clinicians in this important and rapidly changing therapeutic area.

[Fight against cancer of the exocrine pancreas: stagnation or progress? The point of view of the Fondation française de cancérologie digestive (FFCD)]

This paper updates recent trends concerning ductal pancreatic cancer. Knowledge of the cellular mechanisms has improved, and new developments in imaging allow a more accurate staging. Although operative mortality sharply decreased during these last 15 years, the prognosis of pancreatic carcinoma remains dismal, due to late diagnosis, as only one out of ten patients is considered for curative resection. Therapeutic research groups, and among them the Fondation française de cancérologie digestive (FFCD), do their best to develop new therapeutic strategies, including post-operative or preferentially pre-operative radio-chemotherapeutic adjuvant treatments, and to improve chemotherapy in metastatic cancers.

The use of molecular technology in the differentiation of pancreatic cancer and chronic pancreatitis

CONCLUSION

It is concluded that currently there are limitations in the use of some of the proposed tests, whereas in the future, further progress in our understanding of the molecular biology of pancreatic disease and the development and application of existing techniques should have a greater impact on clinical practice.

BACKGROUND

Fifteen to 20% of patients with pancreatic cancer present with a resectable mass in the head of the pancreas, but there is a subgroup of patients for whom it is difficult to reach the correct diagnosis.

METHOD

This article addresses how molecular technology can be used to aid in the diagnosis of this group of patients. The clinical and scientific literature is reviewed by accessing papers through the Medline database.

RESULTS

This article reviews the limitations of conventional imaging techniques and the limitations of fine needle aspiration cytology and cytological examination of pancreatic duct secretions. The molecular biology of both pancreatic cancer and chronic pancreatitis is then reviewed with emphasis on the common molecular defects seen in these diseases. The current use of molecular techniques in the examination of cytological and histological specimens, stool, blood, and pancreatic duct secretions and how this helps discriminate between benign and malignant lesions of the pancreas is addressed. Finally, the use of novel serum screening tests in groups at high risk of pancreatic cancer is discussed.

Prediction of resectability of pancreatic malignancy by computed tomography

BACKGROUND

The accuracy of computed tomography (CT) in predicting resectability of pancreatic malignancy has been questioned recently and alternative methods have been recommended.

METHODS

To determine the accuracy of CT for predicting resectability and its influence on survival, a standard protocol for performing CT and reporting the results was developed and then compared retrospectively with the ability of one surgeon to perform a resection during 1989-1994. Postoperative survival was determined.

RESULTS

Of 88 consecutive patients 35 (40 per cent) had CT-resectable disease and 53 (60 per cent) had CT-irresectable disease. Twenty-one patients were excluded because of advanced disease or poor performance status. Of the remaining 67 patients, 47 (70 per cent) had pancreatic ductal adenocarcinoma and 20 (30 per cent) had ampullary adenocarcinoma, of whom 32 had a resection, 32 had a palliative bypass and three had only a staging laparoscopy. The sensitivity and specificity for computed tomographic prediction of resectability were 72 and 80 per cent respectively. The positive predictive value was 77 per cent and the negative predictive value 76 per cent. There were seven false-positive and nine false-negative findings. Survival was more dependent on whether or not resection was performed than on computed tomographic predictability of resection.

CONCLUSION

CT was reasonably accurate in predicting resectability but cannot be relied on entirely, requiring an improvement in staging methods for pancreatic malignancy.

Low mortality following resection for pancreatic and periampullary tumours in 1026 patients: UK survey of specialist pancreatic units. UK Pancreatic Cancer Group

BACKGROUND

Recent studies have suggested that the mortality rate from pancreatic resection for cancer is high in the UK compared with that in published series. A survey of specialist units was conducted to determine whether the results differed from those in general units.

METHODS

The postoperative outcome following resection of pancreatic and periampullary tumours was analysed from specialist units in the UK and compared with that of other multi-institutional and large single institutional studies published recently (1900-1996).

RESULTS

A total of 1026 resections was reported from 21 units (33 surgeons). Postoperative complications necessitated reoperation in 57 patients (6 per cent) and there were 58 deaths (6 per cent) in hospital. Pylorus-preserving resections were performed in 102 (41 per cent) of 250 patients with ampullary adenocarcinoma undergoing a major right-sided resection and in 123 (32 per cent) of 381 patients with ductal adenocarcinoma of the head of the pancreas undergoing right-sided resection (chi 2 = 4.01, 1 d.f., 2P = 0.04). The mean number of resections for pancreatic ductal adenocarcinoma was 3.41 (range 1.0-7.1) per institution per year. Combining these data with those from the nine published series from specialist units, there was a lower mortality rate compared with the results of five published general surveys (median 4.9 per cent (95 per cent confidence interval (c.i.) 3.1-8.0 per cent) versus 9.8 (2.5-23.2 per cent), 2P < 0.01) and specialist units had a higher volume caseload (median 5.5 (95 per cent c.i. 4.2-8.1) versus 0.5 (-0.2-2.0) cases per institution per year, 2P < 0.001). Postoperative mortality was related to caseload both for the UK (chi 2 = 7.17, 1 d.f., P < 0.01) and for all the data combined (chi 2 = 40.4, 1 d.f., P < 0.0001).

CONCLUSION

The results from specialist units in the UK compare favourably with those from specialist units outside the UK and are superior to those from non-specialist units. The mortality rate is generally lower in units with a higher caseload.

The molecular genetics of pancreatic cancer

Pancreatic cancer is the fifth leading cause of cancer death in the United States, and despite improvements in the results of surgical treatment for this disease, little impact has been made upon overall mortality. New advances in treatment will depend upon improved adjuvant therapy, early diagnosis, and a better understanding of tumor biology. This article summarizes the results of molecular genetic studies in pancreatic cancer and their potential clinical significance. Familial predisposition to pancreatic cancer, cytogenic studies, DNA ploidy analysis, and examination of specific oncogenes and tumor suppressor genes are reviewed. The most frequent mutations detected have been in the K-ras oncogene, which occur in 80% of pancreatic cancers. These mutations do not correlate with tumor stage or survival, but can be useful in differentiating pancreatic exocrine from endocrine tumors and chronic pancreatitis. Mutations in the p53 gene occur in approximately 50% of tumors, and appear to be an independent prognostic factor for patient survival. Mutations in the CDKN2 gene are frequently seen in sporadic pancreatic cancers, and have been implicated in cases of familial pancreatic cancer. The significance of mutations in APC, MCC, DCC, c-erbB-2, RB-1, and mismatch repair genes in the genesis of pancreatic cancer is less clear.

Imbalance of expression of matrix metalloproteinases (MMPs) and tissue inhibitors of the matrix metalloproteinases (TIMPs) in human pancreatic carcinoma

Degradation of the extracellular matrix (ECM) is an essential step in tumour invasion and metastasis. The matrix metalloproteinases (MMPs) each have different substrate specificities within the ECM and are important in its degradation. MMP activity is dependent on the levels of activated MMP and tissue inhibitors of matrix metalloproteinases (TIMPs). The expression of MMPs and TIMPs in pancreatic carcinoma, normal pancreas, and pancreatic carcinoma cell lines has been determined by Northern analysis. The transcripts have been localized by in situ hybridization and the MMP2 protein by immunohistochemistry. Expression of MMP2, -7, and -11 was greater in pancreatic carcinoma than in normal pancreas (P < 0.01). MMP7 expression in normal pancreas and MMP7 and -11 expression in tumours was always seen the TIMP1 expression. TIMP2 was expressed in only half of the tumours and a previously undescribed transcript size is reported for TIMP2. MTMMP was expressed concurrently with MMP2 in 64 per cent of tumours, but concurrent MMP2 and TIMP2 expression occurred in only half. MMP2 mRNA was found more often in the tumour stroma than with the other MMPs or TIMPs (P < 0.02). It is concluded that while overexpression of MMP7 and -11 may be countered by TIMP1, the aggressive phenotype of pancreatic carcinoma may occur because of overexpression of MMP2, activated by MTMMP and associated with a reduced expression of TIMP2.

Chronic pancreatitis and pancreatic carcinoma

The differential diagnosis between pancreatic cancer and chronic pancreatitis is very important as the management and prognosis of these two diseases is different. In most patients with pancreatic disease, the diagnosis can be established but there is a subgroup of patients in whom it is difficult to differentiate between these conditions because the clinical presentation is often similar and currently available diagnostic tests may be unable to distinguish between an inflammatory or neoplastic pancreatic mass. This paper reviews the aetiology, pathology and clinical features of these diseases and discusses the limitations of conventional diagnostic methods and how newer techniques may be of value in the differential diagnosis.

Imbalance of expression of matrix metalloproteinases (MMPs) and tissue inhibitors of the matrix metalloproteinases (TIMPs) in human pancreatic carcinoma

Degradation of the extracellular matrix (ECM) is an essential step in tumour invasion and metastasis. The matrix metalloproteinases (MMPs) each have different substrate specificities within the ECM and are important in its degradation. MMP activity is dependent on the levels of activated MMP and tissue inhibitors of matrix metalloproteinases (TIMPs). The expression of MMPs and TIMPs in pancreatic carcinoma, normal pancreas, and pancreatic carcinoma cell lines has been determined by Northern analysis. The transcripts have been localized by in situ hybridization and the MMP2 protein by immunohistochemistry. Expression of MMP2, -7, and -11 was greater in pancreatic carcinoma than in normal pancreas (P < 0.01). MMP7 expression in normal pancreas and MMP7 and -11 expression in tumours was always seen the TIMP1 expression. TIMP2 was expressed in only half of the tumours and a previously undescribed transcript size is reported for TIMP2. MTMMP was expressed concurrently with MMP2 in 64 per cent of tumours, but concurrent MMP2 and TIMP2 expression occurred in only half. MMP2 mRNA was found more often in the tumour stroma than with the other MMPs or TIMPs (P < 0.02). It is concluded that while overexpression of MMP7 and -11 may be countered by TIMP1, the aggressive phenotype of pancreatic carcinoma may occur because of overexpression of MMP2, activated by MTMMP and associated with a reduced expression of TIMP2.

Expression of Fas-estrogen receptor fusion protein induces cell death in pancreatic cancer cell lines

Recently, a novel system to induce apoptosis was reported. Fusion protein between Fas and the ligand-binding domain of the estrogen receptor (MfasER) could cause apoptotic cell death in an estrogen-dependent manner on murine fibrosarcoma L929 cells and human cervical carcinoma HeLa cells [1]. To investigate the application of this system to the gene therapy of pancreatic cancer, we introduced MfasER cDNA to six cell lines. Transiently expressed MfasER could cause cell death in all the cell lines tested. Furthermore, stably MfasER-expressing cells showed DNA fragmentation as early as 2 h and completely died in 48 h in the presence of estrogen. Combined with effective methods to introduce genes to pancreatic cancer selectively, MfasER would be a good tool for the gene therapy of pancreatic cancer in the future.

Progress report. A randomized multicenter European study comparing adjuvant radiotherapy, 6-mo chemotherapy, and combination therapy vs no-adjuvant treatment in resectable pancreatic cancer (ESPAC-1)

CONCLUSION

The ESPAC-1 trial is the largest study of its kind in pancreatic cancer and should definitively address the question of the role of conventional methods of adjuvant treatment in pancreatic cancer.

BACKGROUND

At the joint International Association of Pancreatology and the European Pancreatic Club meeting in Mannheim, Germany (June 12-15, 1996) a satellite meeting of the European Study Group for Pancreatic Cancer (ESPAC) met to discuss the progress of the ESPAC-1 trial.

METHODS

A randomized multicenter study to address which, if any, of the following adjuvant treatments are of benefit in patients with resectable pancreatic cancer: radiotherapy (40 Gy with 5-FU as a sensitizing agent), 6 mo of chemotherapy (5-FU and folinic acid), or a combination of these treatments.

RESULTS

From February 1994 to June 1996 (the time of the Mannheim meeting) 221 patients so far have been recruited into the three treatment arms and one control arm.

Matrix metalloproteinases

BACKGROUND

The matrix metalloproteinases (MMPs) have a role in gastrointestinal malignancy. This role is reviewed, with particular reference to the gelatinase subgroup of enzymes.

METHODS

All relevant papers derived from the Medline and Enbase databases between 1984 and early 1996 were reviewed.

RESULT AND CONCLUSION

There is now strong evidence that MMPs play a major role in tumour invasion and metastasis. The development of MMP inhibitors may lead to important new treatment for the control of malignant disease.

The matrix metalloproteinases and their inhibitors in pancreatic cancer. From molecular science to a clinical application

The matrix metalloproteinases (MMPs) and their tissue-specific inhibitors (TIMPs) are described and their roles in tumor invasion and metastasis are reviewed. The expression and activity of the MMPs and TIMPs in pancreatic cancer is reported and illustrated with immunohistochemistry and in situ hybridization. The role of MMP inhibitors (MMPIs) is reviewed in vivo and the use of novel MMPIs, e.g., BB94 (Batimastat) and BB2516 (Marimastat); in animal experiments are also described. Finally, the preliminary results from a phase 2 trial of BB2516 (Marimastat) in pancreatic cancer are reported.

Recurrence after resection for ductal adenocarcinoma of the pancreas

We analyzed the pattern of failure and clinicopathologic factors influencing the disease-free survival of 78 patients who died after macroscopic curative resection for pancreatic cancer. Local recurrence was a component of failure in 56 patients (71.8%) and hepatic recurrence in 48 (61.5%), both accounting for 97% of the total recurrence rate. About 95% of recurrences occurred by 24 months after operation. Median disease-free survival time was 8 months, and cumulative 1-, 3-, and 5-year actuarial disease-free survival rates were 66%, 7%, and 3%, respectively. Multivariate analysis showed that tumor grade (p = 0.04), microscopic radicality of resection (p = 0.04), lymph node status (p = 0.01), and size of the tumor (p = 0.005) were independent predictors of disease-free survival. Patterns of failure and disease-free survival were not statistically influenced by the type of surgical procedure performed. Median survival time from the detection of recurrence until death was 7 months for local recurrence versus 3 months for hepatic or local plus hepatic recurrence (p < 0.05). From our experience and the data collected from the literature, it appears that surgery alone is an inadequate treatment for cure in patients with pancreatic carcinoma. Effective adjuvant therapies are needed to improve locoregional control of pancreatic cancer after surgical resection.

Population-based analysis of treatment of pancreatic cancer and Whipple resection: Department of Defense hospitals, 1989-1994

BACKGROUND

The influence of hospital experience and referral patterns on the operative mortality rate of pancreaticoduodenectomy was studied in a worldwide hospital system.

METHODS

We analyzed computerized data on pancreatic cancer patients from U.S. Department of Defense (DOD) hospitals from 1989 to 1994.

RESULTS

Six hundred ninety-eight patients had pancreatic cancer, and 130 Whipple operations (105 for pancreatic and 25 for other cancers) were performed with an 8.5% 30-day operative mortality rate. Although most resections were done in teaching hospitals performing more than 1 Whipple procedure per year, their results were not superior to smaller, lower volume nonteaching hospitals. Patients transported for resection were younger than patients undergoing resection at their local DOD hospital but had similar outcomes. The operative mortality rate was higher after unusual resections and with increasing age; the tumor stage had no effect. Unresected patients undergoing combined radiation and chemotherapy had the longest survival times. Radiation therapy was associated with significantly longer survival times in patients without distant metastases, but chemotherapy was associated with a longer survival time when metastases were present.

CONCLUSIONS

This mortality rate 8.5% for Whipple resections matches that from other large populations. Equivalent results were obtained in DOD teaching hospitals and smaller, community-type institutions. Because the DOD medical system minimizes financial and logistic barriers to transfer, the even distribution of DOD pancreatectomy mortality suggests that these barriers may favorably influence single institutional outcomes.

Pancreatic cancer. The need for critical reassessment

A review of results of 60 years of resections for pancreatic cancer reveals no consistency in reporting. Resected survivors have been reported up to seven times, even from different countries, and nonresected survivors are overlooked. The claimed 5-year survival rate of 30-55% is achieved by reducing the subset on which calculations are based and using methods such as the Kaplan-Meier, which lead to higher figures the more patients are lost to followup (censored). The excess cost of resection versus bypass can be expected to be ca. $150,000, with one in 30 patients living for 5 years. The overall survival rate is < 0.4%; the best proven surgical result is 3.6% and the best nonsurgical result is 1.7%. Resections have had no discernible impact on survival.

Long-term survival after curative resection for pancreatic ductal adenocarcinoma. Clinicopathologic analysis of 5-year survivors

OBJECTIVE

The authors reviewed the clinicopathologic characteristics of patients who underwent resection with curative intent for ductal adenocarcinoma of the pancreas between 1983 and 1989.

SUMMARY BACKGROUND DATA

Recent studies have demonstrated a reduction in the morbidity and mortality of pancreatic resection and improvement in the actuarial 5-year survival for patients with resected ductal adenocarcinoma.

METHODS

Resection with curative intent was performed on 118 of 684 patients (17%) with pancreatic cancer admitted to the authors' institution. Clinical, demographic, treatment, and pathologic variables were analyzed. The original material for all cases was reviewed; nonductal cancers were excluded.

RESULTS

The head of the gland was the predominant tumor site (n = 102), followed by the body (n = 9), and tail (n = 7). Seventy-two percent of the patients underwent pancreaticoduodenectomies, 15% underwent total pancreatectomies, 10% underwent distal pancreatectomies, and 3% underwent distal subtotal pancreatectomies. Operative mortality was 3.4%. Median survival was 14.3 months after resection compared with 4.9 months if patients did not undergo resection (p < 0.0001). Twelve patients survived 5 years after surgery (10.2% overall actual 5-year survival rate). Three of the tumors were well differentiated, five were moderately differentiated, and four were poorly differentiated. Extrapancreatic invasion occurred in nine cases (75%), and perineural invasion was present in ten cases (83%). Five tumors exhibited invasion of duodenum, ampulla of Vater, and/or common bile duct, and an additional tumor invaded the portal vein. Lymph node involvement by carcinoma was noted in five cases (42%). Six patients remain alive without evidence of disease at a median follow-up of 101 months (range, 82-133 months). Five patients died of recurrent or metastatic pancreatic cancer at 60, 61, 62, 64, and 64 months, respectively. One patient died at 84 months of metastatic lung cancer without evidence of recurrent pancreatic disease.

CONCLUSIONS

This paper emphasizes the grim prognosis of pancreatic ductal adenocarcinoma. Five-year survival cannot be equated to cure. Although pancreatectomy offers the only chance for long-term survival, it should be considered as the best palliative procedure currently available for the majority of patients. This emphasizes the need for the development of novel and effective adjuvant therapies for this disease.