High attrition during neoadjuvant therapy (NAT) complicates surgical candidacy for localized pancreatic cancer, affecting patient outcomes.

• Out of 427 patients receiving NAT, 57% did not proceed to pancreatectomy due to disease progression (21%) and persistent inoperability (22%).
• Resectable patients had an attrition rate of 23%, compared to 44% for borderline resectable and 73% for locally advanced cases.

Understanding these attrition drivers is critical for surgical decision-making and patient selection, underscoring the need for proactive management strategies.