Outcomes for pancreatic adenocarcinoma remain dismal despite patients undergoing combinational therapy with surgery and systematic treatment. 5-year outcomes have been recently seen to be improved with modern surgery and multi-agent chemotherapy, however sequencing these treatments has long been a debate. Standard of care for borderline resectable disease has been established to be neoadjuvant therapy followed by surgery in those who do not progress. For up-front resectable cancer the jury is still out on whether systemic therapy should be given before or after surgery. Both sides of the debate are likely driven by a lack of equipoise in this domain. Proponents of neoadjuvant treatment argue pancreas cancer is a systemic disease and chemotherapy is the patient’s most important treatment with an improved chance of receiving their prescribed course prior to morbid surgery, as well as providing an in vivo assessment of tumour biology. Conversely, proceeding with surgery first removes the primary tumour obtaining local control, improving pain and reducing the risk of recurrence of biliary and duodenal obstruction. The issue in this group is not only morbidity of surgery preventing commencement/completion of adjuvant chemotherapy but also early disease relapse putting the patient through unnecessary surgery. In recent years multiple trials have been conducted to answer the question of treatment selection. We will explore the evidence providing an up-to-date review in this space.