Johanna Bendell, MD
The majority of patients with pancreatic adenocarcinoma are diagnosed with late-stage, unresectable tumors, a setting in which combination chemotherapy remains the mainstay. Although progress has been slow, new drugs have become available, important research questions are being addressed, and treatment strategies are continuing to evolve.
The take-home message from a recent OncLive
Peer Exchange® roundtable entitled “Progress and Promise in Advanced Pancreatic Cancer” is that the established way of viewing this disease has been largely supplanted by approaches currently available and that there are encouraging signs of progress from new strategies in development.
“Who would have ever thought we’d have treatment options to discuss for patients with pancreas cancer?” said Johanna Bendell, MD, who served as moderator for the discussion. “There will be controversy about what to use when but finally we’re able to sequence. We’ve probably doubled survival for patients with metastatic disease over the last couple of years. So that’s very impressive, and hopefully we’ll be translating that into curing more patients.”
Before thinking about what therapy to recommend for a newly diagnosed patient, Philip A. Philip, MD, PhD, considers the psychological impact of the diagnosis.
Philip A. Philip, MD, PhD
“The most important thing, in my opinion, is to stabilize the patient physically and mentally,” he said, adding that this includes addressing pain control and managing biliary obstruction if necessary. Instead of moving directly into an established treatment, however, Philip considers enrolling the patient in an appropriate clinical trial. Since clinical trials offer standard treatments plus an experimental agent, patients would not be deprived of active treatment, he noted.
When it comes to selecting a frontline systemic regimen, panelists debated the relative merits of two choices: the combination of gemcitabine and nab-paclitaxel (Abraxane) or FOLFIRINOX (leucovorin, fluorouracil [5-FU], irinotecan, oxaliplatin). Factors that Philip considers in choosing between the two regimens include patient performance status, which helps him determine how aggressive to be; organ function, particularly the liver; and age. He said there is a lack of evidence about FOLFIRINOX for patients over the age of 74 or 75 years of age.
Thomas A. Abrams, MD
The major trials evaluating the two regimens differed in patient selection, explained Thomas A. Abrams, MD. In the PRODIGE trial,1
FOLFIRINOX was given to patients from France who, for the most part, had a slightly better performance status than who received gemcitabine/nab-paclitaxel in the MPACT study.2
The control arms of the major trials of both regimens used gemcitabine.
The median overall survival (OS) of patients who received FOLFIRINOX during the trial was 11.1 months while the median OS for those who were treated with gemcitabine/nab-paclitaxel in the MPACT trial was 8.5 months. FOLFIRINOX patients experienced slightly more toxicity including neutropenia and diarrhea. FOLFIRINOX might be a little bit more effective and have a better response rate, said Abrams, but he cautioned that cross-trial comparison is “fraught with landmines.”