Emerging Approaches: Pancreatic Cancer Systemic Therapy - Episode 10

Approaches to Frontline Management of Pancreatic Cancer

February 20, 2019


Paul E. Oberstein, MD: Welcome to OncLive Insights®. I’m Paul Oberstein, a medical oncologist and director of GI Medical Oncology at NYU Langone’s Perlmutter Cancer Center. I’m here today with one of our dedicated nurses, Shantal Ginsberg, who specializes in treating patients with pancreatic cancer. We’re here to discuss advances in treatment in patients with advanced pancreatic cancer.

In reflecting on the last decade or so, we’ve made tremendous advances in treating patients with pancreatic cancer, though many, many discoveries are yet to be implemented in the clinic. There have been really great advances in the laboratory in terms of developing new drugs, new medications, and new understanding of this disease. And over the last few years, those have really started making a difference in patients’ lives.

In the last 10 years or so, we’ve had 4 or 5 positive phase III trials that have led to new treatments for patients with pancreatic cancers at all stages. Today we’re going to focus on those with advanced or metastatic pancreatic cancer, for which there are 3 or 4 new treatment options that are now part of our practice that we’re going to discuss today. All these treatments happened because of investigation in clinical trials, trying new medications, and learning from experience. And we’re in the process of what we think will be a real change in how we treat patients with this disease.

Shantal Ginsberg, RN: Can you talk a little bit about your treatment approach when you’re treating these patients who are newly diagnosed? What you take into account—what risk factors, disease factors—when it comes to deciding how to treat them?

Paul E. Oberstein, MD: This is something that has become more and more complex because we have more options for treatment. Given that we have medications that are approved for first-line and second-line therapy in metastatic pancreatic cancer, we have to look at this from the beginning—from a patient perspective and from a therapeutic perspective—as to which medications make the most sense and how we use them. The first and most important question when we meet a patient with pancreatic cancer is to understand what stage of disease they have, how to classify them, and almost as importantly, what physical condition that patient is in. How healthy are they? What other medical conditions, comorbidities, and symptoms do they have related to pancreatic cancer?

Those are critical questions. You can’t make decisions about therapy unless we have an answer to those questions. And the most important thing in putting all of that together is informing the patient of the options, discussing options with them, and making an informed decision with them and their family and our entire treatment team such that we understand how to best treat them for their pancreatic cancer.

One of the first questions that comes up when patients come in is the understanding of what side effects they will experience from treatment and what the benefit of treatment is. And we generally use data we have from clinical trials, and of course a lot of clinical experience, to discuss what the average patient will experience during treatment. But there’s a tremendous range of experiences, so it’s important to keep in mind all the possibilities when we have that initial discussion with the patient.

Shantal Ginsberg, RN: When you meet a new patient and you take into account their clinical picture, how do you decide what you’re going to give them, what treatment you’re going to start them on?

Paul E. Oberstein, MD: That’s one of the most complicated questions we deal with, partly because there is an urgency to get patients started on treatment as quickly as possible. But there’s also a real importance to getting it right, to getting the best treatment regimen for that individual patient. In general, we have 3 major categories of treatment that are available for patients with advanced pancreatic cancer. The first is a single-agent chemotherapy with gemcitabine, which provides benefit but only has a very small response rate in terms of shrinking tumors. A more aggressive regimen that is approved is a combination of gemcitabine and nab-paclitaxel. The third and most aggressive regimen is a regimen called FOLFIRINOX [leucovorin, fluorouracil, irinotecan, and oxaliplatin]. We generally choose between giving a patient a gemcitabine-based regimen or FOLFIRINOX based on how physically fit they seem to be.

Sometimes it’s based on age, but the most important measure is how strong a person is and how functional their organs are: their liver and their kidney. And we take those into account. We discuss with the patients what the adverse events they might anticipate with those regimens are. And, after explaining the adverse events and the potential toxicity of the regimen, we make a decision about what we’re going to start.

Shantal Ginsberg, RN: And when you take all of that into account when you’re discussing this with the patient, this is how you then end up trying to sequence their therapy so that we get the most mileage to be able to effectively treat them.

Paul E. Oberstein, MD: Correct. Part of the complexity of what we do is that we now have an approved chemotherapy regimen for second-line pancreatic cancer. So, when we meet a patient initially and it’s their first visit, they’re thinking about getting started on treatment immediately. But we have to keep in mind that there will be not just one round of treatment, hopefully, but there might be subsequent rounds of chemotherapy. And it’s very common for a patient to stay on first-line chemotherapy for somewhere between 6 to 12 months. So it is a long-term decision, but it does play into what we think of for that patient. And there are times where, for whatever reason, FOLFIRINOX is not considered because the patient is not quite strong enough for it or it’s a little bit too toxic. But given that we know we have a second-line chemotherapy regimen, we may be comfortable starting with gemcitabine and nab-paclitaxel with the hope of using that second-line regimen in the future.

Having said that, we also have to keep in mind that there are clinical trials and new approaches, and these all are taken into account. We want to give a patient the most effective chemotherapy they can handle today, but not preclude them from options that are available and will become available in the future.

Transcript Edited for Clarity