Sequencing Strategies: Metastatic Pancreatic Adenocarcinoma - Episode 4
John L. Marshall, MD: You have a patient in front of you. You’re about to describe the chemotherapy regimen to them. Most patients probably want a Mediport. With one regimen, you’ve got to have a Mediport—that’s FOLFIRINOX. You describe that to somebody. “Every 2 weeks, I’m going to give you 2 drugs while you are sitting in this chair. Then, I’m going to send you home with a 48-hour infusion pump. I’m going to probably give you a growth factor. You’re going to feel crummy for a few days and then have a pretty good week. But you may have some diarrhea. And then, guess what? I’m going to do it all over again—just when you start to feel better. I’m going to do that for 4 rounds, and I’m going to do a new scan on you to see how you’re doing.” With gemcitabine/nab-paclitaxel (gemcitabine/Abraxane), you might not need a Mediport. You can get one, but you don’t have to have one.
The standard regimen, of course, is 3 weeks on and 1 week off. It is difficult to get the full dose, 3 weeks in a row, into patients. We try. We set out that way. But, very often, we need to modify that. So, you come in and you get your treatment. It takes a couple of hours. You come back a week later, get another lab, and get your treatment. You come back for a third week, if you can. If you can’t, there are a couple of strategies. One is to go to an every-other-week regimen. There’s some evidence out there that says that giving it every 2 weeks, instead of weekly times 3, is just as effective and is certainly very well tolerated.
It also gives a nice break for the patients. There is no home infusion pump. The treatments can be given, and then you go. And, for most patients, it’s pretty well tolerated. So, you present those 2 options to patients. They have a bias about what they want, as well. They’re similar in outcome, and, of course, most patients opt not to do the pump.
Fadi Braiteh, MD: We practicing medical oncologists say that clinical trials are designed in a certain way. The drugs are approved in a certain way. There is clear instruction in the product insert of how to administer treatment. But it’s not unusual that we try to improvise with the modality of how we provide these drugs to improve the quality of life for our patients and to try to reduce toxicities. Yes, we talk about potentially changing the MPACT protocol, which is Abraxane, or albumin-bound paclitaxel, plus gemcitabine provided at 125 mg/m2 and 1000 mg/m2 for 3 weeks on and 1 week off, to, maybe, every other week. This can definitely be the case—sometimes outside of the label of second-line treatment—if a patient is appropriate. But, if we go back to the frontline setting, there is another question. I don’t like to say it a lot—priming the space and providing the Abraxane even a day before. I want to highlight that the regimen is not gemcitabine, but is albumin-bound paclitaxel plus gemcitabine. In the study, there was clear instruction to provide the albumin-bound paclitaxel first as an infusion, and then the gemcitabine. There has been some talk about maybe infusing it even a day earlier. I do not do that in my practice, unless there is a clear study showing the advantage. It’s not convenient to have the patient come in for 2 consecutive days to get the treatment, premedicate twice, and treat for 2 weeks on and 1 week off. It may be of higher burden.
Transcript Edited for Clarity