Dr Kim on Factors Informing Frontline Chemotherapy Selection in Pancreatic Cancer

"Traditionally, we focused on [factors including] the patient’s age, performance status, and how aggressive they wanted to be…Those [factors] are still relevant, but we’ve learned that age is a wide spectrum and doesn’t always tell us how fit a patient is. The more modern way of thinking is: what’s the probability that this patient may have some platinum sensitivity?"

Dong Kim, MD, an oncologist and hematologist at Maryland Oncology Hematology, discussed key considerations when selecting a frontline chemotherapy regimen for patients with metastatic pancreatic cancer and how patient treatment goals should factor into this decision.

Traditionally, chemotherapy selection for patients with metastatic pancreatic cancer is centered on patient age, performance status, and the desired level of treatment intensity, with a general assumption that gemcitabine/nab-paclitaxel (Abraxane) provided a more tolerable alternative to intensive combinations, Kim detailed. However, he noted that age exists on a wide spectrum and is not always a reliable indicator of a patient's fitness or ability to tolerate aggressive therapy.

The more "modern way of thinking" about frontline treatment selection focuses on the probability of platinum sensitivity rather than just demographics, Kim asserted. Consequently, eligible patients should not be excluded from platinum-based regimens—such as FOLFIRINOX (leucovorin, 5-fluorouracil [5-FU], irinotecan, and oxaliplatin) or NALIRIFOX (liposomal irinotecan [Onivyde], oxaliplatin, 5-FU, and leucovorin)—simply due to advanced age.

Kim added that clinicians must also weigh the timing of next-generation sequencing (NGS) results. Because pancreatic cancer is a time-sensitive disease and many patients may only receive a single line of therapy if clinical trials are unavailable, waiting for NGS results can be difficult, he explained. In such cases, clinicians should consider the pretest probability of a homologous recombination repair deficiency, Kim recommended. For example, a significant family history that might suggest a germline mutation could influence the clinical approach toward platinum-based therapy, he said. Ultimately, Kim emphasized the importance of having up-front conversations with patients to align treatment selection with their specific goals and the likely underlying biology of their disease.