Sequencing Strategies: Metastatic Pancreatic Adenocarcinoma - Episode 11
John L. Marshall, MD: Pancreas cancer still has us sort of on the ropes. We’re a bit on our heels. In other cancers, even cholangiocarcinoma, liver cancers, and colon cancers, we’ve been making nice big jumps in improvement. In pancreas cancer, we’re still making small steps. I’m hopeful that we will uncover all sorts of things. How do people get it? Why do they get it? Will there be a screening test to try and detect early disease? We need improvements in therapies, whether it’s in the neoadjuvant setting or in the metastatic setting. We need to have a better understanding of what makes this thing occur. What’s really fascinating, because this disease is sort of specific, is that it creates this sort of fibrotic shell around the cancer. Our drugs are trying to get in, and they can’t. So, we’re now beginning to target the body’s reaction to the cancer, with hope that we can get our therapies to where they need to go, to improve outcomes. So, we’re learning. We’re taking this baby apart. I am hopeful that in the next 5 to 10 years, we will see those big steps that we’re seeing in other cancers.
Fadi Braiteh, MD: In the field of advanced pancreatic adenocarcinoma, we’re making solid, meaningful, significant steps forward in improvement. These are not giant leaps, yet. We’re hoping that we’ll get there. But at least we’re moving the needle. We’re adding different lines of therapy, and we’re building on the standard of care in the frontline and second-line settings. There is excitement. If we look on the clinicaltrials.gov website, you see a number of ongoing clinical trials in pancreatic adenocarcinoma. I cannot reiterate it more than this: Consider every patient for clinical trials. This is a disease of the elderly. We recognize that, although we even have patients in their 30s. We’re at an aging population, and it’s a problem that’s not going to disappear overnight. We’re going to live long enough that we’re going to be facing this disease at higher risk.
The good news is, with the improvement of bringing different molecules that have been efficacious or have shown a signal of efficacy in one disease state into clinical trials, there is evidence that it can work in pancreatic adenocarcinoma. We’re seeing more collaboration between different pharmaceutical companies, across different academic centers, that really fuels and accelerates the development of these clinical trials. This is the best time that we have had, in the last 20 years—for bringing these combinations to clinics. Only time will tell us about the efficacy. Of course, all of that is taken into consideration, with economic considerations as well. Having the efficacy is not enough. We understand that. The cost of taking care of cancer patients is going up. It’s very important to have the least toxic drugs, to keep the patients out of the hospitals and to give them a great quality of life.
John L. Marshall, MD: For a long time, I thought surgery was not really that useful for pancreas cancer. It’s a big operation, there was a lot of morbidity from it, and it didn’t cure very many people. Unlike most of our surgeries in cancer, where surgery cures people, in pancreas cancer, almost everybody has microscopic metastatic disease.
Yes, we’ve moved the bar in adjuvant therapy. We’ve improved things by adding capecitabine to gemcitabine in the adjuvant setting. So, more people are being cured from their disease. But what I’m really excited about is the sort of combined modality, neoadjuvant approach. We see a lot of patients with locally advanced pancreas cancer and no obvious metastatic disease. Treatments are improving. We’re seeing regressions. Our radiation colleagues, our interventional radiology doctors, are working together—pulling this thing back down, and, ultimately, pulling the root, if you will, surgically. And so, as we’ve begun to think about chemotherapy as a first approach, I’m actually quite excited about this. I hope that this kind of approach will lead to more cures.
Transcript Edited for Clarity