Advanced Pancreatic Cancer: The Road to Personalized Care - Episode 8
John L. Marshall, MD: We do this day in and day out, and we’re really familiar with the regimens; we know how to tweak them. Our community partners, they have to take care of everything that walks in the door. So, let’s give them some inside baseball tips on managing these regimens. Kabir, you get to start. So, you’re giving, let’s say, the FOLFIRINOX—we talked a little bit about this. When you’re sending a patient off with some tweaks to the regimen maybe a little bit, what are some supportive care tips that you might offer?
Kabir Mody, MD: Yes, I think that we already alluded to a couple of them in terms of dropping the bolus and decreasing the irinotecan.
John L. Marshall, MD: I heard some people, they’re 20% across the borders, and some people are including the bolus. So, your strategy is…?
Kabir Mody, MD: I generally will drop the bolus up front and reduce the irinotecan and oxaliplatin somewhat.
John L. Marshall, MD: And the oxaliplatin to maybe 60, 65mg/m².
Kabir Mody, MD: Yes, and in the beginning, just to get them used to the regimen and see how they tolerate it.
John L. Marshall, MD: What about other people—what do you do?
George P. Kim, MD: Twenty percent reduction.
John L. Marshall, MD: You’re across the border.
George P. Kim, MD: Bolus 5-FU, 20% reduction in irinotecan, keep the oxaliplatin at full dose. I agree, though, sometimes people will actually use FOLFOX, especially if they have liver issues.
John L. Marshall, MD: And then they’ll add in the irinotecan. Any other tips on modifying this?
Eileen M. O’Reilly, MD: I’m with Kabir. The original data suggested that the best outcome was 80% of dose intensity. The other thing about dose reducing oxaliplatin up front is that you can probably give it for a couple of cycles longer.
John L. Marshall, MD: You can give it a little longer.
Eileen M. O’Reilly, MD: Whether that matters or not, who knows, but tolerability.
Tanios S. Bekaii-Saab, MD: Drop the leucovorin.
John L. Marshall, MD: Drop the leucovorin. Save some money.
Tanios S. Bekaii-Sab, MD: That leucovorin is a waste. When you drop the bolus 5-FU, drop the leucovorin; you really do not need it. As soon as the infusion of leucovorin is done, the drug is out of the system.
John L. Marshall, MD: Growth factor cycle 1—who’s in?
George P. Kim, MD: No. Let the patient heal themselves.
Kabir Mody, MD: Yes.
Eileen M. O’Reilly, MD: Unless it’s somebody who’s on the edge.
John L. Marshall, MD: On the edge maybe?
Tanios S. Bekaii-Saab, MD: I’d say yes, if it prevents even a small percentage of patients from not having to be hospitalized for that, along with the diarrhea and, febrile neutropenia.
John L. Marshall, MD: A common question I get asked is, when do you do the growth factor? If you’re doing it, do you put a button on them on the disconnect day?
Tanios S. Bekaii-Saab, MD: On the disconnect day, when they come back to get disconnected, they get then the last injection.
John L. Marshall, MD: So, then just give it on the day they’re disconnected. What if their home nurse picks up their pumps?
Tanios S. Bekaii-Saab, MD: We don’t do that anymore.
John L. Marshall, MD: We make them come back.
Eileen M. O’Reilly, MD: We don’t have that luxury in New York City.
John L. Marshall, MD: And then do you see them every 2 weeks, generally?
Kabir Mody, MD: I think it’s important to actually see the patient every 2 weeks before each cycle, because it is a dynamic process, especially in the beginning while that patient’s getting used to the whole idea of getting chemotherapy; and there’s a palliative care aspect to that visit, as well, in terms of wrapping their head around the journey that they’re on.
John L. Marshall, MD: Who gives your patient your cell phone or your email?
George P. Kim, MD: I do.
Kabir Mody, MD: I do.
George P. Kim, MD: You’re very good at that.
John L. Marshall, MD: Yes. I actually like a little check-in. I like the patient to send me an “I’m OK” day 5 email.
Tanios S. Bekaii-Saab, MD: You don’t get that through the portal?
John L. Marshall, MD: We’re not the Mayo Clinic; we still have carrier pigeons at our place.
George P. Kim, MD: I may check a patient’s day 8, and I want to get ahead of the diarrhea—you really want to get ahead of the diarrhea.
Eileen M. O’Reilly, MD: So, 2 of the things that help with quality of life and tolerability are hydrating patients and making sure we’ve optimized the antiemetic gradually, because that can be a troublesome issue. We use a 5-HT3 antagonist, reduced for those who have hypoglycemia issues; lorazepam; and a neurokinin P inhibitor, and then roll back if they’re doing well going forward. People argue about this.
John L. Marshall, MD: Yes, I also think about this regimen. It’s often a first visit that you’re describing, as you’re talking about their cancers and their survival, and then you get into the weeds of the regimen like this, and they’re mentally exhausted. This is a complicated regimen, and we so depend on our nursing staff and our other resources that are out there—the PanCAN sites have some good stuff on this, too. Do you formally refer your patients, or how do you manage that, knowing that there’s that gap going on? Anybody have any thoughts?
Kabir Mody, MD: Well, we make a very early referral to our palliative care colleagues and get them involved early on. I have my own Mayo nurse who helps to try to get on patients and also to provide them support.
George P. Kim, MD: Yes, so this is key—we haven’t talked about this—but taking care of pancreatic cancer patients as a team effort. You have to get everybody involved. You know everybody has to look out for the pain, the digestion, the malabsorption, blood clot, malignant ascites, depression; all sorts of aspects. Palliative medicine has to come forward. Right now, in Jacksonville, it’s more inpatient than you did in the outpatient arena. So, yes, I absolutely agree. You have to get that performance status optimized, especially if you get to pour in FOLFIRINOX. And that’s where the decision with gemcitabine/nab-paclitaxel comes in. And then we also have sequencing now. We have second-line therapies, nanoliposomal irinotecan, and so we can talk to patients in that first meeting about how we’re going to do this, and then we have this option later on. If we go the other route of FOLFIRINOX, that becomes somewhat more limited. And again, when we talk about palliating patients, that does give them some reassurance.
John L. Marshall, MD: Scan at 2 months, 3 months, or don’t—just follow a CA19-9?
Tanios S. Bekaii-Saab, MD: Two months; for the first 6 months, maybe.
Eileen M. O’Reilly, MD: Eight to 10 weeks, I think. It depends on the clinical circumstances.
Eileen M. O’Reilly, MD: Right, and what’s happening with the marker—and just to make the point that sometimes the marker goes up early, right? We have to be very careful about not overinterpreting those early risers due to cell death and release, and then you see it level off.
Tanios S. Bekaii-Saab, MD: So, I think the key is not to check the biomarker. The CA19-9 has to be checked in at the time.
Kabir Mody, MD: Especially not at every visit.
Tanios S. Bekaii-Saab, MD: It has to be at the time you check your scan. That’s the only time it could make some sense.
John L. Marshall, MD: I do it monthly.
George P. Kim, MD: I have a lot of anxiety. I agree with Toni; I do it probably every 2 months.
Tanios S. Bekaii-Saab, MD: It’s not physician anxiety; patients are looking at it. I try to avoid additional anxiety to what they’re going through.
Transcript Edited for Clarity