Advanced Pancreatic Cancer: The Road to Personalized Care - Episode 9
John L. Marshall, MD: Three months, you’ve given 6 cycles. They’ve done OK, maybe not really any sensitivity to cold, but not a lot of residual neuropathy. Scan looks good. Right? It’s a nice response. Patient’s doing okay. Next move? Three more months?
George P. Kim, MD: We are moving to maintenance. I think we’re going to talk about that in a little bit, but yes, like what we do with colorectal.
John L. Marshall, MD: Is there anything magic about 6 months of chemotherapy?
George P. Kim, MD: That’s how the French studied it, right?
Eileen M. O’Reilly, MD: Six months and stopped.
George P. Kim, MD: Yes, so I think there’s an opportunity for maintenance; giving 5-FU and leucovorin, in the maintenance setting, and then adding and studying biologics.
Tanios S. Bekaii-Saab, MD: What do you think the leucovorin is doing to infusional 5-FU?
George P. Kim, MD: The leucovorin augments the effects of 5-FU.
Tanios S. Bekaii-Saab, MD: That sounds very smart for the first 2 hours of the infusion, and then it’s a wasted 30 cents, or a dollar.
George P. Kim, MD: It’s a great drug, it’s better than the others.
Tanios S. Bekaii-Saab, MD: No, I disagree completely.
Eileen M. O’Reilly, MD: It’s one dollar.
John L. Marshall, MD: Let’s shift gears a little bit. What if we did frontline gemcitabine and nab-paclitaxel? What’s your starting regimen on that? Full dose, modified dose? Every other week?
Kabir Mody, MD: So, I tend to start with the standard regimen.
John L. Marshall, MD: Full dose?
Kabir Mody, MD: Yes
John L. Marshall, MD: 3 weeks on, 1 off?
Kabir Mody, MD: Yes. With the mindset, for myself and the patient, that if they’re having a hard time, I’m going to have a lower threshold to back off to maybe every other week scheduling.
John L. Marshall, MD: This is where I’m taking a poll. Anybody different than that?
George P. Kim, MD: You could do 2 out of 3; you could do 2 weeks on, 1 week off, to give that break a week earlier.
John L. Marshall, MD: Every other week, you wrote the study.
Tanios S. Bekaii-Saab, MD: Every other week.
Eileen M. O’Reilly, MD: Usually we will start full dose and all of our studies, which are built on gemcitabine, nab-paclitaxel all full dose, 3 weeks on, 1 week off. But, yes, I think we’re comforted by the prospective data from the Ohio State University and Tanios’ work that tells us that the every-other-week schedule looks very tolerable from the myelosuppression and from the neuropathy perspective.
John L. Marshall, MD: The more I’ve done this myself, following your lead, I find that a lot of patients tolerate it just fine. They’re not really having much myelosuppression. Their neuropathy is not a major issue, and I feel glad that I’ve done it, instead of pre-emptively deciding that it’s going to be spicy and backing off.
George P. Kim, MD: Their toxicities are manageable. You do get some neutropenia, 36% need some growth factors on occasion. I said neutropenia—neuropathy is 17% and grade 3—but you can back off the drug, hold the Abraxane, keep giving them gemcitabine, and the neuropathy reverses, which is unique, unlike what you see with oxaliplatin.
Tanios S. Bekaii-Saab, MD: I don’t know; I have not seen a lot of patients actually reverse on their neuropathy, because the labs are actually limited too. So perhaps for the occasional survivor, 17% neuropathy, grade 3 neuropathy. It’s pretty bad.
Eileen M. O’Reilly, MD: It’ll be nice when we solve the alopecia problem too.
John L. Marshall, MD: Yeah, so I was going to ask about cold caps and things like that. George and I have refined alopecia.
John L. Marshall, MD: In fact, when I’m presenting the 2-versus-3-drug, I present, this one as you’re going to lose all your hair, and this one you probably won’t.
Eileen M. O’Reilly, MD: Sometimes it’s a determining factor.
Tanios S. Bekaii-Saab, MD: Yes, definitely.
John L. Marshall, MD: Same question as before, 3 to 4 months of treatment. Scan looks good, what do you do now?
Tanios S. Bekaii-Saab, MD: We’re talking about FOLFIRINOX?
John L. Marshall, MD: No, we’re talking gemcitabine/nab-paclitaxel.
Kabir Mody, MD: I continue it.
John L. Marshall, MD: Just keep going, 2 drugs? Anybody modify it?
Tanios S. Bekaii-Saab, MD: It is interesting. In the every-other-week regimen, I’ve treated patients beyond a year continuously on treatment with very few toxicities. I have not been able to do that with oxaliplatin-based regimens. The nab-paclitaxel, every other week seems to actually be able to go through much longer mileage. Patients get tired. I mean, with all these regimens patients tire. We’re not sure that we need, frankly, to treat our patients beyond 6 months at this point, but we don’t have the data, other than the European data; we don’t have comparative data about continuation versus FOLFIRINOX.
Eileen M. O’Reilly, MD: Yes. For a very select number of patients we can realistically think about treatment breaks, but I do worry about the disease getting out of hand, and really like the idea of de-escalating the intensity of cytotoxic therapy and continuing on a maintenance basis. We now have some data that tell us that this is reasonable and feasible and appears to be not a compromise in terms of outcome.
Transcript Edited for Clarity