Sequencing Strategies: Metastatic Pancreatic Adenocarcinoma - Episode 9

Pancreatic Cancer: Looking Beyond Second-Line Therapy


John L. Marshall, MD: As we go through lines of therapy, I think the benefit of our treatment seems to be a little less each time. Patients are a little more beat up. They’re a little bit more aware and a little bit more savvy. And so, that initial discussion is often about being aggressive and intensive—second-line therapy, salvage, trying to rescue, save. Then there are patients that are now still OK after 2 lines of therapy. They’re a little bit more tired, a little bit more beat up, but not always, right? There’s also patients who have emerged with a quieter pancreas cancer. We’ve discovered them. Maybe we have caused them? And so, that patient’s looking around and is saying, “You already tried the standard medicines. What else have you got for me?” There is an increasing number of patients with third-line pancreas cancer. I never thought that I would say that, but it’s true.

Fadi Braiteh, MD: Having many options to treat patients in the advanced setting of pancreatic cancer, such as with frontline treatment—whether it’s single-agent gemcitabine or a gemcitabine-based regimen or FOLFIRINOX—there are now opportunities to use second-line nanoliposomal irinotecan plus 5-FU outside of a clinical trial. But the reality is, we’re not curing these patients. And now that we are focusing on quality of life and symptom management, there is an increasing proportion of patients who are making it beyond the second-line setting. They still have a very good quality of life and a very good performance status. They don’t just want to sit and use best supportive care. Often, in my practice, these types of patients are great candidates for phase I clinical trials. I’m not in favor of empirically using any of the preexisting molecules and recycling them. There is no evidence that it provides any benefit, when it comes to disease control and improvement of survival, except maybe cumulative toxicity. So, I encourage patients to reach out to phase I clinical trials, or what we call basket studies—that would consider patients with some molecular characteristics—for enrollment on clinical trials.

Transcript Edited for Clarity