Michael Choti, MD
Although the goal is to cure patients with pancreatic cancer through surgery, many patients who present with this disease are ineligible for resection at the time of diagnosis, making imaging and early detection imperative, said Michael A. Choti, MD.
Ideal surgical candidates are those with localized disease that is away from vital structures like veins and arteries, explained Choti, who is chief of Surgery at Banner MD Anderson Cancer Center. However, as more advanced imaging techniques enter the field, and more patients with borderline operability are recommended for surgery, multimodality therapy will have a larger role. Rather than receiving chemotherapy postoperatively, these patients can receive neoadjuvant chemotherapy.
Additionally, ongoing research is looking into ways to use molecular testing in order to personalize treatment for patients. While immunotherapy has had little impact in these patients thus far, a recent trial with pembrolizumab (Keytruda) may provide a breakthrough in this space.
The open-label, single arm, phase IIa trial (NCT02826486) is evaluating the safety and efficacy of the CXCR4 antagonist BL-8040, both as a single agent and in combination with pembrolizumab in patients with metastatic pancreatic adenocarcinoma. In the study, patients are receiving 5 days of monotherapy with BL-8040, followed by repeated 3-week cycles of pembrolizumab combined with BL-8040 every 3 weeks. Data for 29 evaluable patients presented at the 2018 ESMO Congress showed a median overall survival of 3.4 months in the entire population, and 7.5 months for those who received at least 1 previous line of treatment.
In an interview with OncLive
, Choti highlighted ongoing developments in the field of pancreatic cancer.
OncLive: What is the role of surgery in the pancreatic cancer paradigm? Has it shifted at all in recent years?
: There are many changes happening in the treatment of patients with pancreatic cancer. The most common form, pancreatic adenocarcinoma, is still a very difficult disease and very life-threatening; few of these patients can be cured. As a surgical oncologist, the goal for most of us is to determine if we can cure the disease through surgery. Unfortunately, most patients who present with pancreatic adenocarcinoma are not operable at the time of diagnosis. These patients can either have metastatic disease or have locally advanced disease, precluding the ability to resect it.
Therefore, imaging is very important, and so is early diagnosis. If the tumor is resectable—that is, contained, no evidence of metastatic disease, and away from the vital structures—that patient is a candidate for surgical therapy. Of course, these are big operations depending on where the tumor is located: in the head of the pancreas, the tail, or the body.
What is new in the landscape of patients with operable disease is the multimodality therapy. We are seeing more effective forms of systemic chemotherapy for patients with pancreatic cancer. We are aggressively bringing the regimens in that were being used for patients with advanced disease. Rather than giving chemotherapy postoperatively, we are seeing a strong trend toward neoadjuvant chemotherapy. This is mostly for patients with what we call borderline operability. More often than not, we are recommending systemic chemotherapy prior to surgery.
What are the biggest advances being made in the field?
We are learning more about the area of hereditary or familial high-risk pancreatic cancer. There is a lot of ongoing research trying to [find ways to] screen patients with high-risk disease. Clearly, early diagnosis and prevention are very important, but we are learning that there is a lot of room for improvement in our ability to detect pancreatic cancer.
We are learning more about certain mutations—for instance, BRCA
mutation. These mutations are associated with breast and ovarian cancers, but we are learning that these also might have something to do with risk of pancreatic cancer. We are developing regimens to screen those patients, but there is still a challenge in how we are doing the screening. There is still room for additional research.
There is also the topic of how we can use molecular testing in order to identify or personalize the forms of therapy we use. Can we bring immunotherapy or targeted agents into pancreatic cancer? Unfortunately, most of the molecular information we are getting is not very [useful]. The standard treatments are still cytotoxic chemotherapies.