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Salazar J, Bracchiglione J, Savall-Esteve O, Antequera A, Bottaro-Parra D, Gutiérrez-Valencia M, Martínez-Peralta S, Pericay C, Tibau A, Bonfill X. Treatment with anticancer drugs for advanced pancreatic cancer: a systematic review. BMC Cancer 2023; 23:748. [PMID: 37573294 PMCID: PMC10422698 DOI: 10.1186/s12885-023-11207-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/22/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND Patients with advanced pancreatic cancer have a poor prognosis and high burden of cancer-related symptoms. It is necessary to assess the trade-off of clinical benefits and possible harms of treatments with anticancer drugs (TAD). This systematic review aims to compare the effectiveness of TAD versus supportive care or no treatment, considering all patient-important outcomes. METHODS We searched PubMed, Embase, Cochrane Library, and Epistemonikos. Two reviewers performed selection, data extraction and risk of bias assessment. We assessed certainty of the evidence using the GRADE approach. RESULTS We included 14 randomised controlled trials. Chemotherapy may result in a slight increase in overall survival (MD: 2.97 months (95%CI 1.23, 4.70)) and fewer hospital days (MD: -6.7 (-8.3, -5.1)), however, the evidence is very uncertain about its effect on symptoms, quality of life, functional status, and adverse events. Targeted/biological therapy may result in little to no difference in overall survival and a slight increment in progression-free survival (HR: 0.83 (95%CI 0.63, 1.10)), but probably results in more adverse events (RR: 5.54 (95%CI 1.24, 23.97)). The evidence is very uncertain about the effect of immunotherapy in overall survival and functional status. CONCLUSIONS The evidence is very uncertain about whether the benefits of using treatment with anticancer drugs outweigh their risks for patients with advanced pancreatic cancer. This uncertainty is further highlighted when considering immunotherapy or a second line of chemotherapy and thus, best supportive care would be an appropriate alternative. Future studies should assess their impact on all patient-important outcomes to inform patients in setting their goals of care.
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Affiliation(s)
- Josefina Salazar
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Javier Bracchiglione
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- CIBER Epidemiología Y Salud Pública (CIBERESP), Barcelona, Spain
- Interdisciplinary Centre for Health Studies CIESAL, Universidad de Valparaíso, Viña del Mar, Chile
| | - Olga Savall-Esteve
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Alba Antequera
- International Health Department, ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - David Bottaro-Parra
- Unitat de Cures Pal·Liatives de L'Institut d'Oncologia de La Catalunya Sud, Hospital Universitari Sant Joan de Reus, Tarragona, Spain
| | - Marta Gutiérrez-Valencia
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
| | | | - Carles Pericay
- Servicio de Oncología Médica, Fundació Assistencial Mûtua Terrassa, Terrassa - Barcelona, Spain
| | - Ariadna Tibau
- Oncology Department, Hospital de La Santa Creu I Sant Pau, Barcelona, Spain
- Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain
- Universitat Autònoma Barcelona, Barcelona, Spain
| | - Xavier Bonfill
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
- CIBER Epidemiología Y Salud Pública (CIBERESP), Barcelona, Spain.
- Universitat Autònoma Barcelona, Barcelona, Spain.
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Systemic oncological treatments in patients with advanced pancreatic cancer: a scoping review and evidence map. Support Care Cancer 2023; 31:100. [PMID: 36622453 PMCID: PMC9829581 DOI: 10.1007/s00520-022-07564-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/22/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE To identify, describe, and organise currently available evidence regarding systemic oncological treatments (SOTs) (chemotherapy, targeted/biological therapies, and immunotherapy) compared to best supportive care (BSC) for patients with advanced pancreatic cancer (PC). METHODS We conducted a scoping review and evidence mapping, adhering to PRISMA-ScR checklist. We searched MEDLINE, EMBASE, Cochrane Library, Epistemonikos, PROSPERO, and clinicaltrials.gov for eligible studies. We included systematic reviews (SRs), randomised controlled trials (RCTs), quasi-experimental, and observational studies evaluating SOTs compared to BSC or no treatment in patients with advanced PC. Two independent reviewers performed the screening process and data extraction. We developed evidence maps as an interactive visualization display, including the assessed interventions and outcomes. RESULTS Of the 50,601 records obtained from our search, we included 43 studies: 2 SRs, 16 RCTs, 4 quasi-experimental studies, 20 observational studies, and 1 protocol for a quasi-experimental study. Forty-two studies reported survival-related outcomes and most favoured SOTs, while five reported toxicity and most favoured BSC. Other patient-centred outcomes, such as quality of life, were scarcely reported. CONCLUSIONS This study highlights the current evidence gaps in studies assessing treatments for patients with advanced PC, mainly the lack of reports of non-survival-related outcomes, pointing out research areas that need further attention to make better recommendations for these patients.
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Salazar J, Pérez-Bracchiglione J, Salas-Gama K, Antequera A, Auladell-Rispau A, Dorantes-Romandía R, Meade AG, Jesús Quintana M, Requeijo C, Rodríguez-Grijalva G, Santero M, Acosta-Dighero R, Solà I, Urrútia G, Bonfill Cosp X. Efficacy of systemic oncological treatments in patients with advanced pancreatic cancer at high risk of dying in the short or medium-term: overview of systematic reviews. Eur J Cancer 2021; 154:82-91. [PMID: 34252759 DOI: 10.1016/j.ejca.2021.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/02/2021] [Accepted: 05/23/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Patients with advanced pancreatic cancer (PC) have a high risk of dying in the short or medium-term. This overview aimed to assess the evidence regarding systemic oncological treatments (SOT) versus supportive care for advanced PC. METHODS We searched for systematic reviews (SRs) in MEDLINE, Embase, The Cochrane Library, Epistemonikos, and PROSPERO. Two authors assessed eligibility independently. Data extraction and methodological quality assessment were conducted by one author and cross-checked by another one. We evaluated the overlap of primary studies, performed a de novo meta-analysis, and assessed the certainty of evidence. Primary outcomes were overall survival (OS), quality of life (QoL), functional status (FS), and toxicity. RESULTS We identified three SRs that assessed SOT versus supportive care in patients with advanced PC. All SRs had critically low methodological quality. At 12 months, OS improved with chemotherapy, radiotherapy followed by chemotherapy, and immunotherapy, but the certainty of the evidence supporting these findings is very low. The evidence on chemotherapy is very uncertain about its effects on QoL; it suggests a slight increase in toxicity and little to no difference in FS. The evidence on immunotherapy is very uncertain about its effects in toxicity. CONCLUSIONS The identified evidence is very uncertain about the benefits of oncological treatments on OS and QoL in patients with advanced PC with a high risk of dying in the short or medium-term, so its use should be proposed only to selected patients. Further studies that include a thorough assessment of patient-centred outcomes are needed.
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Affiliation(s)
- Josefina Salazar
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Javier Pérez-Bracchiglione
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; Interdisciplinary Centre for Health Studies (CIESAL), Universidad de Valparaiso, Viña Del Mar, Chile.
| | - Karla Salas-Gama
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Alba Antequera
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Ariadna Auladell-Rispau
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Rosario Dorantes-Romandía
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Adriana G Meade
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - María Jesús Quintana
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Carolina Requeijo
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | | | - Marilina Santero
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Roberto Acosta-Dighero
- School of Physiotherapy, Faculty of Health Sciences, Universidad San Sebastián, Santiago, Chile.
| | - Ivan Solà
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Gerard Urrútia
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Xavier Bonfill Cosp
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain.
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Choi JG, Nipp RD, Tramontano A, Ali A, Zhan T, Pandharipande P, Dowling EC, Ferrone CR, Hong TS, Schrag D, Fernandez-Del Castillo C, Ryan DP, Kong CY, Hur C. Neoadjuvant FOLFIRINOX for Patients with Borderline Resectable or Locally Advanced Pancreatic Cancer: Results of a Decision Analysis. Oncologist 2018; 24:945-954. [PMID: 30559125 PMCID: PMC6656457 DOI: 10.1634/theoncologist.2018-0114] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 11/15/2018] [Indexed: 12/15/2022] Open
Abstract
Decision‐analytic modeling can provide a methodologic platform that integrates the best available data to quantitatively explore clinical decisions by simulating a hypothetical clinical trial between competing strategies. This article analyzes a mathematical decision‐analytic model to estimate the long‐term clinical outcomes and cost‐effectiveness of neoadjuvant FOLFIRINOX compared with surgery followed by adjuvant gemcitabine monotherapy or gemcitabine/capecitabine for patients with potentially resectable pancreatic ductal adenocarcinoma. Background. The effectiveness and cost‐effectiveness of using neoadjuvant FOLFIRINOX (nFOLFIRINOX) for patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma (BR/LA PDAC) are unknown. Our objective was to determine whether nFOLFIRINOX is more effective or cost‐effective for patients with BR/LA PDAC compared with upfront resection surgery and adjuvant gemcitabine plus capecitabine (GEM/CAPE) or gemcitabine monotherapy (GEM). Materials and Methods. We performed a decision‐analysis to assess the value of nFOLFIRINOX versus GEM/CAPE or GEM using a mathematical simulation model. Model transition probabilities were estimated using published and institutional clinical data. Model outcomes included overall and disease‐free survival, quality‐adjusted life‐years (QALYs), cost in U.S. dollars, and cost‐effectiveness expressed as an incremental cost‐effectiveness ratio. Deterministic and probabilistic sensitivity analyses explored the uncertainty of model assumptions. Results. Model results found median overall survival (34.5/28.0/22.0 months) and disease‐free survival (15.0/14.0/13.0 months) were better for nFOLFIRINOX compared with GEM/CAPE and GEM. nFOLFIRINOX was the optimal strategy on an efficiency frontier, resulting in an additional 0.35 life‐years, or 0.30 QALYs, at a cost of $46,200/QALY gained compared with GEM/CAPE. Sensitivity analysis found that cancer recurrence and complete resection rates most affected model results, but were otherwise robust. Probabilistic sensitivity analyses found that nFOLFIRINOX was cost‐effective 92.4% of the time at a willingness‐to‐pay threshold of $100,000/QALY. Conclusion. Our modeling analysis suggests that nFOLFIRINOX is preferable to upfront surgery for patients with BR/LA PDAC from both an effectiveness and cost‐effectiveness standpoint. Additional clinical data that further define the long‐term effectiveness of nFOLFIRINOX are needed to confirm our results. Implications for Practice. Increasingly, neoadjuvant FOLFIRINOX has been used for borderline resectable and locally advanced pancreatic cancer with the goal of rendering them resectable and decreasing risk of recurrence. Despite many efforts to show the benefits of neoadjuvant over adjuvant therapies, clinical evidence to guide this decision is largely lacking. Decision‐analytic modeling can provide a methodologic platform that integrates the best available data to quantitatively explore clinical decisions by simulating a hypothetical clinical trial. This modeling analysis suggests that neoadjuvant FOLFIRINOX is preferable to upfront surgery and adjuvant therapies by various outcome metrics including quality‐adjusted life years, overall survival, and incremental cost‐effectiveness ratio.
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Affiliation(s)
- Jin G Choi
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Health Innovations Research and Evaluations Unit, Columbia University Medical Center, New York, NY, USA
| | - Ryan D Nipp
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Angela Tramontano
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ayman Ali
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tiannan Zhan
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pari Pandharipande
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Emily C Dowling
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah Schrag
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Carlos Fernandez-Del Castillo
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - David P Ryan
- Department of Medical Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Chin Hur
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA
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Di Costanzo F, Sdrobolini A, Gasperoni S. Possibilità Di Palliazione Nel Carcinoma Pancreatico. TUMORI JOURNAL 2018. [DOI: 10.1177/030089169908501s12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Francesco Di Costanzo
- Unità Operativa di Chemioterapia e Terapie Locoregionali dei Tumori, Dipartimento di Medicina Interna ed Oncologia, Azienda Ospedaliera Santa Maria, Terni, Italia
| | - Andrea Sdrobolini
- Unità Operativa di Chemioterapia e Terapie Locoregionali dei Tumori, Dipartimento di Medicina Interna ed Oncologia, Azienda Ospedaliera Santa Maria, Terni, Italia
| | - Sandra Gasperoni
- Unità Operativa di Chemioterapia e Terapie Locoregionali dei Tumori, Dipartimento di Medicina Interna ed Oncologia, Azienda Ospedaliera Santa Maria, Terni, Italia
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Chin V, Nagrial A, Sjoquist K, O'Connor CA, Chantrill L, Biankin AV, Scholten RJPM, Yip D. Chemotherapy and radiotherapy for advanced pancreatic cancer. Cochrane Database Syst Rev 2018; 3:CD011044. [PMID: 29557103 PMCID: PMC6494171 DOI: 10.1002/14651858.cd011044.pub2] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic cancer (PC) is a highly lethal disease with few effective treatment options. Over the past few decades, many anti-cancer therapies have been tested in the locally advanced and metastatic setting, with mixed results. This review attempts to synthesise all the randomised data available to help better inform patient and clinician decision-making when dealing with this difficult disease. OBJECTIVES To assess the effect of chemotherapy, radiotherapy or both for first-line treatment of advanced pancreatic cancer. Our primary outcome was overall survival, while secondary outcomes include progression-free survival, grade 3/4 adverse events, therapy response and quality of life. SEARCH METHODS We searched for published and unpublished studies in CENTRAL (searched 14 June 2017), Embase (1980 to 14 June 2017), MEDLINE (1946 to 14 June 2017) and CANCERLIT (1999 to 2002) databases. We also handsearched all relevant conference abstracts published up until 14 June 2017. SELECTION CRITERIA All randomised studies assessing overall survival outcomes in patients with advanced pancreatic ductal adenocarcinoma. Chemotherapy and radiotherapy, alone or in combination, were the eligible treatments. DATA COLLECTION AND ANALYSIS Two review authors independently analysed studies, and a third settled any disputes. We extracted data on overall survival (OS), progression-free survival (PFS), response rates, adverse events (AEs) and quality of life (QoL), and we assessed risk of bias for each study. MAIN RESULTS We included 42 studies addressing chemotherapy in 9463 patients with advanced pancreatic cancer. We did not identify any eligible studies on radiotherapy.We did not find any benefit for chemotherapy over best supportive care. However, two identified studies did not have sufficient data to be included in the analysis, and many of the chemotherapy regimens studied were outdated.Compared to gemcitabine alone, participants receiving 5FU had worse OS (HR 1.69, 95% CI 1.26 to 2.27, moderate-quality evidence), PFS (HR 1.47, 95% CI 1.12 to 1.92) and QoL. On the other hand, two studies showed FOLFIRINOX was better than gemcitabine for OS (HR 0.51 95% CI 0.43 to 0.60, moderate-quality evidence), PFS (HR 0.46, 95% CI 0.38 to 0.57) and response rates (RR 3.38, 95% CI 2.01 to 5.65), but it increased the rate of side effects. The studies evaluating CO-101, ZD9331 and exatecan did not show benefit or harm when compared with gemcitabine alone.Giving gemcitabine at a fixed dose rate improved OS (HR 0.79, 95% CI 0.66 to 0.94, high-quality evidence) but increased the rate of side effects when compared with bolus dosing.When comparing gemcitabine combinations to gemcitabine alone, gemcitabine plus platinum improved PFS (HR 0.80, 95% CI 0.68 to 0.95) and response rates (RR 1.48, 95% CI 1.11 to 1.98) but not OS (HR 0.94, 95% CI 0.81 to 1.08, low-quality evidence). The rate of side effects increased. Gemcitabine plus fluoropyrimidine improved OS (HR 0.88, 95% CI 0.81 to 0.95), PFS (HR 0.79, 95% CI 0.72 to 0.87) and response rates (RR 1.78, 95% CI 1.29 to 2.47, high-quality evidence), but it also increased side effects. Gemcitabine plus topoisomerase inhibitor did not improve survival outcomes but did increase toxicity. One study demonstrated that gemcitabine plus nab-paclitaxel improved OS (HR 0.72, 95% CI 0.62 to 0.84, high-quality evidence), PFS (HR 0.69, 95% CI 0.58 to 0.82) and response rates (RR 3.29, 95% CI 2.24 to 4.84) but increased side effects. Gemcitabine-containing multi-drug combinations (GEMOXEL or cisplatin/epirubicin/5FU/gemcitabine) improved OS (HR 0.55, 95% CI 0.39 to 0.79, low-quality evidence), PFS (HR 0.43, 95% CI 0.30 to 0.62) and QOL.We did not find any survival advantages when comparing 5FU combinations to 5FU alone. AUTHORS' CONCLUSIONS Combination chemotherapy has recently overtaken the long-standing gemcitabine as the standard of care. FOLFIRINOX and gemcitabine plus nab-paclitaxel are highly efficacious, but our analysis shows that other combination regimens also offer a benefit. Selection of the most appropriate chemotherapy for individual patients still remains difficult, with clinicopathological stratification remaining elusive. Biomarker development is essential to help rationalise treatment selection for patients.
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Affiliation(s)
- Venessa Chin
- Garvan Institute of Medical ResearchThe Kinghorn Cancer Centre384 Victoria Street DarlinghurstSydneyNSWAustralia2010
- St Vincent's HospitalSydneyNSWAustralia
| | - Adnan Nagrial
- Garvan Institute of Medical ResearchThe Kinghorn Cancer Centre384 Victoria Street DarlinghurstSydneyNSWAustralia2010
- The Crown Princess Mary Cancer CentreDarcy RoadWestmeadNSWAustralia2145
| | - Katrin Sjoquist
- University of SydneyNHMRC Clinical Trials CentreK25 ‐ Medical Foundation BuildingSydneyNSWAustralia2006
- Cancer Care Centre, St George HospitalMedical OncologySt George Hospital, Gray StKogarahAustraliaNSW 2217
| | - Chelsie A O'Connor
- St Vincent's HospitalSydneyNSWAustralia
- Genesis Cancer CareSydneyNSWAustralia
- Macquarie University HospitalSydneyAustralia
| | - Lorraine Chantrill
- The Kinghorn Cancer Centre, Garvan Institute of Medical ResearchDepartment of Pancreatic Cancer382 Victoria Street DarlinghurstSydneyNSWAustralia2010
| | - Andrew V Biankin
- University of GlasgowInstitute of Cancer SciencesWolfson Wohl Cancer Research CentreGarscube Estate, Switchback RoadGlasgowUKG61 1QH
- University of New South WalesSouth Western Sydney Clinical School, Faculty of MedicineLiverpoolNSWAustralia2170
- West of Scotland Pancreatic Unit and Glasgow Royal InfirmaryGlasgowUK
| | - Rob JPM Scholten
- Julius Center for Health Sciences and Primary Care / University Medical Center UtrechtCochrane NetherlandsRoom Str. 6.126P.O. Box 85500UtrechtNetherlands3508 GA
| | - Desmond Yip
- The Canberra HospitalDepartment of Medical OncologyYamba DriveGarranACTAustralia2605
- Australian National UniversityANU Medical SchoolActonACTAustralia0200
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Gupta S, Sathishkumar S, Ahmed MM. Influence of cell cycle checkpoints and p53 function on the toxicity of temozolomide in human pancreatic cancer cells. Pancreatology 2010; 10:565-79. [PMID: 20980775 PMCID: PMC2992636 DOI: 10.1159/000317254] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Accepted: 06/06/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND Though an increased efficacy of carmustine and temozolomide (TMZ) has been demonstrated by inactivation of O(6)-methylguanine-DNA methyltransferase (MGMT) with O(6)-benzyl-guanine (BG) in human pancreatic tumors refractive to alkylating agents, the regulatory mechanisms have not been explored. METHODS The effects of TMZ and BG on apoptosis, cell growth, the mitotic index, cell cycle distribution, and protein expression were studied by TUNEL, cell counting, flow cytometry, and Western blot analysis, respectively. RESULTS The wt-p53 human pancreatic tumor cell line Capan-2 and p53-efficient mouse embryonic fibroblasts (MEFs) were more responsive to treatment with TMZ + BG than mutant p53 Capan-1 and p53-null MEFs. S phase delay with a subsequent G2/M arrest was observed in Capans in response to BG + TMZ. The G1-to-S transition delay in Capan-2 was associated with p53-dependent apoptosis and was distinctly different from the presumed mismatch repair (MMR) killing operative during the G2/M arrest. The effect of p53 on BG + TMZ toxicity was supported by a marked change in apoptosis when p53 function was restored/inactivated. There was an early induction of MMR proteins in p53-efficient lines. CONCLUSION p53 provokes a classic proapoptotic response by delaying G1-to-S progression, but it may also facilitate cell killing by enhancing MMR-related cell cycle arrest and cell death.
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Affiliation(s)
- Seema Gupta
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, Fla., USA,Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, Fla., USA
| | | | - Mansoor M. Ahmed
- Department of Radiation Oncology, Miller School of Medicine, University of Miami, Miami, Fla., USA,Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, Fla., USA,*Mansoor M. Ahmed, PhD, Department of Radiation Oncology, 1475 NW 12th Ave (D-31) Miami, FL 33136 (USA), Tel. +1 305 243 5454, Fax +1 305 243 1854, E-Mail
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Yip D, Karapetis C, Strickland A, Steer CB, Goldstein D. WITHDRAWN: Chemotherapy and radiotherapy for inoperable advanced pancreatic cancer. Cochrane Database Syst Rev 2009; 2009:CD002093. [PMID: 19821291 PMCID: PMC10734272 DOI: 10.1002/14651858.cd002093.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pancreatic cancer has a poor prognosis. The benefit of chemotherapy, radiotherapy or both as a palliative treatment of advanced or relapsed disease is uncertain. OBJECTIVES To assess the effects of chemotherapy and/or radiotherapy in the management of pancreatic adenocarcinoma in people with inoperable advanced disease. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which includes the Cochrane Upper Gastrointestinal and Pancreatic Diseases (UGPD) Group Trials Register (The Cochrane Library 2005, Issue 1); CANCERLIT (1975-2002); MEDLINE (1966 to January 2005); and EMBASE (1980 to January 2005). We handsearched reference lists from trials revealed by electronic searches to identify further relevant trials. We searched published abstracts from relevant conference proceedings. We contacted colleagues and experts in the field, and asked them to provide details of outstanding clinical trials and any relevant unpublished materials. SELECTION CRITERIA Randomised controlled trials (single- or double-blind) in patients with advanced inoperable pancreatic cancer, in which one of the intervention types (chemotherapy or radiotherapy) was contrasted with either placebo or another type of intervention. Studies comparing non-chemotherapy agents such as biological agents, hormones, immunostimulants, vaccines and cytokines were excluded. DATA COLLECTION AND ANALYSIS Studies were assessed for eligibility and quality. Data were extracted by groups of two independent reviewers, with conflicts resolved by a third reviewer. Study authors were contacted for more information. MAIN RESULTS Fifty trials (7043 participants) were included. Chemotherapy significantly reduced the one-year mortality (odds ratio (OR) 0.37, 95% confidence interval (CI) 0.25 to 0.57, P value < 0.00001) when compared to best supportive care. Also, chemoradiation improved one year survival (0% versus 58%, P value 0.001) when compared to best supportive care. There was no significant difference in one-year mortality for 5FU alone versus 5FU combinations (OR 0.90, 95% CI 0.62 to 1.30); single-agent chemotherapy versus gemcitabine (OR 1.34, 95% CI 0.88 to 2.02, P value 0.17); or gemcitabine alone versus gemcitabine combinations (OR 0.88, 95% CI 0.74 to 1.05). However, subgroup analysis showed that platinum-gemcitabine combinations reduced six-month mortality compared to gemcitabine alone (OR 0.59, 95% CI 0.43 to 0.81, P value 0.001). A qualitative overview suggested that chemoradiation produced better survivals than either best supportive care or radiotherapy. Chemoradiation treatment was associated with more toxicity. AUTHORS' CONCLUSIONS Chemotherapy appears to prolong survival in people with advanced pancreatic cancer and can confer clinical benefits and improve quality of life. Combination chemotherapy did not improve overall survival compared to single-agent chemotherapy. Gemcitabine is an acceptable control arm for future trials investigating scheduling and combinations with novel agents. There is insufficient evidence to recommend chemoradiation in patients with locally advanced inoperable pancreatic cancer as a superior alternative to chemotherapy alone.
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Affiliation(s)
- Desmond Yip
- Medical Oncology Unit, The Canberra Hospital, Yamba Drive, Garran, ACT, Australia, 2605
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9
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Abstract
GOALS The aim of this study was to evaluate the prognostic significance of clinical and laboratory variables, and to investigate survival benefits for different treatment modalities in unresectable pancreatic cancer. BACKGROUND The majority of pancreatic cancers are found to be unresectable. Therefore, estimations of prognosis and decisions of treatment modalities are important in optimizing the various aspects of care. STUDY Three hundred and forty unresectable locally advanced, or metastatic pancreatic cancer patients were enrolled from January 1998 to January 2005 at the Seoul National University Hospital. RESULTS One hundred and five patients received chemotherapy only and 59 patients received concurrent chemoradiotherapy (CCRT). Age, performance status, tumor location, initial CA 19-9 level, American Joint Committee on Cancer stage, and treatment modality (supportive care only, chemotherapy, vs. CCRT) were found to have prognostic significance for overall survival (OS) by univariate analysis, whereas initial CA 19-9 level, stage, and treatment modality were identified as independent prognostic factors by multivariate analysis. In subgroup analysis, stage III patients treated by CCRT (median OS, 10.4 mo) or chemotherapy alone (11.3 mo) showed survival benefit over supportive care (6.4 mo), and stage IV patients treated by chemotherapy alone (6.4 mo) showed survival benefit over supportive care (3.1 mo). CONCLUSIONS Initial CA 19-9, American Joint Committee on Cancer stage, and treatment modality were independent prognostic factors of OS, and the patients who received chemotherapy or CCRT showed better survival than those who received supportive care only.
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10
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Sultana A, Smith CT, Cunningham D, Starling N, Neoptolemos JP, Ghaneh P. Meta-analyses of chemotherapy for locally advanced and metastatic pancreatic cancer. J Clin Oncol 2007; 25:2607-15. [PMID: 17577041 DOI: 10.1200/jco.2006.09.2551] [Citation(s) in RCA: 284] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE There are a large number of randomized controlled trials involving chemotherapy in the management of advanced pancreatic cancer. Several chemotherapeutic agents, either alone or in combination with other chemotherapy or novel agents, have been used. The aim of these meta-analyses was to examine the different therapeutic approaches, and the comparisons examined were as follows: chemotherapy versus best supportive care; fluorouracil (FU) versus FU combination chemotherapy; gemcitabine versus FU; and gemcitabine versus gemcitabine combination chemotherapy. METHODS Relevant trials were identified by searching databases, trial registers, and conference proceedings. The primary end point was overall survival. RESULTS One hundred thirteen randomized controlled trials were identified, of which 51 trials involving 9,970 patients met the inclusion criteria. Chemotherapy improved survival compared with best supportive care (hazard ratio [HR] = 0.64; 95% CI, 0.42 to 0.98). FU-based combination chemotherapy did not result in better overall survival compared with FU alone (HR = 0.94; 95% CI, 0.82 to 1.08). There was insufficient evidence of a survival difference between gemcitabine and FU, but the wide CI includes clinically important differences in both directions, making a clear conclusion difficult (HR = 0.75; 95% CI, 0.42 to 1.31). Survival was improved after gemcitabine combination chemotherapy compared with gemcitabine alone (HR = 0.91; 95% CI, 0.85 to 0.97). CONCLUSION There was a significant survival benefit for chemotherapy over best supportive care and gemcitabine combinations over gemcitabine alone. This supports the use of gemcitabine-based combination chemotherapy in the treatment of advanced pancreatic cancer.
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Affiliation(s)
- Asma Sultana
- Cancer Research UK Liverpool Cancer Trials Unit and Centre for Medical Statistics and Health Evaluation, University of Liverpool, Liverpool, United Kingdom
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11
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Yip D, Karapetis C, Strickland A, Steer CB, Goldstein D. Chemotherapy and radiotherapy for inoperable advanced pancreatic cancer. Cochrane Database Syst Rev 2006:CD002093. [PMID: 16855985 DOI: 10.1002/14651858.cd002093.pub2] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pancreatic cancer has a poor prognosis. The benefit of chemotherapy, radiotherapy or both as a palliative treatment of advanced or relapsed disease is uncertain. OBJECTIVES To assess the effects of chemotherapy and/or radiotherapy in the management of pancreatic adenocarcinoma in people with inoperable advanced disease. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which includes the Cochrane Upper Gastrointestinal and Pancreatic Diseases (UGPD) Group Trials Register (The Cochrane Library 2005, Issue 1); CANCERLIT (1975-2002); MEDLINE (1966 to January 2005); and EMBASE (1980 to January 2005). We handsearched reference lists from trials revealed by electronic searches to identify further relevant trials. We searched published abstracts from relevant conference proceedings. We contacted colleagues and experts in the field, and asked them to provide details of outstanding clinical trials and any relevant unpublished materials. SELECTION CRITERIA Randomised controlled trials (single- or double-blind) in patients with advanced inoperable pancreatic cancer, in which one of the intervention types (chemotherapy or radiotherapy) was contrasted with either placebo or another type of intervention. Studies comparing non-chemotherapy agents such as biological agents, hormones, immunostimulants, vaccines and cytokines were excluded. DATA COLLECTION AND ANALYSIS Studies were assessed for eligibility and quality. Data were extracted by groups of two independent reviewers, with conflicts resolved by a third reviewer. Study authors were contacted for more information. MAIN RESULTS Fifty trials (7043 participants) were included. Chemotherapy significantly reduced the one-year mortality (odds ratio (OR) 0.37, 95% confidence interval (CI) 0.25 to 0.57, P value < 0.00001) when compared to best supportive care. Also, chemoradiation improved one year survival (0% versus 58%, P value 0.001) when compared to best supportive care. There was no significant difference in one-year mortality for 5FU alone versus 5FU combinations (OR 0.90, 95% CI 0.62 to 1.30); single-agent chemotherapy versus gemcitabine (OR 1.34, 95% CI 0.88 to 2.02, P value 0.17); or gemcitabine alone versus gemcitabine combinations (OR 0.88, 95% CI 0.74 to 1.05). However, subgroup analysis showed that platinum-gemcitabine combinations reduced six-month mortality compared to gemcitabine alone (OR 0.59, 95% CI 0.43 to 0.81, P value 0.001). A qualitative overview suggested that chemoradiation produced better survivals than either best supportive care or radiotherapy. Chemoradiation treatment was associated with more toxicity. AUTHORS' CONCLUSIONS Chemotherapy appears to prolong survival in people with advanced pancreatic cancer and can confer clinical benefits and improve quality of life. Combination chemotherapy did not improve overall survival compared to single-agent chemotherapy. Gemcitabine is an acceptable control arm for future trials investigating scheduling and combinations with novel agents. There is insufficient evidence to recommend chemoradiation in patients with locally advanced inoperable pancreatic cancer as a superior alternative to chemotherapy alone.
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Affiliation(s)
- D Yip
- Canberra Hospital, Medical Oncology Unit, Yamba Drive, Garran, ACT, Australia 2605.
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12
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Lideståhl A, Permert J, Linder S, Bylund H, Edsborg N, Lind P. Efficacy of systemic therapy in advanced pancreatic carcinoma. Acta Oncol 2006; 45:136-43. [PMID: 16546858 DOI: 10.1080/02841860500537861] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
With a worldwide incidence of more than 200,000 cases and almost as many deaths, pancreatic carcinoma (PC) remains one of the leading causes of cancer deaths, especially in the Western world. Due to the late onset of symptoms, almost all patients suffer from disseminated disease at the time of diagnosis and only a minority will ever be candidates for radical surgery. Only about one tenth of the operated patients remain disease free. For these reasons, development of effective palliative systemic therapy is important. Almost a decade ago, gemcitabine replaced 5-Fu as the gold standard in systemic treatment of advanced PC. Since then, a number of trials have investigated the potential additional effect of several cytotoxic or targeted agents in combination with gemcitabine. As shown in this review, nearly all these trials have proved disappointing. This review provides an overview of the results of current phase III trials of gemcitabine based systemic therapy. Furthermore, we discuss the role of systemic therapy compared to BSC only and the potential future role of targeted therapies.
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Affiliation(s)
- Anders Lideståhl
- Department of Oncology, Karolinska University Hospital-Huddinge, Stockholm, Sweden.
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13
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Affiliation(s)
- Günter Schneider
- II. Department of Internal Medicine, Technical University of Munich, Germany
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14
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Abstract
Pancreatic cancer is a common, highly lethal disease that is rising in incidence. Chemotherapy based on 5-fluorouracil (5-FU) has been shown to prolong survival in advanced pancreatic cancer. Gemcitabine improves major symptoms and survival outcomes compared with bolus 5-FU. Many novel small molecules are being widely and actively researched. These compounds are based on classical mechanisms of action as well as biological therapies targeting novel cellular survival pathways, and include fluoropyrimidines, nucleoside cytidine analogues, platinum analogues, topoisomerase-inhibitors, antimicrotubule agents, proteasome inhibitors, vitamin D analogues, arachidonic acid pathway inhibitors, histone deacytylator inhibitors, farnesyltransferase inhibitors and epidermal growth factor receptor therapies. Adjuvant chemotherapy has also demonstrated the best survival outcomes following resection compared to other adjuvant or neo-adjuvant strategies such as radiation-based treatments. These benefits are superimposed on the dramatic increase in resectability rates and reduction in post-operative mortality achieved by centralisation of treatment in high-volume speciality centres. Newer 'small-molecule' drugs as well as the latest 'large-molecule' biological agents hold considerable promise for the future. Real advances are anticipated over the next five years but are dependent on large randomised controlled trials for success.
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Affiliation(s)
- S Shore
- University of Liverpool, Royal Liverpool University Hospital, Liverpool, UK
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15
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el-Rayes BF, Shields AF, Vaitkevicius V, Philip PA. Developments in the systemic therapy of pancreatic cancer. Cancer Invest 2003; 21:73-86. [PMID: 12643012 DOI: 10.1081/cnv-120016406] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Pancreatic adenocarcinoma is the fourth leading cause of cancer mortality in the United States of America. Progress in the treatment of this disease in the past several decades has been very modest. Several new agents with activity against pancreatic cancer have been identified. Of these, gemcitabine is the most promising agent when used in combination with other drugs. Pilot phase II studies combining gemcitabine with 5-flourouracil, irinotecan, docetaxel, or cisplatin show improved outcomes in objective response rates and survival that need to be confirmed in larger randomized studies. Advancement in the understanding of the molecular biology of neoplasia in recent years has helped identify several molecular targets for future new drug development in pancreatic cancer. Assessment of response to therapy of pancreatic cancer has been a difficult challenge. Functional imaging with techniques such as positron emission tomography (PET) may yield a more precise and timely objective evaluation of response to treatment.
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Affiliation(s)
- B F el-Rayes
- Division of Hematology and Oncology, Karmanos Cancer Institute, Wayne State University, 4100 John R Street, Detroit, MI 48201, USA
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16
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Abstract
The incidence of adenocarcinoma of the pancreas has risen steadily over the past four decades. Since pancreatic cancer is usually diagnosed at an advanced stage and because of the lack of effective therapies, the prognosis of such patients is extremely poor. Despite advances in our understanding of the molecular biology of pancreatic cancer, the systemic treatment of this disease remains unsatisfactory. Conventional chemotherapy has not produced dramatic improvements in response rates or patient survival. New treatment strategies are clearly needed. This paper will review emerging therapies for pancreatic carcinoma. A deeper understanding of the molecular biology of cell growth and proliferation, as well as of neoplastic cell transformation, has led to advances in several areas, including the use of hormones and antihormones as adjuvant therapy; inhibition of tumour growth and metastasis by inhibitors of matrix metalloproteases and angiogenesis, and by small molecules, such as retinoids, which interfere with progression through the cell cycle; immunotherapy with monoclonal antibodies; disruption of intracellular signal transduction with farnesyltransferase inhibitors; and, finally, gene therapy with specifically designed vaccines.
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17
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Magee CJ, Ghaneh P, Neoptolemos JP. Surgical and medical therapy for pancreatic carcinoma. Best Pract Res Clin Gastroenterol 2002; 16:435-55. [PMID: 12079268 DOI: 10.1053/bega.2002.0317] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Progress on the treatment of pancreatic ductal adenocarcinoma has involved advances in medical and surgical care with important contributions from disciplines such as radiology and intensive care. In the last decade large randomized controlled trials have been undertaken that demonstrate the improved patient outcomes. There is an increased risk of pancreatic cancer in chronic pancreatitis, hereditary pancreatitis and a variety of familial cancer syndromes. The optimum outcome from pancreatic cancer needs management by multidisciplinary teams in regional specialist units. Endoscopic stenting, good pain relief and pancreatic enzyme supplementation are the basis of care in advanced pancreatic cancer. Chemotherapy prolongs survival in advanced pancreatic cancer with little to be gained using drugs other than 5FU. Resection, if possible, prolongs life and provides the best quality of life. Adjuvant chemoradiotherapy is of no benefit but chemotherapy may improve survival. Alongside the evolution in clinical management has been the elucidation of the molecular events that underlie pancreatic cancer and this knowledge has guided the introduction of targeted treatments for pancreatic cancer.
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Affiliation(s)
- Conor J Magee
- Department of Surgery, University of Liverpool, 5th Floor UCD Building, Royal Liverpool University Hospital, Daulby Street, Liverpool, L69 3GA, UK
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18
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Magee CJ, Ghaneh P, Hartley M, Sutton R, Neoptolemos JP. The role of adjuvant therapy for pancreatic cancer. Expert Opin Investig Drugs 2002; 11:87-107. [PMID: 11772324 DOI: 10.1517/13543784.11.1.87] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Patients with pancreatic cancer have a very poor outlook. There have been major advances in the standard surgical treatment of this disease, resulting in decreased post-operative mortality and morbidity. The use of chemotherapy and radiotherapy has been developed to increase long-term patient survival following potentially curative resection. The standard chemotherapeutic agent is 5-fluorouracil (5-FU), although newer cytotoxic agents are in clinical trials for advanced cancer. Initial studies of adjuvant therapy have been based on small numbers of patients, but recently two large European randomised controlled trials of adjuvant therapy (EORTC and ESPAC-1) have been completed. These suggest that adjuvant chemotherapy has a significant survival advantage over resection alone but chemoradiotherapy does not. Promising new agents are being developed and tested mainly in clinical trials of advanced pancreatic cancer. The results of large-scale randomised controlled trials to assess adjuvant therapies for pancreatic cancer demonstrate the great surgical and oncological progress that has been made over the past decade.
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Affiliation(s)
- Conor J Magee
- Department of Surgery, University of Liverpool, 5th Floor UCD Building, Daulby Street, Liverpool, L69 3GA, UK
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19
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Adsay NV, El-Rayes BF, Philip PA. Pancreatic cancer: the evolving role of systemic therapy. Expert Opin Pharmacother 2001; 2:1939-47. [PMID: 11825326 DOI: 10.1517/14656566.2.12.1939] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Pancreatic adenocarcinoma is the fourth leading cause of cancer mortality in the US. The outcome for patients with pancreatic cancer has not essentially altered over the past few decades. Several new drugs with activity against pancreatic cancer have recently been identified for use in palliative settings. Of these, gemcitabine is the most widely used agent against the disease, but its benefit is very modest. Pilot Phase II studies combining gemcitabine with 5-fluorouracil (5-FU), irinotecan, docetaxel or cisplatin show improved outcomes that need to be confirmed in randomised studies. Concurrent administration of gemcitabine and external beam radiation therapy (EBRT) for locally advanced pancreatic cancer is feasible and is currently undergoing efficacy evaluations. Current research in pancreatic cancer involves newer dosing schedules of gemcitabine, and combinations of gemcitabine with novel agents. Ultimately, better understanding of the molecular biology of pancreatic neoplasia will identify potential cellular targets for future development of new agents for pancreatic cancer.
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Affiliation(s)
- N V Adsay
- Karmanos Cancer Institute, Wayne State University, 4100 John R Street, Detroit, MI 48201, USA
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20
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Ghaneh P, Slavin J, Sutton R, Hartley M, Neoptolemos JP. Adjuvant therapy in pancreatic cancer. World J Gastroenterol 2001; 7:482-9. [PMID: 11819814 PMCID: PMC4688658 DOI: 10.3748/wjg.v7.i4.482] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2000] [Revised: 06/08/2000] [Accepted: 06/15/2000] [Indexed: 02/06/2023] Open
Abstract
The outlook for patients with pancreatic cancer has been grim. There have been major advances in the surgical treatment of pancreatic cancer, leading to a dramatic reduction in post-operative mortality from the development of high volume specialized centres. This stimulated the study of adjuvant and neoadjuvant treatments in pancreatic cancer including chemoradiotherapy and chemotherapy. Initial protocols have been based on the original but rather small GITSG study first reported in 1985. There have been two large European trials totalling over 600 patients (EORTC and ESPAC-1) that do not support the use of chemoradiation as adjuvant therapy. A second major finding from the ESPAC-1 trial (541 patients randomized) was some but not conclusive evidence for a survival benefit associated with chemotherapy. A third major finding from the ESPAC-1 trial was that the quality of life was not affected by the use of adjuvant treatments compared to surgery alone. The ESPAC-3 trial aims to assess the definitive use of adjuvant chemotherapy in a randomized controlled trial of 990 patients.
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Affiliation(s)
- P Ghaneh
- Department of Surgery, University of Liverpool, 5th Floor UCD Building, Daulby Street, Liverpool, L69 3GA, UK
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21
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Marantz A, Jovtis S, Almira E, Balbiani L, Castilla JL, Fein L, Lewi D, Pasccon G, Pinckevicius R, Uranga G, Abal M, Muiño M, Reale M, Agusto S, Lastiri F. Phase II Study of Gemcitabine, 5-Fluorouracil, and Leucovorin in Patients With Pancreatic Cancer. Semin Oncol 2001. [DOI: 10.1016/s0093-7754(01)80008-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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22
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Melville A, Morris E, Forman D, Eastwood A. Management of upper gastrointestinal cancers. Qual Health Care 2001; 10:57-64. [PMID: 11239144 PMCID: PMC1743416 DOI: 10.1136/qhc.10.1.57] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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23
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Mulvihill SJ. Pancreas. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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24
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Burch PA, Ghosh C, Schroeder G, Allmer C, Woodhouse CL, Goldberg RM, Addo F, Bernath AM, Tschetter LK, Windschitl HE, Cobau CD. Phase II evaluation of continuous-infusion 5-fluorouracil, leucovorin, mitomycin-C, and oral dipyridamole in advanced measurable pancreatic cancer: a North Central Cancer Treatment Group Trial. Am J Clin Oncol 2000; 23:534-7. [PMID: 11039519 DOI: 10.1097/00000421-200010000-00021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
At present there remains a need for more effective systemic therapy in advanced pancreatic cancer. Some studies have suggested that infusional chemotherapy schedules and biomodulation of 5-fluorouracil (5-FU) may improve the therapeutic outcome in advanced colon cancer. One such regimen that uses continuous infusion 5-FU, weekly leucovorin, daily dipyridamole, and intermittent mitomycin-C has activity in both colon and unresectable pancreatic carcinoma. The intent of this trial was to test the effectiveness of this four-drug regimen in advanced pancreatic cancer. Patients received 5-FU 200 mg/m2 daily by continuous infusion, leucovorin 30 mg/m2 IV weekly, mitomycin-C 10 mg/m2 day 1, and dipyridamole 75 mg orally four times daily for 5 weeks. After a 1-week break, treatment cycles were repeated every 6 weeks. Eligibility included biopsy-proven advanced measurable pancreatic cancer, Eastern Cooperative Oncology Group performance status 0 and 2, and no prior systemic chemotherapy. Of 46 evaluable patients, 9 partial responses and 1 complete tumor response were seen, for an overall response rate of 22% (95% confidence interval 11-36%). The median survival in the group of 50 patients registered to this trial was 4.6 months, with a range of 0.33 to 40.2 months. Toxicity was manageable, with the most common toxicities (> or =grade III National Cancer Institute Common Toxicity Criteria) being anorexia (13%), stomatitis (17%), and hand-foot syndrome (13%). Of note, little severe hematologic toxicity and no significant headaches were reported. Although some patients did respond, the therapeutic results are not encouraging enough to take this regimen to phase III testing.
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Affiliation(s)
- P A Burch
- Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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25
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Di Costanzo F, Canaletti R, Sdrobolini A, Olmeo N, Luppi G, Pucci F, Cavicchi F, Gasperoni S, Rodinò C, Zironi S, Angiona S, Contu A. Modulation of fluorouracil by methotrexate, leucovorin, and cisplatin (M-FLP) in the treatment of advanced pancreatic cancer: a phase II study of the Italian Oncology Group for Clinical Research (GOIRC). Am J Clin Oncol 2000; 23:314-8. [PMID: 10857901 DOI: 10.1097/00000421-200006000-00022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The objective of this trial was to evaluate the activity and tolerability of biomodulation of 5-fluorouracil by leucovorin, methotrexate, and platinum in patients with advanced measurable disease. Thirty-five patients with histologically or cytologically proven adenocarcinoma of the pancreas were treated with methotrexate (100 mg/m2 in 500 ml 5% dextrose in a 2-hour infusion, day 1), 5-fluorouracil (800 mg/m2/day, i.v. in continuous infusion from days 2 to 5) plus 1-leucovorin (7.5 mg/m2 given per os every 6 hours, from days 2 to 5) and platinum (60 mg/m2 i.v., day 2), every 28 days. Four partial responses (12%; exact 95% confidence interval: 1-23%) were obtained in 34 evaluable patients with a median survival time of 49 weeks (range, 20-77 weeks). Ten (29%) of 34 patients had stable disease. Median time to treatment failure from the beginning of therapy was 11 weeks (range, 4-59 weeks) and median survival time was 20 weeks (range, 4-77 weeks). The most common grade III-IV toxicities were diarrhea (15%), stomatitis (41%), and vomiting (17%). Hematologic toxicity was mild. There were no therapy-related deaths. In conclusion, this trial did not report an increase or improvement in response rate and survival rates, and this regimen cannot be recommended as effective therapy for advanced pancreatic cancer.
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26
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Abstract
The incidence of adenocarcinoma of the pancreas has risen steadily over the past 4 decades. Since pancreatic cancer is diagnosed at an advanced stage, and because of the lack of effective therapies, the prognosis of such patients is extremely poor. Despite advances in our understanding of the molecular biology of pancreatic cancer, the systemic treatment of this disease remains unsatisfactory. Conventional chemotherapy has not produced dramatic improvements in response rates or patient survival. New treatment strategies are clearly needed. This paper reviews emerging therapies for pancreatic carcinoma. A more profound understanding of the molecular biology of cell growth and proliferation, as well as of neoplastic cell transformation, has led to advances in several areas, including the use of somatostatin analogues and antiandrogens as adjuvant therapy; inhibition of tumour growth and metastasis by inhibitors of matrix metalloproteinases and angiogenesis, and by small molecules such as retinoids, which interfere with progression through the cell cycle; immunotherapy with monoclonal antibodies; disruption of intracellular signal transduction with farnesyltransferase inhibitors; and finally gene therapy with specifically designed vaccines.
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Affiliation(s)
- L Rosenberg
- The Pancreatic Diseases Centre, Montreal General Hospital, McGill University Health Centre, Quebec, Canada.
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27
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Chang KJ, Nguyen PT, Thompson JA, Kurosaki TT, Casey LR, Leung EC, Granger GA. Phase I clinical trial of allogeneic mixed lymphocyte culture (cytoimplant) delivered by endoscopic ultrasound-guided fine-needle injection in patients with advanced pancreatic carcinoma. Cancer 2000; 88:1325-35. [PMID: 10717613 DOI: 10.1002/(sici)1097-0142(20000315)88:6<1325::aid-cncr8>3.0.co;2-t] [Citation(s) in RCA: 168] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND To the authors' knowledge, there are no other published clinical studies that have employed either systemic or local biologic response modifiers in the treatment of patients with pancreatic carcinoma. The purpose of this study was to determine the feasibility and safety of allogeneic mixed lymphocyte culture (cytoimplant) delivered by endoscopic ultrasound (EUS)-guided fine-needle injection (FNI) in patients with advanced pancreatic carcinoma. METHODS Eight patients with unresectable adenocarcinoma of the pancreas were enrolled: 4 patients in Stage II, 3 in Stage III, and 1 in Stage IV. Cytoimplants were delivered locally into the tumor using a novel EUS-guided FNI technique. Escalating doses of 3, 6, or 9 billion cells were implanted into the pancreatic tumor by a single EUS-guided FNI. Toxicity (modified National Cancer Institute criteria) was assessed at Day 1, Week 1, and Months 1 and 3. Clinical endpoints included Karnofsky performance status (KPS), CA 19-9, tumor response (computed tomography and/or EUS), and survival with follow-up examinations and imaging tests on months 3, 6, 9, 12, and 24. RESULTS There were no bone marrow, hemorrhagic, infectious, renal, cardiac, or pulmonary toxicities. There were 3 transient Grade 3 gastrointestinal toxicities, and 3 patients had transient episodes of hyperbilirubinemia that were reversed by replacement of biliary stents. Seven of 8 patients (86%) experienced low grade fever that responded to acetaminophen, and all fever was resolved within the first 4 weeks. There were no procedure-related complications. There were 2 partial responses and 1 minor response, with a median survival of 13.2 months. CONCLUSIONS A single injection of cytoimplant immunotherapy by EUS-guided FNI appears to be feasible and is not associated with substantial toxicity.
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Affiliation(s)
- K J Chang
- Gastrointestinal Oncology, Department of Medicine, University of California-Irvine, Chao Family Comprehensive Cancer Center, Orange, California 92868, USA
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28
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DiMagno EP, Reber HA, Tempero MA. AGA technical review on the epidemiology, diagnosis, and treatment of pancreatic ductal adenocarcinoma. American Gastroenterological Association. Gastroenterology 1999; 117:1464-84. [PMID: 10579989 DOI: 10.1016/s0016-5085(99)70298-2] [Citation(s) in RCA: 252] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the Committee in March 1999 and by the AGA Governing Board in May 1999.
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29
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30
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Lombard-Bohas C, Mornex F, Saurin JC. [Locally advanced adenocarcinoma of the pancreas: current therapeutic modalities]. Cancer Radiother 1998; 1:547-54. [PMID: 9587388 DOI: 10.1016/s1278-3218(97)89637-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pancreatic cancer still have bad prognosis. At the time of diagnosis, less than 10% of patients can undergo surgery with an overall 5-year survival rate of less than 2%. For patients with localized pancreatic adenocarcinoma, the combination of radiation therapy and chemotherapy has been shown to control symptoms and to enhance patient survival. This treatment should be proposed to all the patients with good performance status and without icterus. Pain management should be optimized and often need morphinic and co-antalgic (anticonvulsivants, steroids) consumption. The celiac plexus block with alcohol gives an excellent pain relief and should be more frequently used.
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Affiliation(s)
- C Lombard-Bohas
- Unité d'oncologie médicale, CHU Edouard-Herriot, Lyon, France
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31
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Affiliation(s)
- C Kollmannsberger
- University of Tuebingen Medical Center, Department of Haematology-Oncology, Germany
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Von Hoff DD, Goodwin AL, Garcia L. Advances in the treatment of patients with pancreatic cancer: improvement in symptoms and survival time. The San Antonio Drug Development Team. Br J Cancer 1998; 78 Suppl 3:9-13. [PMID: 9717985 PMCID: PMC2062801 DOI: 10.1038/bjc.1998.748] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Pancreatic cancer is a major cause of death from cancer in both men and women in the USA and Europe. The disease causes pain and has a significant impact on the performance status of the patient. In a randomized trial vs 5-fluorouracil, the novel nucleoside analogue gemcitabine (GEMZAR) has been shown to provide clinical benefit for patients (decreased pain and improved performance status) as well as to improve the time to tumour progression and survival for patients with the disease. There are also other new agents that are presented in this discussion, such as the multi-targeted antifolate MTA, capecitabine and the ONYX-015 adenovirus, which replicates in, and kills, only p53-abnormal cells, which have the potential to have an impact on this terrible disease.
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Affiliation(s)
- D D Von Hoff
- Institute for Drug Development, Cancer Therapy & Research Center, San Antonio, Texas 78245, USA
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Rosenberg L. Treatment of pancreatic cancer. Promises and problems of tamoxifen, somatostatin analogs, and gemcitabine. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1997; 22:81-93. [PMID: 9387029 DOI: 10.1007/bf02787465] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The clinical problem posed by pancreatic cancer is introduced, and the epidemiology and pathology of the disease are briefly presented. The natural history of this tumor is then described in order to highlight the deficiencies of current therapeutic modalities. The extremely poor results of the early drug trials are reviewed, followed by a detailed discussion and critique of the trials of novel treatments that include gemcitabine, somatostatin analogs, and tamoxifen. Finally, areas for future development are indicated.
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Affiliation(s)
- L Rosenberg
- Department of Surgery and Medicine, McGill University, Montreal, Canada
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34
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Adjuvante Chemo- und Radiotherapie beim Pankreaskarzinom. Eur Surg 1997. [DOI: 10.1007/bf02621321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Fennelly JJ. Being honest with the patient and ourselves: do we give our patients accurate insight into anticipated results of treatment? An Irish perspective. Ann N Y Acad Sci 1997; 809:393-9. [PMID: 9103590 DOI: 10.1111/j.1749-6632.1997.tb48102.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Glimelius B, Hoffman K, Sjödén PO, Jacobsson G, Sellström H, Enander LK, Linné T, Svensson C. Chemotherapy improves survival and quality of life in advanced pancreatic and biliary cancer. Ann Oncol 1996; 7:593-600. [PMID: 8879373 DOI: 10.1093/oxfordjournals.annonc.a010676] [Citation(s) in RCA: 602] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In certain patients with pancreatic and biliary cancer, chemotherapy may relieve tumour-related symptoms, improve quality of life and possibly prolong survival. The extent of these improvements is not completely known in spite of the extensive use of this treatment modality. The aim of this study was to estimate any gain in the quantity and quality of life produced by chemotherapy in patients with pancreatic and biliary cancer. PATIENTS AND METHODS Between January 1991 and February 1995, 90 eligible patients with pancreatic or biliary cancer were randomized to either chemotherapy in addition to best supportive care or to best supportive care. Chemotherapy was allowed in the latter group if the supportive measures did not lead to palliation. Chemotherapy was either sequential 5-fluorouracil/leucovorin combined with etoposide (FELv) or, in elderly and poor performance patients, the same regimen without etoposide (FLv). Quality of life was evaluated with the EORTC-QLQ-C30 instrument. RESULTS Mean scale scores in the QLQ-C30 improved more often/deteriorated less frequently in the chemotherapy group than in the best supportive care group. More patients in the chemotherapy group (36%, 17/49) had an improved or prolonged high quality of life for a minimum period of 4 months compared to those in the best supportive care group (10%, 4/41, P < 0.01). Overall survival was significantly longer in the chemotherapy group (median 6 vs. 2.5 months, P < 0.01). Also, the quality-adjusted survival time was longer for patients randomized to chemotherapy (median 4 vs. 1 months, P < 0.01). The effects were seen both in pancreatic and biliary cancer. CONCLUSIONS The results show that chemotherapy can add to both quantity and quality of life in advanced pancreatic and biliary cancer. The number of patients who benefit from treatment is, however, still limited; for this reason careful selection before, and close monitoring during, treatment are necessary.
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Affiliation(s)
- B Glimelius
- Department of Oncology, University of Uppsala, Sweden
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Abstract
BACKGROUND In early phase II trials in advanced pancreatic cancer, gemcitabine demonstrated modest antitumor activity. The investigators in these studies reported that gemcitabine should be studied further in view of the degree and frequency of symptomatic improvement observed, the durability of some of the remissions, and the favorable toxicity profile. METHODS In order to quantify such symptomatic improvement, a rigorous endpoint of Clinical Benefit was developed that incorporated measures including pain intensity, analgesic consumption and performance status, which have been shown to be reliable and valid endpoints in other studies. RESULTS Two trials have been conducted using this methodology in patients with advanced pancreatic carcinoma. CONCLUSIONS The results of these studies suggest that gemcitabine is the first cytotoxic agent with any meaningful impact on survival and disease-related symptoms in advanced pancreatic adenocarcinoma. The degree of improvement seen is one which patients with cancer often consider to be most important. Further studies will be required to define more fully the role of gemcitabine in the treatment of pancreatic cancer.
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Affiliation(s)
- M Moore
- Department of Medicine, Princess Margaret Hospital, University of Toronto, Canada
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Abstract
BACKGROUND Pancreatic cancer is an aggressive disease and its patients typically have a short survival, usually marked by pain and rapid debilitation. The disease has been considered relatively chemoresistant, although many chemotherapy regimens have been described. METHODS Clinical results with chemotherapy, since the first publication of response in 1960, were reviewed for efficacy and toxicity. Emphasis was given to prospective trials with adequate power and clear evaluation criteria and endpoints. RESULTS Published response rates vary enormously in this disease, with rates in earlier single-institution trials tending to be much higher than those in studies with stringent response criteria, particularly recent cooperative group trials. Using stringent criteria, the upper limit of the objective response rate is approximately 20%. No convincing improvements in median survival can yet be attributed to chemotherapy. Few trials have measured quality of life, but symptomatic palliation rates may exceed objective response rates. Some low-toxicity regimens (such as those based on infusional 5-FU) yield response rates as high as some more toxic combinations. CONCLUSIONS Many early trials significantly overstate the efficacy of chemotherapy for patients with pancreatic cancer, apparently due to flexibility of response criteria. However, useful symptomatic palliation may occur even without an objective partial response. It is possible that slow resolution of the desmoplastic component of these tumors may underestimate tumor killing. Thus, quality of life is an important parallel endpoint (with survival and response) in chemotherapy trials in this disease.
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Affiliation(s)
- J D Ahlgren
- Division of Hematology and Oncology, The George Washington University Medical Center, Washington, DC 20037, USA
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André T, Lotz JP, Bouleuc C, Azzouzi K, Houry S, Hannoun L, See J, Esteso A, Avenin D, Izrael V. Phase II trial of 5-fluorouracil, leucovorin and cisplatin for treatment of advanced pancreatic adenocarcinoma. Ann Oncol 1996; 7:173-8. [PMID: 8777174 DOI: 10.1093/oxfordjournals.annonc.a010545] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Advanced pancreatic adenocarcinoma is a rapidly fatal disease for which an active chemotherapy regimen is sought. Here we report the outcome of a phase II trial to assess the toxicity and efficacy of a combination of 5-fluorouracil (5-FU), leucovorin and cisplatin (CDDP). METHODS A regimen combining leucovorin (200 mg/m2/d x 5d), 5-FU (375 mg/m2/d x 5d in a 2-hour infusion) and CDDP (15 mg/m2/d x 5d) was given to 52 patients with histologically-proven, previously untreated, locally advanced (n = 13) and/or metastatic (n = 39) pancreatic adenocarcinoma. RESULTS Of 48 patients evaluable for response, 10 achieved partial responses, for an overall response rate of 21% (95% CI 9.5%-32.5%), and a palliative effect was observed in 52%. The median survival was 9.5 months (18 months for locally-advanced and 5 months for metastatic disease) with a 1-year survival of 34.6% and a median progression-free survival of 4.5 months. Chemotherapy was well tolerated with grades 3 or 4 nausea/vomiting in 12%, diarrhea in 6%, anaemia in 17%, neutropenia in 12%, and thrombocytopenia in 10%. Eleven patients (21%) had Grade 2 peripheral neuropathy. CONCLUSION The combination of leucovorin, 5-FU and CDDP seems to be an effective palliative treatment, with moderate toxic effects, in advanced pancreatic adenocarcinoma.
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Affiliation(s)
- T André
- Department of Medical Oncology, Tenon Hospital, Paris, France
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Lionetto R, Pugliese V, Bruzzi P, Rosso R. No standard treatment is available for advanced pancreatic cancer. Eur J Cancer 1995; 31A:882-7. [PMID: 7646915 DOI: 10.1016/0959-8049(94)00445-5] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
All randomised trials, published from 1980 to 1993, of treatments in advanced and locally unresectable exocrine pancreatic carcinoma were critically reviewed to identify the most effective therapeutic strategy for use as a control arm in randomised trials for such patients. All the published randomised trials on patients with pancreatic cancer were identified, and the treatment results summarised by means of published methodological guidelines. Twenty-seven reports, including 21 on hormonal or chemotherapy and six on radio/chemotherapy were identified. Very different treatment programmes were used in the trials, without a rationale sequence for testing hypotheses. Furthermore, several methodological drawbacks undermined both the internal and the external validity of these studies. Therefore, no meta-analysis can be conducted, combining the results of the randomised controlled trials in pancreatic cancer published from 1990 to 1993; no standard treatment is currently available for patients with advanced pancreatic cancer; future studies should screen new drugs or new combinations; and an untreated control group should be included in future comparative studies until real advantages in terms of better quality of life or improved survival are demonstrated.
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Affiliation(s)
- R Lionetto
- Department of Clinical Epidemiology and Trials, National Institute for Cancer Research, Genoa, Italy
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Friess H, Büchler M, Kiesel L, Krüger M, Beger HG. LH-RH receptors in the human pancreas. ACTA ACUST UNITED AC 1991. [DOI: 10.1007/bf02924118] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
The course of 196 patients with proven carcinoma of the pancreas seen at Yale New Haven Hospital from 1972 to 1982 was analyzed. Only 73% of the patients were preoperatively expected to have cancer of the pancreas. The patients who underwent resection had the longest mean survival but also the longest total hospital stay. Twenty-seven patients survived 1 year or more, but nonresected patients constituted 81.5% of this group. The only 5-year survivor did not undergo resection. Forty-seven percent of patients who survived 1 year and had not undergone gastroduodenal bypass, developed duodenal obstruction. It was not possible to identify a subset of patients with a favorable prognosis. A review totaling approximately 37000 patients, of whom 4100 had undergone resections, revealed only 156 survivors, 12 of whom had not been resected, for an overall survival rate of only 0.4%. No author had more than 3.4% of the total number of patients as 5-year survivors.
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Affiliation(s)
- B Gudjonsson
- Yale University School of Medicine, New Haven, Connecticut
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Woodruff KH, Castro JR, Quivey JM, Saunders WM, Chen GT, Lyman JT, Pitluck S, Tobias CA, Walton RE, Peters TC. Postmortem examination of 22 pancreatic carcinoma patients treated with helium ion irradiation. Cancer 1984; 53:420-5. [PMID: 6318947 DOI: 10.1002/1097-0142(19840201)53:3<420::aid-cncr2820530309>3.0.co;2-d] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Postmortem findings are available in this report in 22 patients with pancreatic carcinoma treated with helium ions at Lawrence Berkeley Laboratory; California. This represents the largest group evaluated histologically in the literature and is the first report evaluating effects of particle radiation in pancreatic tissue. Patient survival after therapy averaged 9 months. Most died of infection and/or pulmonary emboli. Local control was achieved in 27%. The pancreatic tumors had histologically more severe radiation changes than nontumor bearing pancreas. Irradiated bone marrow was severely hypocellular, and irradiated skin was atrophic. Five patients had radiation injury in the gastrointestinal tract. The spinal cord, liver, and kidneys showed no damage. This study demonstrates the safety of helium particle irradiation with present therapeutic planning. Injury to tumor was seen without excessive damage to adjacent tissues.
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Bukowski RM, Balcerzak SP, O'Bryan RM, Bonnet JD, Chen TT. Randomized trial of 5-fluorouracil and mitomycin C with or without streptozotocin for advanced pancreatic cancer. A Southwest Oncology Group study. Cancer 1983; 52:1577-82. [PMID: 6225508 DOI: 10.1002/1097-0142(19831101)52:9<1577::aid-cncr2820520906>3.0.co;2-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
A prospective randomized trial comparing streptozotocin, mitomycin C, and 5-FU (SMF) with mitomycin C and 5-FU (MF) in patients with advanced pancreatic cancer was performed. In patients with measurable disease the response rates were 34% (19/56) to SMF, and 8% (5/60) to MF (P = 0.009). Median survivals were similar, however, 18 versus 17 weeks (P = 0.356). Median survival of patients responding to chemotherapy was 33 weeks, and for nonresponders it was 17 weeks (P = 0.002). In patients with nonmeasurable disease, median survivals were 21 weeks (SMF) and 18 weeks (MF) (P = 0.797). Patients surviving greater than or equal to 48 weeks, however, appeared to be increased in the SMF arm (14 patients) compared to the MF (7 patients). Toxicity was moderate for both regimens, with SMF having greater gastrointestinal and renal toxicity. Chemotherapy with SMF appears to produce objective responses in patients with pancreatic cancer, but does not improve survival compared to MF.
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48
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Metzger UF, Kisner DL, Ghosh BC. Combined modality treatment of pancreatic cancer: implications for the surgeon. J Surg Oncol 1983; 24:107-12. [PMID: 6355662 DOI: 10.1002/jso.2930240208] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Since pancreatic cancer is still increasing and has a poor prognosis, there is great interest in improving treatment results by combined modality approaches. This paper considers the most appropriate studies to analyze the status of treatment and future implications for surgeons. With new radiation sources and more sophisticated treatment plans, intra- and post-operative radiotherapy now has an established role in local tumor control. Combination chemotherapy has yielded response rates of 40-45% and improved chemotherapy will play a role in the treatment and perhaps in the prevention of disseminated disease. Although it seems likely that chemotherapy combined with newer radiotherapeutic technique could improve treatment results in advanced pancreatic cancer, treatment-related and limiting toxicity still must be defined. There are suggestions that more surgeons become involved in the combined modality approach, as both radiotherapy and chemotherapy may be more valuable in primary management. The unsatisfactory results of surgical treatment imply the need for adjuvant treatment, which must be tested in randomized multicenter trials. Future efforts will require an interdisciplinary approach to this disease.
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