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Agnihotri N, Ambavane A, Fan L, Li W, Yoo H, Joo S, Muston D. Modeling health outcomes associated with BRCA testing and treatment strategies for patients with metastatic pancreatic cancer. Pancreatology 2024; 24:271-278. [PMID: 38286712 DOI: 10.1016/j.pan.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 12/08/2023] [Accepted: 01/10/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND Germline BRCA mutations (gBRCAm) occur in 4%-8% patients with metastatic pancreatic cancer (mPC); guidelines recommend platinum-based chemotherapies and olaparib maintenance in this population. We evaluated, through modeling, the role of treatments and gBRCA testing on health outcomes of mPC patients. METHODS A decision tree/partitioned survival model was developed to assess lifetime health outcomes for four strategies: 1) no testing; 2) early testing/no olaparib maintenance; 3) early testing (i.e., before 1L treatment)/olaparib maintenance; and 4) late testing/olaparib maintenance. Treatment patterns were assumed to follow current practice in the United States. Overall survival and progression-free survival curves were extrapolated from pivotal trials, including POLO trial for outcomes from olaparib maintenance after at least 16 weeks of platinum-based chemotherapy. RESULTS Among patients with gBRCAm, almost twice as many patients received platinum-based regimens in strategies involving early testing compared to when early testing was not employed (78.7 % vs 40.2 %). Health outcomes were highest in the strategy with early testing and available olaparib treatment whether considering progression-free life years (PF LYs, 1.27 vs 0.55-0.87), LYs (1.82 vs 0.95-1.27) or quality adjusted life years (QALYs, 1.15 vs 0.73-0.92 for others). Consistent patterns of results were observed in the overall cohort of mPC patients (i.e., irrespective of gBRCAm). CONCLUSION Patients with mPC achieved longest health outcomes (as measured by mean PF LYs, LYs and QALYs) with a scenario of early gBRCA testing and availability of olaparib maintenance. The results were primarily driven by improved health outcomes associated with higher efficacy of platinum-based chemotherapies and olaparib used in gBRCAm patients.
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Affiliation(s)
| | | | - Lin Fan
- Merck & Co., Inc, Rahway, NJ, USA
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2
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Furuse J, Ueno M, Ikeda M, Okusaka T, Teng Z, Furuya M, Ioka T. Liposomal irinotecan with fluorouracil and leucovorin after gemcitabine-based therapy in Japanese patients with metastatic pancreatic cancer: additional safety analysis of a randomized phase 2 trial. Jpn J Clin Oncol 2022; 53:130-137. [PMID: 36412114 PMCID: PMC9885735 DOI: 10.1093/jjco/hyac177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 10/27/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Nanoliposomal irinotecan (nal-IRI) was recently authorized in Japan for unresectable pancreatic cancer after disease progression following chemotherapy. Physicians now consider certain aspects of nal-IRI safety profile as slightly different from conventional irinotecan. This report aims to explore additional aspects of the nal-IRI safety in Japanese phase 2 study. METHODS We analyzed the incidence, time to first onset, and time to resolution for adverse events that require special attention and other selected toxicities in the nal-IRI combination group (n = 46). RESULTS Leukopenia/neutropenia (76.1%/71.7%), diarrhea (58.7%) and hepatic dysfunction (41.3%) were the most commonly reported treatment-emergent adverse events, with a median time to onset of 21.0 days (range: 8, 97), 9.0 days (1, 61) and 22.0 days (2, 325), respectively, and a median time to resolution of 8.0 days (95% confidence intervals: 8, 9), 4.0 days (4, 8) and 40.0 days (9, -), respectively. Eight patients experienced Grade ≥ 3 diarrhea and their symptoms were well controlled by dose modification except one patient who had drug withdrawal. The median time to resolution for Grade ≥ 3 and Grade ≤ 2 diarrhea was 17.5 days (95% confidence intervals: 1, 31) and 4 days (3, 7), respectively. Anorexia occurred in 28/46 patients (60.9%) with a median time to onset of 4.0 days (range: 2, 132) and a median time to resolution of 12.0 days (95% confidence intervals: 6, 26). CONCLUSIONS We explored safety profile of nal-IRI combination regimen recognized as effective and tolerable treatment for Japanese unresectable pancreatic cancer patients. Although the treatment-emergent adverse events occurred were controllable, patients with prolonged toxicities should be closely managed.
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Affiliation(s)
- Junji Furuse
- For reprints and all correspondence: Junji Furuse, Kanagawa Cancer Center, Yokohama, Japan, 2-3-2 Nakao, Asahi-ku, Yokohama, Kanagawa, 241-8515, Japan, E-mail:
| | - Makoto Ueno
- Department of Gastroenterology, Kanagawa Cancer Center, Yokohama, Japan
| | - Masafumi Ikeda
- Department of Hepatobiliary & Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Zhaoyang Teng
- Biometrics Department, Servier Pharmaceuticals, Boston MA, USA
| | - Momoko Furuya
- Medical Affairs Department, Nihon Servier CO., LTD., Tokyo, Japan
| | - Tatsuya Ioka
- Oncology Center, Yamaguchi University Hospital, Ube, Japan
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3
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Nasser A, Forse CL, Walsh C, Moyana T, Goel R. Mixed pancreatic acinar cell-ductal adenocarcinoma: Complexities in diagnosis and treatment. CURRENT PROBLEMS IN CANCER: CASE REPORTS 2022. [DOI: 10.1016/j.cpccr.2022.100144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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4
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Orsi G, Di Marco M, Cavaliere A, Niger M, Bozzarelli S, Giordano G, Noventa S, Rapposelli IG, Garajova I, Tortora G, Rodriquenz MG, Bittoni A, Penzo E, De Lorenzo S, Peretti U, Paratore C, Bernardini I, Mosconi S, Spallanzani A, Macchini M, Tamburini E, Bencardino K, Giommoni E, Scartozzi M, Forti L, Valente MM, Militello AM, Cascinu S, Milella M, Reni M. Chemotherapy toxicity and activity in patients with pancreatic ductal adenocarcinoma and germline BRCA1-2 pathogenic variants (gBRCA1-2pv): a multicenter survey. ESMO Open 2021; 6:100238. [PMID: 34392104 PMCID: PMC8371213 DOI: 10.1016/j.esmoop.2021.100238] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Germline BRCA1-2 pathogenic variants (gBRCA1-2pv)-related pancreatic ductal adenocarcinoma (PDAC) showed increased sensitivity to DNA cross-linking agents. This study aimed at exploring safety profile, dose intensity, and activity of different chemotherapy regimens in this setting. PATIENTS AND METHODS gBRCA1-2pv PDAC patients of any age and clinical tumor stage who completed a first course of chemotherapy were eligible. A descriptive analysis of chemotherapy toxicity, dose intensity, response, and survival outcomes was performed. RESULTS A total of 85 gBRCA1-2pv PDAC patients treated in 21 Italian centers between December 2008 and March 2021were enrolled. Seventy-four patients were assessable for toxicity and dose intensity, 83 for outcome. Dose intensity was as follows: nab-paclitaxel 72%, gemcitabine 76% (AG); cisplatin 75%, nab-paclitaxel 73%, capecitabine 73%, and gemcitabine 65% (PAXG); fluorouracil 35%, irinotecan 58%, and oxaliplatin 64% (FOLFIRINOX). When compared with the literature, grade 3-4 neutropenia, thrombocytopenia, and diarrhea were increased with PAXG, and unmodified with AG and FOLFIRINOX. RECIST responses were numerically higher with the three- (81%) or four-drug (73%) platinum-containing regimens that outperformed AG (41%) and oxaliplatin-based doublets (56%). Carbohydrate antigen 19.9 (CA19.9) reduction >89% at nadir was reported in two-third of metastatic patients treated with triplets and quadruplets, as opposed to 33% and 45% of patients receiving oxaliplatin-based doublets or AG, respectively. All patients receiving AG experienced disease progression, with a median progression-free survival (mPFS) of 6.4 months, while patients treated with platinum-containing triplets or quadruplets had an mPFS >10.8 months. Albeit still immature, data on overall survival seemed to parallel those on PFS. CONCLUSIONS Our data, as opposed to figures expected from the literature, highlighted that platinum-based regimens provoked an increased toxicity on proliferating cells, when dose intensity was maintained, or an as-expected toxicity, when dose intensity was reduced, while no change in toxicity and dose intensity was evident with AG. Furthermore, an apparently improved outcome of platinum-based triplets or quadruplets over other regimens was observed.
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Affiliation(s)
- G Orsi
- Medical Oncology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy; Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - M Di Marco
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola - Malpighi University Hospital, Bologna, Italy
| | - A Cavaliere
- Section of Oncology, Department of Medicine, University of Verona School of Medicine and Verona University Hospital Trust, Verona, Italy
| | - M Niger
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - S Bozzarelli
- Department of Medical Oncology and Hematology, Humanitas Cancer Center, Humanitas Clinical and Research Center - IRCCS, Rozzano (Milan), Italy
| | - G Giordano
- Unit of Medical Oncology and Biomolecular Therapy, Policlinico Riuniti, Foggia, Italy; Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - S Noventa
- Department of Medical Oncology, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - I G Rapposelli
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori "Dino Amadori" - IRST, Meldola, Italy
| | - I Garajova
- Medical Oncology Unit, University Hospital of Parma, Parma, Italy
| | - G Tortora
- Unit of Medical Oncology, Comprehensive Cancer Center, Fondazione Policlinico Universitario, Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - M G Rodriquenz
- Oncology Unit, Ospedale IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
| | - A Bittoni
- Oncology Unit, Azienda Ospedaliero-Universitaria Ospedali Riuniti Umberto I, GM Lancisi, G Salesi di Ancona, Ancona, Italy
| | - E Penzo
- Medical Oncology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - S De Lorenzo
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - U Peretti
- Medical Oncology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy; Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - C Paratore
- Department of Oncology, University of Turin, Ordine Mauriziano Hospital, Turin, Italy
| | - I Bernardini
- Medical Oncology Unit, Ospedale Ramazzini, Carpi (MO), Italy
| | - S Mosconi
- Oncology Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - A Spallanzani
- Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
| | - M Macchini
- Medical Oncology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy; Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - E Tamburini
- Medical Oncology and Palliative Care Department, Azienda Ospedaliera Cardinale G. Panico, Tricase-Lecce, Italy
| | - K Bencardino
- Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - E Giommoni
- Medical Oncology Division, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - M Scartozzi
- Medical Oncology, University and University Hospital, Cagliari, Italy
| | - L Forti
- Medical Oncology Division, Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - M M Valente
- Medical Oncology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy; Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - A M Militello
- Medical Oncology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy; Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - S Cascinu
- Medical Oncology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - M Milella
- Section of Oncology, Department of Medicine, University of Verona School of Medicine and Verona University Hospital Trust, Verona, Italy
| | - M Reni
- Medical Oncology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy; Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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5
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George TJ, Ali A, Wang Y, Lee JH, Ivey AM, DeRemer D, Daily KC, Allegra CJ, Hughes SJ, Fan ZH, Cameron ME, Judge AR, Trevino JG. Phase II Study of 5-Fluorouracil, Oxaliplatin plus Dasatinib (FOLFOX-D) in First-Line Metastatic Pancreatic Adenocarcinoma. Oncologist 2021; 26:825-e1674. [PMID: 34101295 DOI: 10.1002/onco.13853] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 05/25/2021] [Indexed: 11/09/2022] Open
Abstract
LESSONS LEARNED Preclinical studies have demonstrated that Src inhibition through dasatinib synergistically enhances the antitumor effects of oxaliplatin. In this phase II, single-arm study, FOLFOX with dasatinib in previously untreated patients with mPC only showed only modest clinical activity, with a progressive-free survival of 4 months and overall survival of 10.6 months. Continued investigation is ongoing to better understand the role of Src inhibition with concurrent 5-fluorouracil and oxaliplatin in a subset of exceptional responders. BACKGROUND Src tyrosine kinase activity is overexpressed in many human cancers, including metastatic pancreatic cancer (mPC). Dasatinib is a potent inhibitor of Src family of tyrosine kinases. This study was designed to investigate whether dasatinib can synergistically enhance antitumor effects of FOLFOX regimen (FOLFOX-D). METHODS In this single-arm, phase II study, previously untreated patients received dasatinib 150 mg oral daily on days 1-14, oxaliplatin 85 mg/m2 intravenous (IV) on day 1 every 14 days, leucovorin (LV) 400 mg/m2 IV on day 1 every 14 days, 5-fluorouracil (5-FU) bolus 400 mg/m2 on day 1 every 14 days, and 5-FU continuous infusion 2,400 mg/m2 on day 1 every 14 days. Primary endpoint was progression-free survival (PFS) with preplanned comparison to historical controls. RESULTS Forty-four patients enrolled with an estimated median PFS of 4.0 (95% confidence interval [CI], 2.3-8.5) months and overall survival (OS) of 10.6 (95% CI, 6.9-12.7) months. Overall response rate (ORR) was 22.7% (n = 10): one patient (2.3%) with complete response (CR) and nine patients (20.5%) with partial response (PR). Fifteen patients (34.1%) had stable disease (SD). Nausea was the most common adverse event (AE) seen in 35 patients (79.5%). CONCLUSION The addition of dasatinib did not appear to add incremental clinical benefit to FOLFOX in untreated patients with mPC.
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Affiliation(s)
- Thomas J George
- Division of Hematology Oncology, Department of Medicine, University of Florida, Gainesville, Florida, USA.,University of Florida Health Cancer Center, Gainesville, Florida, USA
| | - Azka Ali
- Division of Hematology Oncology, Department of Medicine, University of Florida, Gainesville, Florida, USA.,University of Florida Health Cancer Center, Gainesville, Florida, USA
| | - Yu Wang
- Division of Quantitative Sciences, University of Florida Health Cancer Center, Gainesville, Florida, USA
| | - Ji-Hyun Lee
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA.,Division of Quantitative Sciences, University of Florida Health Cancer Center, Gainesville, FL, USA
| | - Alison M Ivey
- University of Florida Health Cancer Center, Gainesville, Florida, USA
| | - David DeRemer
- University of Florida Health Cancer Center, Gainesville, Florida, USA.,Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Karen C Daily
- Division of Hematology Oncology, Department of Medicine, University of Florida, Gainesville, Florida, USA.,University of Florida Health Cancer Center, Gainesville, Florida, USA
| | - Carmen J Allegra
- Division of Hematology Oncology, Department of Medicine, University of Florida, Gainesville, Florida, USA.,University of Florida Health Cancer Center, Gainesville, Florida, USA
| | - Steven J Hughes
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Z Hugh Fan
- Department of Mechanical and Aerospace Engineering, University of Florida, Gainesville, FL, USA
| | - Miles E Cameron
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Andrew R Judge
- Department of Physical Therapy, University of Florida, Gainesville, Florida, USA
| | - Jose G Trevino
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
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6
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Neoadjuvant Phase II Trial of Chemoradiotherapy in Patients With Resectable and Borderline Resectable Pancreatic Cancer. Am J Clin Oncol 2020; 43:435-441. [PMID: 32251119 DOI: 10.1097/coc.0000000000000688] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma is a largely incurable cancer. Surgical resection remains the only potential option for cure. Even in surgically resectable patients, only about 10% to 20% are long-term survivors. Emerging data suggest a role for neoadjuvant therapy to target occult micrometastatic disease. AIM To report our institutional experience with a novel neoadjuvant chemoradiation (CRT) regimen in resectable and borderline resectable pancreatic cancer. MATERIALS AND METHODS Patients were treated with 2 cycles of induction chemotherapy with FOLFOX and then received CRT with gemcitabine and intensity-modulated radiotherapy (IMRT). RESULTS From April 2014 to June 2017, 24 patients were enrolled. Eighteen patients were borderline resectable and 6 patients were resectable. All patients received induction chemotherapy with FOLFOX. Thirteen patients underwent pancreatectomy after CRT with a resection rate of 62%. R0 resection achieved in 11 patients (84.6%) and 2 patients had R1 resection (15.4%). For patients who underwent resection, the median progression-free survival (PFS) was 31 months, 1-year PFS rate was 69.2% (95% confidence interval [CI], 0.48-0.99), and 2-year PFS rate was 51.9% (95% CI, 0.3-0.89). Median overall survival (OS) was 34.8 months (95% CI, 1.045 to infinity), 1-year OS rate was 91.7% (95% CI, 0.77-1.0), and 2-year OS rate was 75% (95% CI, 0.54-1.0). Median CA 19-9 at screening for patients who underwent surgery was 659 (range, 18 to 2154), which decreased to 146.9 (range, 18 to 462) after CRT before resection. CONCLUSION Neoadjuvant therapy for borderline resectable and resectable pancreatic ductal adenocarcinoma with CRT facilitated R0 resection in 84% patients who underwent surgery.
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7
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Affiliation(s)
- Eileen M. O’Reilly
- Eileen M. O’Reilly, MD; Wungki Park, MD; and David P. Kelsen, MD, Memorial Sloan Kettering Cancer Center, and Weill Cornell Medical College, New York, NY
| | - Wungki Park
- Eileen M. O’Reilly, MD; Wungki Park, MD; and David P. Kelsen, MD, Memorial Sloan Kettering Cancer Center, and Weill Cornell Medical College, New York, NY
| | - David P. Kelsen
- Eileen M. O’Reilly, MD; Wungki Park, MD; and David P. Kelsen, MD, Memorial Sloan Kettering Cancer Center, and Weill Cornell Medical College, New York, NY
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8
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Franck C, Müller C, Rosania R, Croner RS, Pech M, Venerito M. Advanced Pancreatic Ductal Adenocarcinoma: Moving Forward. Cancers (Basel) 2020; 12:E1955. [PMID: 32708493 PMCID: PMC7409054 DOI: 10.3390/cancers12071955] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 02/06/2023] Open
Abstract
Globally, the death rate of pancreatic ductal adenocarcinoma (PDAC) has doubled over 30 years and is likely to further increase, making PDAC a leading cause of cancer-related death in the coming years. PDAC is typically diagnosed at an advanced stage, and modified FOLFIRINOX or nab-paclitaxel and gemcitabine are the mainstay of systemic therapy. For elderly patients with good performance status, low-dose treatment can preserve quality of life without compromising cancer control or survival. Maintenance therapy should be considered in PDAC patients achieving disease control with systemic therapy. In particular, olaparib has demonstrated a progression-free survival benefit of 3.6 months in a subgroup of PDAC patients with germline BRCA1/2 mutations (ca. 10% of all PDAC). Pancreatic enzyme replacement therapy is often omitted in the treatment of patients with PDAC, with possibly deleterious consequences. Small intestinal bacterial overgrowth is highly prevalent in patients with PDAC and should be considered in the diagnostic algorithm of PDAC patients with bloating and diarrhea. Rivaroxaban has been associated with a reduced risk of thrombosis without an increase in major bleeding events, and its use should be considered in every patient with advanced PDAC undergoing systemic therapy.
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Affiliation(s)
- Caspar Franck
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, 39120 Magdeburg, Germany; (C.F.); (C.M.); (R.R.)
| | - Christian Müller
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, 39120 Magdeburg, Germany; (C.F.); (C.M.); (R.R.)
| | - Rosa Rosania
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, 39120 Magdeburg, Germany; (C.F.); (C.M.); (R.R.)
| | - Roland S. Croner
- Department of General-, Visceral-, Vascular- and Transplant Surgery, Otto-von-Guericke University Hospital Magdeburg, 39120 Magdeburg, Germany;
| | - Maciej Pech
- Department of Radiology and Nuclear Medicine, Otto-von-Guericke University Hospital, 39120 Magdeburg, Germany;
| | - Marino Venerito
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, 39120 Magdeburg, Germany; (C.F.); (C.M.); (R.R.)
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9
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Morales ASR, Joy JK, Zbona DM. Administration sequence for multi-agent oncolytic regimens. J Oncol Pharm Pract 2020; 26:933-942. [DOI: 10.1177/1078155219895070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The existence of a multitude of oncolytics regimens containing two or more agents (combination) outlines the need to define their most adequate sequence of administration. However, limited resources are currently available to specify a particular sequence, presenting challenges potentially impacting on patient safety, and Pharmacy & Infusion Nursing workflows. Methods A comprehensive literature search was performed leading to the compilation of a document containing drug administration sequencing instructions for our Nursing, Pharmacy, and Oncology providers to follow. Regimens prioritized in our literature review represented regimens selected as part of our approved Clinical Pathways, regimens inquiries from Pharmacy or Nursing, as well as less frequently used regimens. We stratified the regimens by tumor type and arranged them alphabetically by indication. Results A table was compiled containing all the supporting literature for the recommended drug administration sequences. If, in certain instances, no literature support was identified outlining rationale such as enhanced management of adverse effects, a specific institutional decision was made by our enterprise Medical Oncology Committee with recommendations from Pharmacy experts. The primary guiding principles for outlining our recommendations were the following: administration of vesicant agents first; administration of biologic agents first; administration of taxanes prior to platinum agents; and duration of infusion (shorter infusions prioritized). Conclusion This guideline is not exhaustive. The compilation provided here is intended to be utilized as guidance for oncolytics administration sequence. We will continue to review and incorporate treatment sequencing recommendations for additional regimens.
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Affiliation(s)
| | - Jamie K Joy
- Cancer Treatment Centers of America Global, Boca Raton, FL, USA
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10
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Costa JG, de Jesus VHF, Camandaroba MPG, Dettino ALA. Characteristics and survival of older patients with metastatic pancreatic cancer: a retrospective analysis of the AC Camargo Cancer Center experience. Ther Adv Med Oncol 2019; 11:1758835919874650. [PMID: 31534492 PMCID: PMC6737872 DOI: 10.1177/1758835919874650] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 07/25/2019] [Indexed: 12/28/2022] Open
Abstract
Background: Advanced age is the most important risk factor for pancreatic cancer and about half of patients are diagnosed with metastatic disease. In the first-line setting, multidrug chemotherapy regimens were shown to be more effective than gemcitabine alone. However, the older population was under-represented in randomized clinical trials. We aimed to describe the clinical profile of older patients with metastatic pancreatic cancer and their survival outcomes. Materials and methods: This was a retrospective, unicentric study that included patients diagnosed with metastatic pancreatic cancer (non-neuroendocrine), aged 65 years and over. Results: The study population comprised 196 patients. The median age was 73 years; 67% of these patients presented Eastern Cooperative Oncology Group performance status (ECOG) ⩽ 1 and the median Charlson Comorbidity score was 10. Chemotherapy was given to 89% of the patients. The most frequently used chemotherapy regimens were gemcitabine (44%), 5-fluorouracil and oxaliplatin [FOLFOX; 26%], and 5-fluorouracil, oxaliplatin and irinotecan (FOLFIRINOX; 20%). Patients treated with FOLFIRINOX were younger and they presented better performance status. After a median follow up of 19.8 months, the median overall survival (OS) was of 7.2 months and the median time to first-line-treatment failure was 4.6 months. Among patients treated with chemotherapy, the median OS was highest for those treated with FOLFIRINOX (13.8 months), as compared with FOLFOX (7.0 months) or gemcitabine (6.7 months); p = 0.004. Nonetheless, treatment with FOLFIRINOX was associated with increased risk of severe toxicity (p = 0.008). Conclusion: Older patients with metastatic pancreatic cancer benefit from palliative chemotherapy, and FOLFIRINOX is a therapeutic option in rigorously selected older patients.
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Affiliation(s)
| | - Victor Hugo Fonseca de Jesus
- Medical Oncology Department AC Camargo Cancer Center Rua Prof. Antônio Prudente, 211 - 01509-010, São Paulo, Brazil
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11
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Tesfaye AA, Wang H, Hartley ML, He AR, Weiner L, Gabelia N, Kapanadze L, Shezad M, Brody JR, Marshall JL, Pishvaian MJ. A Pilot Trial of Molecularly Tailored Therapy for Patients with Metastatic Pancreatic Ductal Adenocarcinoma. J Pancreat Cancer 2019; 5:12-21. [PMID: 31065624 PMCID: PMC6503449 DOI: 10.1089/pancan.2019.0003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Purpose: Despite the wide adoption of tumor molecular profiling, there is a dearth of evidence linking molecular biomarkers for treatment selection to prediction of treatment outcomes in patients with metastatic pancreatic cancer. We initiated a pilot study to test the feasibility of designing a larger phase II trial of molecularly tailored treatment for metastatic pancreatic cancer. Methods: Our study aimed to assess the feasibility of following a treatment algorithm based on the expression of three published predictive markers of response to chemotherapy: ribonucleotide reductase catalytic subunit M1 (for gemcitabine); excision repair cross-complementation group 1 (for platinum agents); and thymidylate synthase (for 5-fluorouracil) in patients with untreated, metastatic pancreatic cancer. Results of the tumor biopsy analysis were used to assign patients to one of seven doublet regimens. Key secondary objectives included response rate (RR), disease control rate (DCR), progression-free survival (PFS), and overall survival (OS). Results: Between December 2012 and March 2015, 30 patients were enrolled into the study. Ten patients failed screening primarily due to inadequate tumor tissue availability. Of the remaining 20 patients, 19 were assigned into 6 different chemotherapy doublets, and achieved an RR of 28%, with a DCR rate of 78%. The median PFS and OS were 5.78 and 8.21 months, respectively. Conclusions: The incorporation of biomarkers into a treatment algorithm is feasible and resulted in a PFS and OS similar to other doublet therapies for patients with metastatic pancreatic cancer. Based on the results from this pilot study, a larger phase II randomized trial of molecularly targeted therapy versus physicians' choice of standard of care has been initiated in the second-line setting (NCT02967770).
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Affiliation(s)
- Anteneh A Tesfaye
- Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | - Hongkun Wang
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia
| | - Marion L Hartley
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia
| | - Aiwu Ruth He
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia
| | - Louis Weiner
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia
| | - Nina Gabelia
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia
| | - Lana Kapanadze
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia
| | - Muhammad Shezad
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia
| | - Jonathan R Brody
- Department of Surgery, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - John L Marshall
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia
| | - Michael J Pishvaian
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia
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Abendroth A, Noureddine R, Abramczyk M, Paul A, Gerken G, Schmid KW, Markus P, Schumacher B, Wiesweg M, Köhler J, Markus M, Mende B, Dechêne A, Schuler M, Kasper S. Long-term outcome of patients with advanced pancreatic cancer treated with sequential chemotherapies before the era of modern combination therapy protocols. J Cancer Res Clin Oncol 2018; 145:445-455. [PMID: 30430229 DOI: 10.1007/s00432-018-2789-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 11/08/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Patients (pts) with locally advanced (LAPC) or metastatic pancreatic ductal adenocarcinoma (mPDAC) have a dismal prognosis. Recently, new combination chemotherapies such as FOLFIRINOX and nab-paclitaxel/gemcitabine have demonstrated superiority over gemcitabine monotherapy. However, a substantial proportion of pts cannot tolerate these intensive front-line protocols. Moreover, the long-term superiority of multiagent protocols over less intensive strategies remains to be shown. To provide a benchmark for future studies, we analyzed the outcome of patients with LAPC or mPDAC treated at the West German Cancer Center before the FOLFIRINOX/nab-paclitaxel + gemcitabine era. METHODS This retrospective analysis included 201 consecutive pts with LAPC and mPDAC treated between 2007 and 2011. Efficacy parameters were correlated with type of chemotherapy, number of treatment lines and clinicopathological parameters. RESULTS Gemcitabine monotherapy was given as first-line therapy in 51.1%, whereas 48.9% received combination chemotherapies such as gemcitabine/oxaliplatin or FOLFOX. Patients received a median of two lines of treatment, with 54.8% receiving second-line and 37.9% receiving third- and further-line therapies. There was no significant difference between gemcitabine monotherapy and combination therapies. Despite moderate activity of first-line treatment, median overall survival for LAPC was 11.3 months and 8.7 months for mPDAC. Multivariate analysis identified age and number of treatment lines as prognostic markers. CONCLUSION The long-term outcome of unselected pts with LAPC and mPDAC treated before the introduction of aggressive multiagent chemotherapy protocols compares favorably with the results of contemporary benchmark trials. This suggests a multifactorial benefit from interdisciplinary care provided over sequential treatment lines at high volume expert centers.
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Affiliation(s)
- A Abendroth
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - R Noureddine
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - M Abramczyk
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - A Paul
- Department of General, Visceral and Transplant Surgery, West German Cancer Center, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner site University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - G Gerken
- Department of Gastroenterology and Hepatology, West German Cancer Center, University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - K W Schmid
- West German Cancer Center, Institute of Pathology Essen, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner site University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - P Markus
- Department of General Surgery and Traumatology, Elisabeth Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - B Schumacher
- Department of Gastroenterology, Elisabeth Hospital Essen, Essen, Germany
| | - M Wiesweg
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - J Köhler
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - M Markus
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - B Mende
- Central Pharmacy, University Hospital Essen, Essen, Germany
| | - A Dechêne
- Department of Gastroenterology and Hepatology, West German Cancer Center, University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - M Schuler
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner site University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - S Kasper
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany.
- Medical Faculty, University Duisburg-Essen, Essen, Germany.
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Ji Y, Zhang Y, Zhu J, Zhu L, Zhu Y, Hu K, Zhao H. Response of patients with locally advanced pancreatic adenocarcinoma to high-intensity focused ultrasound treatment: a single-center, prospective, case series in China. Cancer Manag Res 2018; 10:4439-4446. [PMID: 30349376 PMCID: PMC6188211 DOI: 10.2147/cmar.s173740] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Purpose Patients with unresectable locally advanced pancreatic cancer (LAPC) are still in dire need of effective therapies. We performed this cohort study in order to assess the efficacy and safety of high-intensity focused ultrasound (HIFU) ablation in treating patients with unresectable LAPC. Patients and methods Eighty-seven cases with unresectable LAPC from January 2014 to December 2016 were finally recruited according to the inclusion criteria. The primary end point of our study was OS of all the cases, and the secondary end points included 6-month and 12-month survival rate, tumor response rate, carbohydrate antigen (CA) 19-9 response rate, VAS, quality of life, and safety. Results All the 87 patients received HIFU ablation successfully, and were included in the efficacy and safety analysis. With a median follow-up of 16 months, median OS was estimated to be 12.2 months, with 95 % CI of 11.1–12.7 months. The 6-month and 12-month survival rates were 94.25% (95% CI =86.74–97.57) and 50.85% (95% CI =38.17–62.21), respectively. Multivariate analysis revealed that patients with VAS <4, Karnofsky performance status ≥80, and tumor size <3 cm have a significant improvement in their OS (adjusted HR [aHR] =0.26 [95% CI =0.12–0.57], P=0.001; aHR =0.34 [95% CI =0.17–0.68], P=0.02; and aHR =0.39 [95% CI =0.20–0.78], P=0.007; respectively). Tumor responses were observed in 32 (36.8%) of 87 patients and CA 19-9 response rate was 56.2%. Global health status, physical function, emotional function, and cognitive function of patients were significantly improved after HIFU treatment, and symptoms of fatigue and pain were significantly reduced. A total of 28.7% (25/87) of patients reported adverse events (AEs), mainly including fatigue (14/87), abdominal pain (7/87), fever (7/87), nausea (5/87), and rash (4/87). No severe AEs and HIFU-related deaths were reported. Conclusion HIFU ablation might be a potentially effective and safe therapeutic option for the patients with unresectable LAPC.
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Affiliation(s)
- Yongshuo Ji
- HIFU Center of Oncology Department, Huadong Hospital Affiliated to Fudan University, Shanghai 200000, China,
| | - Yu Zhang
- HIFU Center of Oncology Department, Huadong Hospital Affiliated to Fudan University, Shanghai 200000, China,
| | - Junqiu Zhu
- HIFU Center of Oncology Department, Huadong Hospital Affiliated to Fudan University, Shanghai 200000, China,
| | - Linglin Zhu
- HIFU Center of Oncology Department, Huadong Hospital Affiliated to Fudan University, Shanghai 200000, China,
| | - Yanfei Zhu
- HIFU Center of Oncology Department, Huadong Hospital Affiliated to Fudan University, Shanghai 200000, China,
| | - Kaimeng Hu
- Marketing Department, Shanghai A&S Science Technology Development Co., Ltd, Shanghai 200000, China
| | - Hong Zhao
- HIFU Center of Oncology Department, Huadong Hospital Affiliated to Fudan University, Shanghai 200000, China,
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Tiwari A, Kumar L. Pancreatic ductal adenocarcinoma: Role of chemotherapy & future perspectives. Indian J Med Res 2018; 148:254-257. [PMID: 30425214 PMCID: PMC6251265 DOI: 10.4103/ijmr.ijmr_615_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Akash Tiwari
- Department of Medical Oncology, Dr BRA-Institute Rotary Cancer Hospital (IRCH), All India Institute of Medical Sciences, New Delhi 110 029, India
| | - Lalit Kumar
- Department of Medical Oncology, Dr BRA-Institute Rotary Cancer Hospital (IRCH), All India Institute of Medical Sciences, New Delhi 110 029, India
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Schwarz L, Vernerey D, Bachet JB, Tuech JJ, Portales F, Michel P, Cunha AS. Resectable pancreatic adenocarcinoma neo-adjuvant FOLF(IRIN)OX-based chemotherapy - a multicenter, non-comparative, randomized, phase II trial (PANACHE01-PRODIGE48 study). BMC Cancer 2018; 18:762. [PMID: 30041614 PMCID: PMC6057099 DOI: 10.1186/s12885-018-4663-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 07/05/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND At time of diagnosis, less than 10% of patients with pancreatic adenocarcinomas (PDAC) are considered to be immediately operable (i.e. resectable). Considering their poor overall survival (OS), only tumours without vascular invasion (NCCN 2017) should be considered for resection, i.e. those for which resection with disease-free margins (R0) is theoretically possible in absence of presurgery treatment. With regard to high R1 rates and undetectable locoregional and/or metastatic spreading prior to surgery explain (at least in part) the observed 1-year relapse and mortality rates of 50 and 25%, respectively. Today, upfront surgery followed by adjuvant chemotherapy is the reference treatment in Europe. The main limitation of the adjuvant approach is the low rate of completion of the full therapeutic sequence. Indeed, only 47 to 60% patients received any adjuvant therapy after resection compared to more than 75% for neoadjuvant therapy. No previous prospective study has compared this approach to a neoadjuvant FOLFIRINOX or FOLFOX chemotherapy for resectable PDAC. METHODS PANACHE01-PRODIGE48 is a prospective multicentre controlled randomized non comparative Phase II trial, evaluating the safety and efficacy of two regimens of neo-adjuvant chemotherapy (4 cycles of mFOLFIRINOX or FOLFOX) relative to the current reference treatment (surgery and then adjuvant chemotherapy) in patients with resectable PDAC. The main co-primary endpoints are OS rate at 12 months and the rate of patients undergoing the full therapeutic sequence. DISCUSSION The "ideal" cancer treatment for resectable PDAC would have the following characteristics: administration to the highest possible proportion of patients, ability to identify fast-progressing patients (i.e. poor candidates for surgery), a low rate of R1 resections (through optimisation of local disease control), and an acceptable toxicity profile. The neoadjuvant approach may meet all these criteria. With respect to published data on the efficacy of FOLFOX and mFOLFIRINOX, these two regimens are potential candidates for neoadjuvant use in the aim to optimising oncological outcomes in resectable PDAC. TRIAL REGISTRATION ClinicalTrials.gov , NCT02959879 . Trial registration date: November 9, 2016.
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Affiliation(s)
- Lilian Schwarz
- Department of Digestive Surgery, Hôpital Charles Nicolle, Rouen, France
- UNIROUEN, UMR 1245 INSERM, Rouen University Hospital, Department of Genomic and Personalized Medicine in Cancer and Neurological Disorders, Normandie Univ, F-76000 Rouen, France
| | - Dewi Vernerey
- Methodological and Quality of Life in Oncology Unit, INSERM UMR 1098, University Hospital of Besançon, Besançon, France
| | | | - Jean-Jacques Tuech
- Department of Digestive Surgery, Hôpital Charles Nicolle, Rouen, France
- UNIROUEN, UMR 1245 INSERM, Rouen University Hospital, Department of Genomic and Personalized Medicine in Cancer and Neurological Disorders, Normandie Univ, F-76000 Rouen, France
| | - Fabienne Portales
- Department of Digestive Oncology, Institut régional du Cancer de Montpellier (ICM) - Val d’Aurelle, Montpellier, France
| | - Pierre Michel
- UNIROUEN, UMR 1245 INSERM, Rouen University Hospital, Department of Genomic and Personalized Medicine in Cancer and Neurological Disorders, Normandie Univ, F-76000 Rouen, France
- Department of Hepato-Gastroenterology, Rouen University Hospital, Rouen, France
| | - Antonio Sa Cunha
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France
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16
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Bullock A, Stuart K, Jacobus S, Abrams T, Wadlow R, Goldstein M, Miksad R. Capecitabine and oxaliplatin as first and second line treatment for locally advanced and metastatic pancreatic ductal adenocarcinoma. J Gastrointest Oncol 2017; 8:945-952. [PMID: 29299353 DOI: 10.21037/jgo.2017.06.06] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background There are limited treatment options available for patients with advanced pancreatic ductal adenocarcinoma (PDAC). We conducted a phase II study evaluating the efficacy and safety of capecitabine/oxaliplatin (CAPOX) in patients with locally advanced and metastatic PDAC treated in the first and second lines. Methods Forty subjects with advanced PDAC and ECOG performance status ≥2 were enrolled. Treatment consisted of capecitabine 2,000 mg/m2 orally in two divided doses daily for 14 days and oxaliplatin 130 mg/m2 intravenously day 1 every 21 days. The primary endpoint was response rate (RR); secondary endpoints included safety analysis, progression free survival (PFS) and overall survival (OS). Results The overall RR was 12.5% (N=3); the disease control rate was 67% (N=16). Due to the protocol definition for eligibility of response evaluation, only 60% (N=24) were evaluable for the primary endpoint. Median progression free survival (mPFS) was 3.8 months (95% CI: 1.3, 6.2); median OS (mOS) was 7.4 months (95% CI: 4.8, 12.2). The most common grade 3/4 toxicities included: fatigue (19%), nausea (17%), and diarrhea (14%). Conclusions CAPOX is an active regimen in patients with advanced PDAC and is associated with acceptable toxicity. Careful consideration should be given to response endpoints and outcome measures when studying this characteristically ill population.
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Affiliation(s)
| | - Keith Stuart
- Lahey Hospital and Medical Center, Burlington, MA, USA
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17
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Marinova M, Rauch M, Mücke M, Rolke R, Gonzalez-Carmona MA, Henseler J, Cuhls H, Radbruch L, Strassburg CP, Zhang L, Schild HH, Strunk HM. High-intensity focused ultrasound (HIFU) for pancreatic carcinoma: evaluation of feasibility, reduction of tumour volume and pain intensity. Eur Radiol 2016; 26:4047-4056. [PMID: 26886904 DOI: 10.1007/s00330-016-4239-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 11/08/2015] [Accepted: 01/21/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Prognosis of patients with locally advanced pancreatic adenocarcinoma is extremely poor. They often suffer from cancer-related pain reducing their quality of life. This prospective observational study aimed to evaluate feasibility, local tumour response, and changes in quality of life and symptoms in Caucasian patients with locally advanced pancreatic cancer treated by ultrasound-guided high-intensity focused ultrasound (HIFU). METHODS Thirteen patients underwent HIFU, five with stage III, eight with stage IV UICC disease. Ten patients received simultaneous palliative chemotherapy. Postinterventional clinical assessment included evaluation of quality of life and symptom changes using standardized questionnaires. CT and MRI follow-up evaluated the local tumour response. RESULTS HIFU was successfully performed in all patients. Average tumour reduction was 34.2 % at 6 weeks and 63.9 % at 3 months. Complete or partial relief of cancer-related pain was achieved in 10 patients (77 %), five of whom required less analgesics for pain control. Quality of life was improved revealing increased global health status and alleviated symptoms. HIFU treatment was well tolerated. Eight patients experienced transient abdominal pain directly after HIFU. CONCLUSIONS HIFU ablation of pancreatic carcinoma is a feasible, safe and effective treatment with a crucial benefit in terms of reduction of tumour volume and pain intensity. KEY POINTS • US-guided HIFU is feasible and safe for patients with unresectable pancreatic cancer. • HIFU can considerably reduce tumour volume and cancer-related pain. • Patients treated with HIFU experienced significant and lasting reduction of pain intensity. • HIFU has a crucial clinical benefit for patients with pancreatic cancer.
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Affiliation(s)
- Milka Marinova
- Department of Radiology, Medical School & Hospital, University of Bonn, Siegmund-Freud-Str. 25, D-53105, Bonn, Germany.
| | - Maximilian Rauch
- Department of Radiology, Medical School & Hospital, University of Bonn, Siegmund-Freud-Str. 25, D-53105, Bonn, Germany
| | - Martin Mücke
- Department of Palliative Medicine, Medical School & Hospital, University of Bonn, Bonn, Germany.,Department of General Practice and Family Medicine, Medical School & Hospital, University of Bonn, Bonn, Germany
| | - Roman Rolke
- Department of Palliative Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
| | | | - Jana Henseler
- Department of Radiology, Medical School & Hospital, University of Bonn, Siegmund-Freud-Str. 25, D-53105, Bonn, Germany
| | - Henning Cuhls
- Department of Palliative Medicine, Medical School & Hospital, University of Bonn, Bonn, Germany
| | - Lukas Radbruch
- Department of Palliative Medicine, Medical School & Hospital, University of Bonn, Bonn, Germany
| | - Christian P Strassburg
- Department of Internal Medicine I, Medical School & Hospital, University of Bonn, Bonn, Germany
| | - Lian Zhang
- Clinical Center of Tumor Therapy Chongqing, Chongqing, China
| | - Hans H Schild
- Department of Radiology, Medical School & Hospital, University of Bonn, Siegmund-Freud-Str. 25, D-53105, Bonn, Germany
| | - Holger M Strunk
- Department of Radiology, Medical School & Hospital, University of Bonn, Siegmund-Freud-Str. 25, D-53105, Bonn, Germany
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A phase II trial of modified FOLFOX6 as first-line therapy for adenocarcinoma of an unknown primary site. Cancer Chemother Pharmacol 2015; 77:163-8. [DOI: 10.1007/s00280-015-2904-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/03/2015] [Indexed: 11/27/2022]
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19
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Alemi F, Alseidi A, Scott Helton W, Rocha FG. Multidisciplinary management of locally advanced pancreatic ductal adenocarcinoma. Curr Probl Surg 2015; 52:362-98. [PMID: 26363649 DOI: 10.1067/j.cpsurg.2015.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 07/13/2015] [Indexed: 12/13/2022]
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Marsh RDW, Talamonti MS, Katz MH, Herman JM. Pancreatic cancer and FOLFIRINOX: a new era and new questions. Cancer Med 2015; 4:853-63. [PMID: 25693729 PMCID: PMC4472208 DOI: 10.1002/cam4.433] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 01/10/2015] [Accepted: 01/12/2015] [Indexed: 12/24/2022] Open
Abstract
FOLFIRINOX (FFX) was introduced to clinical practice in 2010 following publication of the PRODIGE 4/ACCORD 11 study, which compared this novel regimen to gemcitabine in metastatic pancreatic cancer. Median overall survival, progression-free survival, and objective responses were all superior with FFX and there was improved time to definitive deterioration in quality of life. Despite initial concerns over toxicity, there has been rapid uptake of this regimen, both revolutionizing management and opening the door to innovative research. As experience with FFX has accrued, many questions have arisen including the management of toxicities, the impact of frequent modifications, the optimal number of cycles, integration with other regimens and modalities, interpretation of radiologic and serologic response, utility of molecular signatures, and potential benefit in unique clinical settings such as pre- and postsurgery. This review will closely examine these issues, not only to summarize current knowledge but also to fuel scientific debate.
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Affiliation(s)
- Robert De W Marsh
- Department of Medicine, NorthShore University HealthSystemEvanston, Illinois, 60201
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystemEvanston, Illinois, 60201
| | - Matthew Harold Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer CenterHouston, Texas
| | - Joseph M Herman
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins HospitalBaltimore, Maryland
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Goel G, Sun W. Novel approaches in the management of pancreatic ductal adenocarcinoma: potential promises for the future. J Hematol Oncol 2015; 8:44. [PMID: 25935754 PMCID: PMC4431030 DOI: 10.1186/s13045-015-0141-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 04/21/2015] [Indexed: 02/08/2023] Open
Abstract
Despite a few breakthroughs in therapy for advanced disease in the recent years, pancreatic ductal adenocarcinoma continues to remain one of the most challenging human malignancies to treat. The overall prognosis for the majority of patients with pancreatic cancer is rather dismal, and therefore, more effective treatment options are being desperately sought. The practical goals of management are to improve the cure rates for patients with resectable disease, achieve a higher conversion rate of locally advanced tumor into potentially resectable disease, and finally, prolong the overall survival for those who develop metastatic disease. Our understanding of the complex genetic alterations, the implicated molecular pathways, and the role of desmoplastic stroma in pancreatic cancer tumorigenesis has increased several folds in the recent years. This has facilitated the development of novel therapeutic strategies against pancreatic cancer, some of which are currently under evaluation in ongoing preclinical and clinical studies. This review will summarize the existing treatment approaches for this devastating disease and also discuss the promising therapeutic approaches that are currently in different stages of clinical development.
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Affiliation(s)
- Gaurav Goel
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, 5150 Centre Avenue, Fifth Floor, Pittsburgh, PA, 15232, USA.
| | - Weijing Sun
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, 5150 Centre Avenue, Fifth Floor, Pittsburgh, PA, 15232, USA.
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Wolin EM. Treatment options for advanced pancreatic neuroendocrine tumors: what is on the horizon? INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2015. [DOI: 10.2217/ije.14.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract: Treatment options for patients with advanced or metastatic pancreatic tumors (pNET) have expanded greatly in recent years. These treatments include resection, ablation or embolization of liver metastases and systemic therapy with everolimus or sunitinib and cytotoxic agents. New investigational approaches include the use of inhibitors of multiple downstream effectors in the PI3K/Akt/mTOR pathway, novel antiangiogenics, somatostatin analogues, new tyrosine kinase inhibitors and peptide receptor radionuclide therapy. The treatment horizon for pNET patients may offer improved duration of tumor control and survival and more effective symptom control.
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He J, Page AJ, Weiss M, Wolfgang CL, Herman JM, Pawlik TM. Management of borderline and locally advanced pancreatic cancer: Where do we stand? World J Gastroenterol 2014; 20:2255-2266. [PMID: 24605025 PMCID: PMC3942831 DOI: 10.3748/wjg.v20.i9.2255] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/10/2013] [Accepted: 01/15/2014] [Indexed: 02/06/2023] Open
Abstract
Many patients with pancreas cancer present with locally advanced pancreatic cancer (LAPC). The principle tools used for diagnosis and staging of LAPC include endoscopic ultrasound, axial imaging with computed tomography and magnetic resonance imaging, and diagnostic laparoscopy. The definition of resectability has historically been vague, as there is considerable debate and controversy as to the definition of LAPC. For the patient with LAPC, there is some level of involvement of the surrounding vascular structures, which include the superior mesenteric artery, celiac axis, hepatic artery, superior mesenteric vein, or portal vein. When feasible, most surgeons would recommend possible surgical resection for patients with borderline LAPC, with the goal of an R0 resection. For initially unresectable LAPC, neoadjuvant should be strongly considered. Specifically, these patients should be offered neoadjuvant therapy, and the tumor should be assessed for possible response and eventual resection. The efficacy of neoadjuvant therapy with this approach as a bridge to potential curative resection is broad, ranging from 3%-79%. The different modalities of neoadjuvant therapy include single or multi-agent chemotherapy combined with radiation, chemotherapy alone, and chemotherapy followed by chemotherapy with radiation. This review focuses on patients with LAPC and addresses recent advances and controversies in the field.
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LoConte NK, Holen KD, Schelman WR, Mulkerin DL, Deming DA, Hernan HR, Traynor AM, Goggins T, Groteluschen D, Oettel K, Robinson E, Lubner SJ. A phase I study of sorafenib, oxaliplatin and 2 days of high dose capecitabine in advanced pancreatic and biliary tract cancer: a Wisconsin oncology network study. Invest New Drugs 2012; 31:943-8. [PMID: 23263993 DOI: 10.1007/s10637-012-9916-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 12/12/2012] [Indexed: 12/11/2022]
Abstract
Chemotherapy has yielded minimal clinical benefit in pancreatic and biliary tract cancer. A high-dose, short course capecitabine schedule with oxaliplatin, has shown some efficacy with a lower incidence of palmar-plantar erythrodysesthesia. Achieving high exposures of the targeted agent sorafenib may be possible with this shorter schedule of capecitabine by avoiding dermatologic toxicity. All patients had pancreatic or biliary tract cancer. Patients in both cohorts received oxaliplatin 85 mg/m2 followed by capecitabine 2,250 mg/m2 PO every 8 h x 6 doses starting on days 1 and 15 of a 28 day cycle, or 2DOC (2 Day Oxaliplatin/Capecitabine). Cohort 1 used sorafenib 200 mg BID, and cohort 2 used sorafenib 400 mg BID. Sixteen patients were enrolled. Across all cycles the most common grade 1 or 2 adverse events were fatigue (10 pts), diarrhea (10 pts), nausea (9 pts), vomiting (8 pts), sensory neuropathy (8 pts), thrombocytopenia (7 pts), neutropenia (5 pts), and hand-foot syndrome (5 pts). Grade 3 toxicites included neutropenia, mucositis, fatigue, vomiting and diarrhea. Cohort 1 represented the MTD. Two partial responses were seen, one each in pancreatic and biliary tract cancers. The recommended phase II dose of sorafenib in combination with 2DOC is 200 mg BID. There were infrequent grade 3 toxicities, most evident with sorafenib at 400 mg BID.
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Affiliation(s)
- Noelle K LoConte
- University of Wisconsin Carbone Cancer Center and the University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, K6/548 CSC, Madison, WI 53792, USA.
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Herreros-Villanueva M, Hijona E, Cosme A, Bujanda L. Adjuvant and neoadjuvant treatment in pancreatic cancer. World J Gastroenterol 2012; 18:1565-72. [PMID: 22529684 PMCID: PMC3325521 DOI: 10.3748/wjg.v18.i14.1565] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 10/23/2011] [Accepted: 01/22/2012] [Indexed: 02/06/2023] Open
Abstract
Pancreatic adenocarcinoma is one of the most aggressive human malignancies, ranking 4th among causes for cancer-related death in the Western world including the United States. Surgical resection offers the only chance of cure, but only 15 to 20 percent of cases are potentially resectable at presentation. Different studies demonstrate and confirm that advanced pancreatic cancer is among the most complex cancers to treat and that these tumors are relatively resistant to chemotherapy and radiotherapy. Currently there is no consensus around the world on what constitutes “standard” adjuvant therapy for pancreatic cancer. This controversy derives from several studies, each fraught with its own limitations. Standards of care also vary somewhat with regard to geography and economy, for instance chemo-radiotherapy followed by chemotherapy or vice versa is considered the optimal therapy in North America while chemotherapy alone is the current standard in Europe. Regardless of the efforts in adjuvant and neoadjuvant improved therapy, the major goal to combat pancreatic cancer is to find diagnostic markers, identifying the disease in a pre-metastatic stage and making a curative treatment accessible to more patients. In this review, authors examined the different therapy options for advanced pancreatic patients in recent years and the future directions in adjuvant and neoadjuvant treatments for these patients.
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Sequential FOLFOX-6 and gemcitabine for locally advanced and/or metastatic pancreatic cancer. Med Oncol 2012; 29:2831-7. [PMID: 22392197 DOI: 10.1007/s12032-012-0197-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 02/18/2012] [Indexed: 01/05/2023]
Abstract
This prospective phase II trial aims to evaluate the sequential FOLFOX-6 and gemcitabine followed by adapted maintenance for advanced pancreatic cancer. Treatment included FOLFOX-6 for 4 cycles, followed sequentially by gemcitabine for 3 cycles. Patients, who show clinical benefit after both sequences, will receive maintenance treatment based on the investigator's discretion. From January 2005 to June 2008, 32 patients with median age of 63 were included; 75% of patients had metastatic disease, 81% had pure adenocarcinoma, while 19% had adenocarcinoma with a neuroendocrine component. There were 22% PR and 22% SD resulting in 44% tumor growth control. Under FOLFOX, grade 3/4 toxicities were neutropenia in 8 patients, thrombocytopenia and anemia in 3 patients each, and diarrhea in 2 patients. Under Gem, grade 3/4 neutropenia was observed in 4 patients, thrombocytopenia and anemia were observed in 2 patients, and hand-foot syndrome was observed in 3 patients. The median TTP and OS were 4 and 10 months, respectively. In APC, FOLFOX-6 regimen followed by gemcitabine achieved an interesting RR within a tolerable level of toxicity. This regimen seems to warrant further investigation to confirm its efficacy.
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Heinemann V, Haas M, Boeck S. Systemic treatment of advanced pancreatic cancer. Cancer Treat Rev 2012; 38:843-53. [PMID: 22226241 DOI: 10.1016/j.ctrv.2011.12.004] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 12/09/2011] [Accepted: 12/12/2011] [Indexed: 02/08/2023]
Abstract
Pancreatic cancer belongs to the most malignant gastrointestinal cancers and, in its advanced stage, remains a deadly disease for nearly all affected patients. Treatment of metastatic adenocarcinoma of the pancreas not only involves chemotherapy and targeted therapy, but also requires attention to accompanying comorbidities as well as frequently intensive supportive treatment and psychosocial support. Gemcitabine-based combinations with fluoropyrimidines and platin analogs have essentially failed to provide a substantial prolongation of survival and may constitute a treatment option only in patients with a good performance status. Among targeted therapies, only the EGFR tyrosine kinase inhibitor erlotinib has shown activity which is marginal in the overall population, but clinically relevant in patients developing skin rash. New avenues of polychemotherapy are presently explored since the gemcitabine-free FOLFIRINOX-regimen (infusional 5-fluorouracil/folinic acid plus irinotecan and oxaliplatin) was shown to be markedly superior to gemcitabine in selected good-performance patients. Pancreatic cancer is notably characterized as a hypovascular tumor rich in desmoplastic stromal tissue. An innovative approach to treatment therefore focuses on peritumoral fibroblasts and aims to induce a depletion of the stroma either by inhibition of the hedgehog pathway or by targeting SPARC (secreted protein acidic and rich in cysteine) via application of albumin-bound paclitaxel.
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Affiliation(s)
- Volker Heinemann
- Klinikum Grosshadern, Department of Oncology and Comprehensive Cancer Center, Ludwig-Maximilians-Universität München, Germany.
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A multimodal approach to the management of neuroendocrine tumour liver metastases. Int J Hepatol 2012; 2012:819193. [PMID: 22518323 PMCID: PMC3296190 DOI: 10.1155/2012/819193] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 12/02/2011] [Indexed: 12/13/2022] Open
Abstract
Neuroendocrine tumours (NETs) are often indolent malignancies that commonly present with metastatic disease in the liver. Surgical, locoregional, and systemic treatment modalities are reviewed. A multidisciplinary approach to patient care is suggested to ensure all therapeutic options explored.
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Abstract
PURPOSE OF REVIEW Metastatic pancreatic ductal adenocarcinoma has a grim prognosis and gemcitabine has been the reference treatment for 15 years. In this article, we will review current first-line treatments for metastatic pancreatic adenocarcinoma focusing on randomized studies. RECENT FINDINGS Among the numerous randomized phase III studies comparing gemcitabine as single agent to gemcitabine combined to a new agent, only the gemcitabine-erlotinib combination has shown a small, but statistical improvement in survival. A trend to better survival was also observed with a gemcitabine-capecitabine regimen. The use of low-weight heparin may be of value to reduce venous thromboembolic events. In selected patients with good performance status ECOG 0-1, the Folfirinox regimen, when compared with gemcitabine, was associated with more toxicities and significantly increased median survival from 6.8 to 11.1 months. SUMMARY Gemcitabine (with or without erlotinib or capecitabine) is still the reference treatment in patients with ECOG performance status 2. Folfirinox is a new more toxic and more efficient regimen that may be considered in patients with good performance status.
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Abstract
Pancreatic cancer is the fourth leading cause of cancer death in the United States. In 2008, an estimated 34,290 people died from pancreatic cancer and 37,680 new cases were diagnosed. Despite modern treatment, 90% of patients die within 1 year of diagnosis. Pancreatectomy is still the only potentially curative approach, but most patients have incurable disease by the time they are diagnosed, and fewer than 20% are candidates for surgery. In the present paper the English-language literature addressing the medical management in pancreatic cancer was reviewed. Based on these data we will discuss the role of currently used chemotherapy and target therapy in pancreatic cancer, as well as perspectives of the emerging strategies that are arising in order to improve the outcomes of this complex disease.
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Phase II study of biweekly gemcitabine followed by oxaliplatin and simplified 48-h infusion of 5-fluorouracil/leucovorin (GOFL) in advanced pancreatic cancer. Cancer Chemother Pharmacol 2009; 64:1173-9. [DOI: 10.1007/s00280-009-0980-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 03/03/2009] [Indexed: 11/27/2022]
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Phase II trial of oxaliplatin combined with leucovorin and fluorouracil for recurrent/metastatic biliary tract carcinoma. Anticancer Drugs 2008; 19:631-5. [DOI: 10.1097/cad.0b013e3283017f94] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Abstract
Pancreatic cancer remains a significant therapeutic challenge in oncology as the 21st century begins. Currently available cytotoxic chemotherapeutic agents provide only a modest survival benefit for patients with advanced disease. Recent efforts to improve survival in the setting of locally advanced and metastatic disease have focused on combinations of cytotoxic agents and the integration of newer molecular agents. To date, these strategies have been somewhat disappointing, prompting some experts to consider changes in clinical trial design with more rigorous patient eligibility criteria. In the adjuvant therapy setting, investigation of newer agents has lagged behind studies in more advanced disease, but recent results suggested some evidence of incremental advance. However, just as in advanced pancreatic cancer, without a more disciplined approach to patient selection for surgical intervention and subsequent adjuvant therapy, progress can be expected to remain very slow. This review will provide a brief summary of the history of chemotherapy in the treatment of pancreatic cancer and focus on its current and future role in adjuvant therapy.
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Affiliation(s)
- Robert A Wolff
- Department of Gastrointestinal Medical Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
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Saif MW, Kim R. Role of platinum agents in the management of advanced pancreatic cancer. Expert Opin Pharmacother 2007; 8:2719-27. [DOI: 10.1517/14656566.8.16.2719] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Muhammad Wasif Saif
- Associate Professor Yale University School of Medicine, Section of Medical Oncology, 333 Cedar Street, FMP: 116, New Haven, Connecticut 06520, USA ;
| | - Richard Kim
- Yale University School of Medicine, Section of Medical Oncology, 333 Cedar Street, FMP: 116, New Haven, Connecticut 06520, USA
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