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Ladekarl M, Rasmussen LS, Kirkegård J, Chen I, Pfeiffer P, Weber B, Skuladottir H, Østerlind K, Larsen JS, Mortensen FV, Engberg H, Møller H, Fristrup CW. Disparity in use of modern combination chemotherapy associated with facility type influences survival of 2655 patients with advanced pancreatic cancer. Acta Oncol 2022; 61:277-285. [PMID: 34879787 DOI: 10.1080/0284186x.2021.2012252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIM Academic and high volume hospitals have better outcome for pancreatic cancer (PC) surgery, but there are no reports on oncological treatment. We aimed to determine the influence of facility types on overall survival (OS) after treatment with chemotherapy for inoperable PC. MATERIAL AND METHODS 2,657 patients were treated in Denmark from 2012 to 2018 and registered in the Danish Pancreatic Cancer Database. Facilities were classified as either secondary oncological units or comprehensive, tertiary referral cancer centers. RESULTS The average yearly number of patients seen at the four tertiary facilities was 71, and 31 at the four secondary facilities. Patients at secondary facilities were older, more frequently had severe comorbidity and lived in non-urban municipalities. As compared to combination chemotherapy, monotherapy with gemcitabine was used more often (59%) in secondary facilities than in tertiary (34%). The unadjusted median OS was 7.7 months at tertiary and 6.1 months at secondary facilities. The adjusted hazard ratio (HR) of 1.16 (confidence interval 1.07-1.27) demonstrated an excess risk of death for patients treated at secondary facilities, which disappeared when taking type of chemotherapy used into account. Hence, more use of combination chemotherapy was associated with the observed improved OS of patients treated at tertiary facilities. Declining HR's per year of first treatment indicated improved outcomes with time, however the difference among facility types remained significant. DISCUSSION Equal access to modern combination chemotherapy at all facilities on a national level is essential to ensure equality in treatment results.
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Affiliation(s)
- Morten Ladekarl
- Department of Oncology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Louise Skau Rasmussen
- Department of Oncology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Jakob Kirkegård
- Department of Gastrointestinal Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Inna Chen
- Department of Oncology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Britta Weber
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Kell Østerlind
- Department of Oncology, North Zealand Hospital, Hillerød, Denmark
| | - Jim Stenfatt Larsen
- Department of Oncology, Zealand University Hospital, Naestved and Roskilde, Denmark
| | | | - Henriette Engberg
- The Danish Clinical Quality Program and Clinical Registries (RKKP), Aalborg, Denmark
| | - Henrik Møller
- The Danish Clinical Quality Program and Clinical Registries (RKKP), Aalborg, Denmark
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Claus Wilki Fristrup
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Danish Pancreatic Cancer Database (DPCD), Denmark
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Pijnappel EN, Wassenaar NPM, Gurney-Champion OJ, Klaassen R, van der Lee K, Pleunis-van Empel MCH, Richel DJ, Legdeur MC, Nederveen AJ, van Laarhoven HWM, Wilmink JW. Phase I/II Study of LDE225 in Combination with Gemcitabine and Nab-Paclitaxel in Patients with Metastatic Pancreatic Cancer. Cancers (Basel) 2021; 13:4869. [PMID: 34638351 PMCID: PMC8507646 DOI: 10.3390/cancers13194869] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 09/17/2021] [Accepted: 09/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Desmoplasia is a central feature of the tumor microenvironment in pancreatic ductal adenocarcinoma (PDAC). LDE225 is a pharmacological Hedgehog signaling pathway inhibitor and is thought to specifically target tumor stroma. We investigated the combined use of LDE225 and chemotherapy to treat PDAC patients. METHODS This was a multi-center, phase I/II study for patients with metastatic PDAC establishing the maximum tolerated dose of LDE225 co-administered with gemcitabine and nab-paclitaxel (phase I) and evaluating the efficacy and safety of the treatment combination after prior FOLFIRINOX treatment (phase II). Tumor microenvironment assessment was performed with quantitative MRI using intra-voxel incoherent motion diffusion weighted MRI (IVIM-DWI) and dynamic contrast-enhanced (DCE) MRI. RESULTS The MTD of LDE225 was 200 mg once daily co-administered with gemcitabine 1000 mg/m2 and nab-paclitaxel 125 mg/m2. In phase II, six therapy-related grade 4 adverse events (AE) and three grade 5 were observed. In 24 patients, the target lesion response was evaluable. Three patients had partial response (13%), 14 patients showed stable disease (58%), and 7 patients had progressive disease (29%). Median overall survival (OS) was 6 months (IQR 3.9-8.1). Blood plasma fraction (DCE) and diffusion coefficient (IVIM-DWI) significantly increased during treatment. Baseline perfusion fraction could predict OS (>222 days) with 80% sensitivity and 85% specificity. CONCLUSION LDE225 in combination with gemcitabine and nab-paclitaxel was well-tolerated in patients with metastatic PDAC and has promising efficacy after prior treatment with FOLFIRINOX. Quantitative MRI suggested that LDE225 causes increased tumor diffusion and works particularly well in patients with poor baseline tumor perfusion.
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Affiliation(s)
- Esther N. Pijnappel
- Cancer Center Amsterdam, Department of Medical Oncology, Amsterdam University Medical Centers, University of Amsterdam, 1012 Amsterdam, The Netherlands; (E.N.P.); (R.K.); (K.v.d.L.); (D.J.R.); (H.W.M.v.L.)
| | - Nienke P. M. Wassenaar
- Cancer Center Amsterdam, Department of Radiology, Amsterdam University Medical Centers, University of Amsterdam, 1012 Amsterdam, The Netherlands; (N.P.M.W.); (O.J.G.-C.); (A.J.N.)
| | - Oliver J. Gurney-Champion
- Cancer Center Amsterdam, Department of Radiology, Amsterdam University Medical Centers, University of Amsterdam, 1012 Amsterdam, The Netherlands; (N.P.M.W.); (O.J.G.-C.); (A.J.N.)
| | - Remy Klaassen
- Cancer Center Amsterdam, Department of Medical Oncology, Amsterdam University Medical Centers, University of Amsterdam, 1012 Amsterdam, The Netherlands; (E.N.P.); (R.K.); (K.v.d.L.); (D.J.R.); (H.W.M.v.L.)
| | - Koen van der Lee
- Cancer Center Amsterdam, Department of Medical Oncology, Amsterdam University Medical Centers, University of Amsterdam, 1012 Amsterdam, The Netherlands; (E.N.P.); (R.K.); (K.v.d.L.); (D.J.R.); (H.W.M.v.L.)
| | | | - Dick J. Richel
- Cancer Center Amsterdam, Department of Medical Oncology, Amsterdam University Medical Centers, University of Amsterdam, 1012 Amsterdam, The Netherlands; (E.N.P.); (R.K.); (K.v.d.L.); (D.J.R.); (H.W.M.v.L.)
| | - Marie C. Legdeur
- Department of Medical Oncology, Medisch Spectrum Twente, Twente, 7512 Enschede, The Netherlands; (M.C.H.P.-v.E.); (M.C.L.)
| | - Aart J. Nederveen
- Cancer Center Amsterdam, Department of Radiology, Amsterdam University Medical Centers, University of Amsterdam, 1012 Amsterdam, The Netherlands; (N.P.M.W.); (O.J.G.-C.); (A.J.N.)
| | - Hanneke W. M. van Laarhoven
- Cancer Center Amsterdam, Department of Medical Oncology, Amsterdam University Medical Centers, University of Amsterdam, 1012 Amsterdam, The Netherlands; (E.N.P.); (R.K.); (K.v.d.L.); (D.J.R.); (H.W.M.v.L.)
| | - Johanna W. Wilmink
- Cancer Center Amsterdam, Department of Medical Oncology, Amsterdam University Medical Centers, University of Amsterdam, 1012 Amsterdam, The Netherlands; (E.N.P.); (R.K.); (K.v.d.L.); (D.J.R.); (H.W.M.v.L.)
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Blomstrand H, Batra A, Cheung WY, Elander NO. Real-world evidence on first- and second-line palliative chemotherapy in advanced pancreatic cancer. World J Clin Oncol 2021; 12:787-799. [PMID: 34631442 PMCID: PMC8479347 DOI: 10.5306/wjco.v12.i9.787] [Citation(s) in RCA: 13] [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: 02/28/2021] [Revised: 05/09/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
In spite of recent diagnostic and therapeutic advances, the prognosis of pancreatic ductal adenocarcinoma (PDAC) remains very poor. As most patients are not amenable to curative intent treatments, optimized palliative management is highly needed. One key question is to what extent promising results produced by randomized controlled trials (RCTs) correspond to clinically meaningful outcomes in patients treated outside the strict frames of a clinical trial. To answer such questions, real-world evidence is necessary. The present paper reviews and discusses the current literature on first- and second-line palliative chemotherapy in PDAC. Notably, a growing number of studies report that the outcomes of the two predominant first-line multidrug regimens, i.e. gemcitabine plus nab-paclitaxel (GnP) and folfirinox (FFX), is similar in RCTs and real-life populations. Outcomes of second-line therapy following failure of first-line regimens are still dismal, and considerable uncertainty of the optimal management remains. Additional RCTs and real-world evidence studies focusing on the optimal treatment sequence, such as FFX followed by GnP or vice versa, are urgently needed. Finally, the review highlights the need for prognostic and predictive biomarkers to inform clinical decision making and enable personalized management in advanced PDAC.
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Affiliation(s)
- Hakon Blomstrand
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping 58185, Sweden
| | - Atul Batra
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Winson Y Cheung
- Department of Oncology, University of Calgary, Calgary T2N 4N1, Canada
| | - Nils Oskar Elander
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping 58185, Sweden
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Mie T, Sasaki T, Takeda T, Okamoto T, Mori C, Furukawa T, Yamada Y, Kasuga A, Matsuyama M, Ozaka M, Sasahira N. Treatment outcomes of erlotinib plus gemcitabine as late-line chemotherapy in unresectable pancreatic cancer. Jpn J Clin Oncol 2021; 51:1416-1422. [PMID: 34128055 DOI: 10.1093/jjco/hyab091] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 05/28/2021] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE With the introduction of modified FOLFIRINOX and gemcitabine plus nab-paclitaxel therapy for unresectable pancreatic cancer, erlotinib plus gemcitabine therapy is now occasionally used as late-line therapy. This study investigates outcomes of treatment with erlotinib plus gemcitabine for unresectable pancreatic cancer. METHODS We retrospectively analysed consecutive patients with unresectable pancreatic cancer treated with erlotinib plus gemcitabine as the third or later-line chemotherapy between March 2014 and December 2020 in our hospital. RESULTS A total of 56 patients were included (third line/fourth or later line = 42/14). All patients were previously treated with gemcitabine plus nab-paclitaxel and 45 patients were previously treated with modified FOLFIRINOX. The median progression-free survival (PFS) and overall survival (OS) were 1.6 and 4.6 months, respectively. The disease control rate was 21.4%. Performance status, modified Glasgow prognostic score and carcinoembryonic antigen level were independently associated with survival. Our prognostic model using these parameters could classify patients into good (n = 32) and poor (n = 24) prognostic groups. The median PFS and OS were longer in good than in poor prognostic group, but the difference in PFS was very small (PFS: 2.1 vs. 1.4 months, P = 0.01. OS: 6.8 vs. 2.4 months, P < 0.01). Interstitial pneumonia occurred in one patient (1.8%). CONCLUSIONS Benefits of erlotinib plus gemcitabine as late-line chemotherapy were limited, particularly with respect to PFS. Development of more effective third-line treatment options is desirable in the future.
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Affiliation(s)
- Takafumi Mie
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tsuyoshi Takeda
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takeshi Okamoto
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Chinatsu Mori
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takaaki Furukawa
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yuto Yamada
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akiyoshi Kasuga
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masato Matsuyama
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masato Ozaka
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Naoki Sasahira
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
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5
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Real-world Outcomes Among Patients Treated With Gemcitabine-based Therapy Post-FOLFIRINOX Failure in Advanced Pancreatic Cancer. Am J Clin Oncol 2020; 42:903-908. [PMID: 31693510 DOI: 10.1097/coc.0000000000000625] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Limited evidence exists for chemotherapy selection in advanced pancreatic cancer (APC) after first-line FOLFIRINOX. Second-line gemcitabine/nab-paclitaxel (GEMNAB) is publicly funded in the Canadian provinces of Alberta (AB) and Manitoba (MB), but not in British Columbia (BC). We compared population-based outcomes by region to examine the utility of second-line GEMNAB versus gemcitabine (GEM) alone. METHODS We identified patients treated with first-line FOLFIRINOX between 2013 and 2015 across BC, AB, and MB. Baseline characteristics and treatment regimens were compared between AB/MB and BC. Survival outcomes were assessed by the Kaplan-Meier method and compared with log-rank test. RESULTS A total of 368 patients were treated with first-line FOLFIRINOX (143 AB/MB, 225 BC): median age 61 (interquartile range: 55 to 68) years, 42% comprising female individuals, and 67% with metastatic disease. Receipt of second-line therapy was 48% in AB/MB versus 44% in BC (P=0.35), and time from diagnosis to second-line therapy was 7.7 (AB/MB) versus 9.4 months (BC; P=0.1). Distribution of second-line GEM use: 73% GEMNAB, 23% GEM (AB/MB) versus 27% GEMNAB, 66% GEM (BC; P<0.001). Median overall survival (OS) from diagnosis was similar: 12.4 (AB/MB) versus 11.5 months (BC; P=0.91). On Cox regression analysis, region was not significant. Secondary survival analysis by second-line regimen demonstrated a median OS of 18.0 months with GEMNAB versus 14.3 months with GEM (P<0.01). CONCLUSIONS In this population-based comparison of APC patients treated with first-line FOLFIRINOX, survival outcomes were comparable regardless of funded access to second-line GEMNAB. OS by regimen favored second-line GEMNAB, but patient selection may be largely responsible for this difference.
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6
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Kieler M, Unseld M, Bianconi D, Schindl M, Kornek GV, Scheithauer W, Prager GW. Impact of New Chemotherapy Regimens on the Treatment Landscape and Survival of Locally Advanced and Metastatic Pancreatic Cancer Patients. J Clin Med 2020; 9:jcm9030648. [PMID: 32121198 PMCID: PMC7141274 DOI: 10.3390/jcm9030648] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 02/26/2020] [Indexed: 02/06/2023] Open
Abstract
Background: New chemotherapy regimens for the treatment of metastatic pancreatic cancer have changed the therapy paradigm. We aimed to assess their impact on the treatment landscape and clinical outcome at our academic institution. Methods: In this single institutional posthoc registry analysis, we assessed characteristics and survival rates from all patients with locally advanced and metastatic pancreatic cancer who started a systemic treatment between 01/2011 and 12/2017. Survival analyses were performed by Kaplan-Meier and Cox proportional hazards model. Results: A total of 301 patients started a systemic treatment in the observation period. In the first line treatment, we observed a shift from the four different main regimens (gemcitabine/nab-paclitaxel, modified FOLFIRINOX, gemcitabine/oxaliplatin +/− erlotinib or gemcitabine alone) to gemcitabine/nab-paclitaxel and modified FOLFIRINOX that add up to more than 80% of administered first line treatments in each of the time cohorts (2011–2013 vs. 2014–2017). The rate for first line modified FOLFIRINOX treatment was balanced between the two groups (19% and 15%). Median overall survival differed significantly between the two time cohorts (8.89 versus 11.9 months, p = 0.035). Survival rates for different first to second line treatment sequences (modified FOLFIRINOX to gemcitabine/nab-paclitaxel, gemcitabine/nab-paclitaxel to fluoropyrimidines plus nanoliposomal irinotecan, or gemcitabine/nab-paclitaxel to fluoropyrimidines plus oxaliplatin) were not significantly different and median overall survival ranged from 14.27 to 15.64 months. Conclusion: Our study provides real-world evidence for the effectiveness of the new chemotherapy regimens and underscores the importance of the choice of the front-line regimen when considering different sequencing strategies.
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Affiliation(s)
- Markus Kieler
- Department of Medicine I, Division of Oncology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria; (M.K.); (M.U.); (D.B.); (G.V.K.); (W.S.)
| | - Matthias Unseld
- Department of Medicine I, Division of Oncology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria; (M.K.); (M.U.); (D.B.); (G.V.K.); (W.S.)
| | - Daniela Bianconi
- Department of Medicine I, Division of Oncology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria; (M.K.); (M.U.); (D.B.); (G.V.K.); (W.S.)
| | - Martin Schindl
- Department of Surgery, Division of General Surgery, Pancreatic Cancer Unit, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria;
| | - Gabriela V. Kornek
- Department of Medicine I, Division of Oncology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria; (M.K.); (M.U.); (D.B.); (G.V.K.); (W.S.)
| | - Werner Scheithauer
- Department of Medicine I, Division of Oncology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria; (M.K.); (M.U.); (D.B.); (G.V.K.); (W.S.)
| | - Gerald W. Prager
- Department of Medicine I, Division of Oncology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria; (M.K.); (M.U.); (D.B.); (G.V.K.); (W.S.)
- Correspondence: ; Tel.: +43-1-40400-44500
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7
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Shi S, Yu X. Selecting chemotherapy for pancreatic cancer: Far away or so close? Semin Oncol 2019; 46:39-47. [PMID: 30611527 DOI: 10.1053/j.seminoncol.2018.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 01/26/2018] [Accepted: 12/19/2018] [Indexed: 02/06/2023]
Abstract
Pancreatic cancer is a lethal disease with a very poor prognosis. In contrast to treatments for many other tumor types, cytotoxic agents are still the first-line drugs for pancreatic cancer in both the palliative and adjuvant settings. Some progress has been made in recent years, but most large phase 3 studies have not shown significant improvements in survival. Because the available drugs and regimens are limited in both type and effect, the selection of chemotherapy based on clinicopathologic characteristics may be consequential for pancreatic cancer. In the present report, we focused on 7 landmark clinical trials for pancreatic cancer. We observed that FOLFIRINOX (oxaliplatin, irinotecan, fluorouracil, and leucovorin) and NG (nab-paclitaxel and gemcitabine), 2 first-line regimens, exerted opposite effects on metastatic pancreatic cancer patients with different baseline carbohydrate antigen 19-9 (CA19-9) levels. This suggested that not only the performance status but possibly also CA19-9 levels should be considered when making a therapeutic choice for patients with advanced pancreatic cancer. Moreover, we found that patients with a diagnosis of pancreatic cancer who have undergone a surgical resection with a negative margin (R0) may benefit more from fluorouracil and/or oral prodrugs of fluorouracil-based adjuvant therapy than from gemcitabine. Conversely, gemcitabine or gemcitabine-based regimens may be more effective for patients with a positive resection margin (R1). Based on these findings, we propose flowcharts for selecting chemotherapy for both advanced and resected pancreatic cancer. Furthermore, we present possible mechanisms and interpretations underlying the selection of chemotherapy for pancreatic cancer and propose the tumor burden as a key variable in this process. Regardless of the possible bias and exact treatment selection process, this study offers an opportunity to improve patient outcomes by using agents currently used in the therapy of pancreatic cancer. Although these conclusions are based on indirect evidence, we provide insights and possibilities to drive the selection of chemotherapy for pancreatic cancer.
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Affiliation(s)
- Si Shi
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China.
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8
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de Jesus VHF, Camandaroba MPG, Donadio MDS, Cabral A, Muniz TP, de Moura Leite L, Sant'Ana LF. Retrospective analysis of efficacy and safety of Gemcitabine-based chemotherapy in patients with metastatic pancreatic adenocarcinoma experiencing disease progression on FOLFIRINOX. J Gastrointest Oncol 2018; 9:806-819. [PMID: 30505579 DOI: 10.21037/jgo.2018.06.08] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Metastatic pancreatic adenocarcinoma (MPA) represents a highly lethal condition. Despite the improvements seen with FOLFIRINOX, there is no randomized data to guide treatment selection beyond this regimen. We aimed to evaluate the outcomes of patients with MPA progressing on FOLFIRINOX who were treated with Gemcitabine-based chemotherapy afterwards. Methods We included patients aged 18 years or older, treated for MPA with FOLFIRINOX in the first-line setting and who experienced disease progression, with Eastern Cooperative Oncology Group (ECOG) performance status 0-2, and treated with at least one cycle of Gemcitabine-based chemotherapy in second or further lines of treatment. We used descriptive statistics to characterize the study population and Cox proportional-hazards models to describe factors associated with survival. As an exploratory analysis, we compared the outcomes of patients treated with single-agent Gemcitabine with those of patients undergoing Gemcitabine-based polychemotherapy. Results The study population consisted of 42 patients. Median age was 59 years and 78.6% of patients presented ECOG 0-1. Thirty-three patients (78.6%) were treated with Gemcitabine-based chemotherapy in the second-line setting and 27 patients (64.3%) were treated with single-agent Gemcitabine. Objective response rate and disease control rate were 2.4% and 33.4%, respectively. Median progression-free survival (PFS) and median overall survival (OS) were 2.9 and 5.5 months, respectively. Six-month PFS and OS rates were 19.2% and 46.2%, respectively. We observed no significant difference in OS according to the type of Gemcitabine-based chemotherapy, despite numerically improved disease control rate and PFS for those treated with Gemcitabine-based polychemotherapy. In multivariate analysis, ECOG 2 (vs. ECOG 0-1) was the only factor significantly associated with inferior PFS and OS. Conclusions a subgroup of patients with MPA derives benefit from treatment with Gemcitabine-based regimens after FOLFIRINOX. There is a suggestion that Gemcitabine-based combinations, in particular Gemcitabine plus Nab-Paclitaxel, provide superior outcomes compared to single-agent Gemcitabine. Additionally, treatment in this setting should be offered carefully to patients with ECOG 2, as they present shorter survival and increased risk of toxicity.
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Affiliation(s)
| | | | | | - Audrey Cabral
- Medical Oncology Department, A.C. Camargo Cancer Center, São Paulo, SP, Brazil
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9
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Uccello M, Moschetta M, Mak G, Alam T, Henriquez CM, Arkenau HT. Towards an optimal treatment algorithm for metastatic pancreatic ductal adenocarcinoma (PDA). ACTA ACUST UNITED AC 2018; 25:e90-e94. [PMID: 29507500 DOI: 10.3747/co.25.3708] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Chemotherapy remains the mainstay of treatment for advanced pancreatic ductal adenocarcinoma (pda). Two randomized trials have demonstrated superiority of the combination regimens folfirinox (5-fluorouracil, leucovorin, oxaliplatin, and irinotecan) and gemcitabine plus nab-paclitaxel over gemcitabine monotherapy as a first-line treatment in adequately fit subjects. Selected pda patients progressing to first-line therapy can receive secondline treatment with moderate clinical benefit. Nevertheless, the optimal algorithm and the role of combination therapy in second-line are still unclear. Published second-line pda clinical trials enrolled patients progressing to gemcitabine-based therapies in use before the approval of nab-paclitaxel and folfirinox. The evolving scenario in second-line may affect the choice of the first-line treatment. For example, nanoliposomal irinotecan plus 5-fluouracil and leucovorin is a novel second-line option which will be suitable only for patients progressing to gemcitabine-based therapy. Therefore, clinical judgement and appropriate patient selection remain key elements in treatment decision. In this review, we aim to illustrate currently available options and define a possible algorithm to guide treatment choice. Future clinical trials taking into account sequential treatment as a new paradigm in pda will help define a standard algorithm.
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Affiliation(s)
- M Uccello
- Drug Development, Sarah Cannon Research Institute UK, London, United Kingdom; and
| | - M Moschetta
- Drug Development, Sarah Cannon Research Institute UK, London, United Kingdom; and
| | - G Mak
- Drug Development, Sarah Cannon Research Institute UK, London, United Kingdom; and
| | - T Alam
- Drug Development, Sarah Cannon Research Institute UK, London, United Kingdom; and
| | - C Murias Henriquez
- Drug Development, Sarah Cannon Research Institute UK, London, United Kingdom; and
| | - H-T Arkenau
- Drug Development, Sarah Cannon Research Institute UK, London, United Kingdom; and.,UCL Cancer Institute, University College of London, London, United Kingdom
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10
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Palacio S, Hosein PJ, Reis I, Akunyili II, Ernani V, Pollack T, Macintyre J, Restrepo MH, Merchan JR, Rocha Lima CM. The nab-paclitaxel/gemcitabine regimen for patients with refractory advanced pancreatic adenocarcinoma. J Gastrointest Oncol 2018; 9:135-139. [PMID: 29564179 DOI: 10.21037/jgo.2017.10.12] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The phase III MPACT trial for metastatic pancreatic cancer (PC) showed improved overall survival (OS), progression free survival (PFS) and response rates (RRs) for first-line nab-paclitaxel (Abraxane) and gemcitabine (the AG combination) compared to gemcitabine monotherapy. The safety and efficacy of the AG combination has not been systematically studied as second-line therapy or beyond for metastatic PC. We conducted an IRB-approved retrospective analysis of all patients diagnosed between September 2010 and August 2014 with advanced refractory PC that received combination treatment with AG at our institution. Demographic and survival data were extracted from the registry. Patients received nab-paclitaxel 125 mg/m2 and gemcitabine 1,000 mg/m2 and on days 1, 8 and 15 of a 28-day cycle with subsequent dose modifications based on tolerance. Data on 59 patients was available; the median age was 61; 55% were male; 56% received AG as second line therapy and 44% received it as third-line or beyond. Five (10%) patients had a confirmed partial response (PR), 23 (47%) had stable disease (SD) and 21 (43%) had disease progression as their best response. Among the 31 (52%) patients who received prior gemcitabine, 18 (58%) had clinical benefit; 3 had a PR and 15 had SD. The median OS was 3.9 months and the median progression-free survival was 3 months. Toxicity was similar to what was reported in the MPACT trial. This retrospective analysis suggests that AG is active in PC patients previously treated with either fluoropyrimidine-based therapy or gemcitabine-based therapy with manageable toxicities.
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Affiliation(s)
- Sofia Palacio
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Peter J Hosein
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Isildinha Reis
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Ikechukwu I Akunyili
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Vinicius Ernani
- Department of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Terri Pollack
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Jessica Macintyre
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Maria H Restrepo
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Jaime R Merchan
- Department of Medicine, University of Miami Miller School of Medicine and Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Caio M Rocha Lima
- Division of Oncology, Gibbs Comprehensive Cancer Center and Research Institute, Spartanburg, SC, USA
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11
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Giovannetti E, van der Borden CL, Frampton AE, Ali A, Firuzi O, Peters GJ. Never let it go: Stopping key mechanisms underlying metastasis to fight pancreatic cancer. Semin Cancer Biol 2017; 44:43-59. [PMID: 28438662 DOI: 10.1016/j.semcancer.2017.04.006] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/12/2017] [Accepted: 04/18/2017] [Indexed: 02/07/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an extremely aggressive neoplasm, predicted to become the second leading cause of cancer-related deaths before 2030. This dismal trend is mainly due to lack of effective treatments against its metastatic behavior. Therefore, a better understanding of the key mechanisms underlying metastasis should provide new opportunities for therapeutic purposes. Genomic analyses revealed that aberrations that fuel PDAC tumorigenesis and progression, such as SMAD4 loss, are also implicated in metastasis. Recently, microRNAs have been shown to play a regulatory role in the metastatic behavior of many tumors, including PDAC. In particular, miR-10 and miR-21 have appeared as master regulators of the metastatic program, while members of the miR-200 family are involved in the epithelial-to-mesenchymal switch, favoring cell migration and invasiveness. Several studies have also found a close relationship between cancer stem cells (CSCs) and biological features of metastasis, and the CSC markers ALDH1, ABCG2 and c-Met are expressed at high levels in metastatic PDAC cells. Emerging evidence reveals that exosomes are involved in the modulation of the tumor microenvironment and can initiate PDAC pre-metastatic niche formation in the liver and lungs. In this review, we provide an overview of the role of all these pivotal factors in the metastatic behavior of PDAC, and discuss their potential exploitation in the clinic to improve current therapeutics and identify new drug targets.
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Affiliation(s)
- E Giovannetti
- Lab Medical Oncology, Dept. Medical Oncology, VU University Medical Center (VUmc), Amsterdam, The Netherlands; Cancer Pharmacology Lab, AIRC Start Up Unit, University of Pisa, Pisa, Italy
| | - C L van der Borden
- Lab Medical Oncology, Dept. Medical Oncology, VU University Medical Center (VUmc), Amsterdam, The Netherlands
| | - A E Frampton
- HPB Surgical Unit, Dept. of Surgery & Cancer, Imperial College, Hammersmith Hospital Campus, London, UK
| | - A Ali
- Institute of Basic Medical Sciences, Khyber Medical University, Peshawar, KP, Pakistan; Institute of Cancer Sciences, University of Glasgow, UK
| | - O Firuzi
- Lab Medical Oncology, Dept. Medical Oncology, VU University Medical Center (VUmc), Amsterdam, The Netherlands; Medicinal and Natural Products Chemistry Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - G J Peters
- Lab Medical Oncology, Dept. Medical Oncology, VU University Medical Center (VUmc), Amsterdam, The Netherlands.
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12
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El Rassy E, Assi T, El Karak F, Ghosn M, Kattan J. Could the combination of Nab-paclitaxel plus gemcitabine salvage metastatic pancreatic adenocarcinoma after folfirinox failure? A single institutional retrospective analysis. Clin Res Hepatol Gastroenterol 2017; 41:e26-e28. [PMID: 28215539 DOI: 10.1016/j.clinre.2016.11.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/22/2016] [Accepted: 11/28/2016] [Indexed: 02/04/2023]
Affiliation(s)
- Elie El Rassy
- Department of Oncology, Faculty of Medicine, Saint Joseph University, Hôtel-Dieu de France University Hospital, Beirut, Lebanon.
| | - Tarek Assi
- Department of Oncology, Faculty of Medicine, Saint Joseph University, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Fadi El Karak
- Department of Oncology, Faculty of Medicine, Saint Joseph University, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Marwan Ghosn
- Department of Oncology, Faculty of Medicine, Saint Joseph University, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Joseph Kattan
- Department of Oncology, Faculty of Medicine, Saint Joseph University, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
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13
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Buanes TA. Updated therapeutic outcome for patients with periampullary and pancreatic cancer related to recent translational research. World J Gastroenterol 2016; 22:10502-10511. [PMID: 28082802 PMCID: PMC5192261 DOI: 10.3748/wjg.v22.i48.10502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 10/14/2016] [Accepted: 11/23/2016] [Indexed: 02/06/2023] Open
Abstract
Chemotherapy with improved effect in patients with metastatic pancreatic cancer has recently been established, launching a new era for patients with this very aggressive disease. FOLFIRINOX and gemcitabine plus nab-paclitaxel are different regimens, both capable of stabilizing the disease, thus increasing the number of patients who can reach second line and even third line of treatment. Concurrently, new windows of opportunity open for nutritional support and other therapeutic interventions, improving quality of life. Also pancreatic surgery has changed significantly during the latest years. Extended operations, including vascular/multivisceral resections are frequently performed in specialized centers, pushing borders of resectability. Potentially curative treatment including neoadjuvant and adjuvant chemotherapy is offered new patient groups. Translational research is the basis for the essential understanding of the ongoing development. Even thou biomarkers for clinical management of patients with periampullary tumors have almost been lacking, biomarker driven trials are now in progress. New insight is constantly made available for clinicians; one recent example is selection of patients for gemcitabine treatment based on the expression level of the human equilibrium nucleoside transporter 1. An example of new diagnostic tools is identification of early pancreatic cancer patients by a three-biomarker panel in urine: The proteins lymphatic vessel endothelial hyaluronan receptor 1, regenerating gene 1 alpha and translation elongation factor 1 alpha. Requirement of treatment guideline revisions is intensifying, as combined chemotherapy regimens result in unexpected advantages. The European Study Group for Pancreatic Cancer 4 trial outcome is an illustration: Addition of capecitabine in the adjuvant setting improved overall survival more than expected from the effect in advanced disease. Rapid implementation of new treatment options is mandatory when progress finally extends to patients with this serious disease.
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14
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Comment on: ‘Nab-paclitaxel plus gemcitabine for metastatic pancreatic adenocarcinoma after Folfirinox failure: an AGEO prospective multicentre cohort’. Br J Cancer 2016; 114:e8. [PMID: 27124336 PMCID: PMC4891507 DOI: 10.1038/bjc.2016.69] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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