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Safyan RA, Kim E, Dekker E, Homs M, Aguirre AJ, Koerkamp BG, Chiorean EG. Multidisciplinary Standards and Evolving Therapies for Patients With Pancreatic Cancer. Am Soc Clin Oncol Educ Book 2024; 44:e438598. [PMID: 38781541 DOI: 10.1200/edbk_438598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Pancreatic ductal adenocarcinoma (PDA) is a challenging disease that presents at an advanced stage and results in many symptoms that negatively influence patients' quality of life and reduce their ability to receive effective treatment. Early implementation of expert multidisciplinary care with nutritional support, exercise, and palliative care for both early-stage and advanced disease promises to maintain or improve the patients' physical, social, and psychological well-being, decrease aggressive interventions at the end of life, and ultimately improve survival. Moreover, advances in treatment strategies in the neoadjuvant and metastatic setting combined with novel therapeutic agents targeting the key drivers of the disease are leading to improvements in the care of patients with pancreatic cancer. Here, we emphasize the multidisciplinary supportive and therapeutic care of patients with PDA, review current guidelines and new developments of neoadjuvant and perioperative treatments for localized disease, as well as the treatment standards and the evolving field of precision oncology and immunotherapies for advanced PDA.
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Affiliation(s)
- Rachael A Safyan
- University of Washington School of Medicine, Department of Medicine, Division of Hematology-Oncology, Seattle, WA
- Fred Hutchinson Cancer Center, Clinical Research Division, Seattle, WA
| | - Eejung Kim
- Dana-Farber Cancer Center, Department of Medical Oncology, Boston, MA
- Harvard Medical School, Boston, MA
| | - Emmelie Dekker
- Erasmus MC Cancer Institute, Department of Surgery, Rotterdam, the Netherlands
| | - Marjolein Homs
- Erasmus MC Cancer Institute, Department of Medical Oncology, Rotterdam, the Netherlands
| | - Andrew J Aguirre
- Dana-Farber Cancer Center, Department of Medical Oncology, Boston, MA
- Harvard Medical School, Boston, MA
| | - Bas Groot Koerkamp
- Erasmus MC Cancer Institute, Department of Surgery, Rotterdam, the Netherlands
| | - E Gabriela Chiorean
- University of Washington School of Medicine, Department of Medicine, Division of Hematology-Oncology, Seattle, WA
- Fred Hutchinson Cancer Center, Clinical Research Division, Seattle, WA
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Mehra T, Lupatsch JE, Kössler T, Dedes K, Siebenhüner AR, von Moos R, Wicki A, Schwenkglenks ME. Olaparib not cost-effective as maintenance therapy for platinum-sensitive, BRCA1/2 germline-mutated metastatic pancreatic cancer. PLoS One 2024; 19:e0301271. [PMID: 38573891 PMCID: PMC10994352 DOI: 10.1371/journal.pone.0301271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/13/2024] [Indexed: 04/06/2024] Open
Abstract
OBJECTIVE To assess the cost-effectiveness and budget impact of olaparib as a maintenance therapy in platinum-responsive, metastatic pancreatic cancer patients harboring a germline BRCA1/2 mutation, using the Swiss context as a model. METHODS Based on data from the POLO trial, published literature and local cost data, we developed a partitioned survival model of olaparib maintenance including full costs for BRCA1/2 germline testing compared to FOLFIRI maintenance chemotherapy and watch-and-wait. We calculated the incremental cost-effectiveness ratio (ICER) for the base case and several scenario analyses and estimated 5-year budget impact. RESULTS Comparing olaparib with watch-and wait and maintenance chemotherapy resulted in incremental cost-effectiveness ratios of CHF 2,711,716 and CHF 2,217,083 per QALY gained, respectively. The 5-year costs for the olaparib strategy in Switzerland would be CHF 22.4 million, of which CHF 11.4 million would be accounted for by germline BRCA1/2 screening of the potentially eligible population. This would amount to a budget impact of CHF 15.4 million (USD 16.9 million) versus watch-and-wait. CONCLUSIONS Olaparib is not a cost-effective maintenance treatment option. Companion diagnostics are an equally important cost driver as the drug itself.
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Affiliation(s)
- Tarun Mehra
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Judith E. Lupatsch
- Department of Public Health, Institute of Pharmaceutical Medicine (ECPM) and Health Economics Facility, University of Basel, Basel, Switzerland
| | - Thibaud Kössler
- Service d’oncologie, Hôpitaux Universitaires Genève, Genève, Switzerland
| | | | | | - Roger von Moos
- Department of Medical Oncology and Hematology, Cantonal Hospital of Graubünden, Chur, Switzerland
| | - Andreas Wicki
- Department of Medical Oncology and Hematology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Matthias E. Schwenkglenks
- Department of Public Health and Head of Research, Health Economics Facility, Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
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Garajová I, Peroni M, Gelsomino F, Leonardi F. A Simple Overview of Pancreatic Cancer Treatment for Clinical Oncologists. Curr Oncol 2023; 30:9587-9601. [PMID: 37999114 PMCID: PMC10669959 DOI: 10.3390/curroncol30110694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/13/2023] [Accepted: 10/24/2023] [Indexed: 11/25/2023] Open
Abstract
Pancreatic cancer (PDAC) is one of the most aggressive solid tumors and is showing increasing incidence. The aim of our review is to provide practical help for all clinical oncologists and to summarize the current management of PDAC using a simple "ABC method" (A-anatomical resectability, B-biological resectability and C-clinical conditions). For anatomically resectable PDAC without any high-risk factors (biological or conditional), the actual standard of care is represented by surgery followed by adjuvant chemotherapy. The remaining PDAC patients should all be treated with initial systemic therapy, though the intent for each is different: for borderline resectable patients, the intent is neoadjuvant; for locally advanced patients, the intent is conversion; and for metastatic PDAC patients, the intent remains just palliative. The actual standard of care in first-line therapy is represented by two regimens: FOLFIRINOX and gemcitabine/nab-paclitaxel. Recently, NALIRIFOX showed positive results over gemcitabine/nab-paclitaxel. There are limited data for maintenance therapy after first-line treatment, though 5-FU or FOLFIRI after initial FOLFIRINOX, and gemcitabine, after initial gemcitabine/nab-paclitaxel, might be considered. We also dedicate space to special rare conditions, such as PDAC with germline BRCA mutations, pancreatic acinar cell carcinoma and adenosquamous carcinoma of the pancreas, with few clinically relevant remarks.
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Affiliation(s)
- Ingrid Garajová
- Medical Oncology Unit, University Hospital of Parma, 43125 Parma, Italy; (M.P.)
| | - Marianna Peroni
- Medical Oncology Unit, University Hospital of Parma, 43125 Parma, Italy; (M.P.)
| | - Fabio Gelsomino
- Department of Oncology and Hematology, University Hospital of Modena, 41124 Modena, Italy
| | - Francesco Leonardi
- Medical Oncology Unit, University Hospital of Parma, 43125 Parma, Italy; (M.P.)
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Sütcüoğlu O, Doğan A, Yilmaz F, Şahin AB, Şahin TK, Esen SA, Erol C, Üner A, Özet A, Turan N, Eraslan E, Deligönül A, Odabaş H, Günel N, Uçar G, Dede DŞ, Dizdar Ö, Çubukçu E, Öksüzoğlu ÖB, Emre Yildirim M, Yazici O, Özdemir N. Retrospective Evaluation of the Efficacy of Gemcitabine-Based Therapies After FOLFIRINOX Failure in Advanced Pancreatic Cancer, Multi-Center Real-Life Data. Pancreas 2023; 52:e235-e240. [PMID: 37816170 DOI: 10.1097/mpa.0000000000002238] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
OBJECTIVE Combination therapies such as FOLFIRINOX or gemcitabine-nanoparticle albumin-bound paclitaxel (GnP) are recommended for the first-line treatment of patients with advanced pancreatic cancer. The purpose of this study was to evaluate the efficacy of gemcitabine-based second-line therapies in patients whose disease progressed on FOLFIRINOX. METHOD Patients diagnosed with advanced pancreatic cancer in 7 tertiary hospitals in Turkey were included. Patients were divided into 3 different groups according to their treatment regimens: GnP, gemcitabine doublet (gemcitabine-cisplatin or gemcitabine-capecitabine), and gemcitabine monotherapy. RESULTS A total of 144 patients were included in the study. In the second-line treatment, 65% of patients were given GnP, 20% were given gemcitabine doublet, and 15% were given gemcitabine monotherapy. The median exposure of the patients to gemcitabine-based therapy was 3 cycles, whereas the median progression-free survival was calculated as 3.4 months. The median overall survival for patients who received GnP was 4.6 months, 6.4 months for patients who received gemcitabine doublet therapy, and 3.7 months for patients who received gemcitabine monotherapy ( P = 0.248). CONCLUSION In conclusion, it has been shown that gemcitabine-based second-line treatments contribute to survival in patients with advanced pancreatic cancer. In addition, there was no difference in efficacy between gemcitabine monotherapy or combination treatments.
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Affiliation(s)
- Osman Sütcüoğlu
- From the Department of Medical Oncology, Gazi University, Ankara
| | - Akif Doğan
- Department of Medical Oncology, Kartal Dr. Lütfi Kirdar City Hospital, İstanbul
| | - Funda Yilmaz
- Department of Medical Oncology, Dr. Abdurrahman Yurtarslan Oncology Training and Research Hospital, Ankara
| | | | | | | | - Cihan Erol
- Department of Medical Oncology, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Aytuğ Üner
- From the Department of Medical Oncology, Gazi University, Ankara
| | - Ahmet Özet
- From the Department of Medical Oncology, Gazi University, Ankara
| | - Nedim Turan
- Department of Medical Oncology, Kartal Dr. Lütfi Kirdar City Hospital, İstanbul
| | - Emrah Eraslan
- Department of Medical Oncology, Dr. Abdurrahman Yurtarslan Oncology Training and Research Hospital, Ankara
| | - Adem Deligönül
- Department of Medical Oncology, Uludağ University, Bursa
| | - Hatice Odabaş
- Department of Medical Oncology, Kartal Dr. Lütfi Kirdar City Hospital, İstanbul
| | - Nazan Günel
- From the Department of Medical Oncology, Gazi University, Ankara
| | - Gökhan Uçar
- Department of Medical Oncology, Ankara City Hospital
| | - Didem Şener Dede
- Department of Medical Oncology, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Ömer Dizdar
- Department of Medical Oncology, Hacettepe University
| | - Erdem Çubukçu
- Department of Medical Oncology, Uludağ University, Bursa
| | - Ömür Berna Öksüzoğlu
- Department of Medical Oncology, Dr. Abdurrahman Yurtarslan Oncology Training and Research Hospital, Ankara
| | | | - Ozan Yazici
- From the Department of Medical Oncology, Gazi University, Ankara
| | - Nuriye Özdemir
- From the Department of Medical Oncology, Gazi University, Ankara
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Dayyani F, Macarulla T, Johnson A, Wainberg ZA. Second-line treatment options for patients with metastatic pancreatic ductal adenocarcinoma: A systematic literature review. Cancer Treat Rev 2023; 113:102502. [PMID: 36641880 DOI: 10.1016/j.ctrv.2022.102502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION The aim of this review was to characterize the second- and later-line (≥2L) treatment landscape for patients with metastatic pancreatic ductal adenocarcinoma (mPDAC). METHODS This systematic literature review (PROSPERO: CRD42021279753) involved searches of MEDLINE® and Embase to identify results from prospective studies of ≥2L treatment options for metastatic pancreatic cancer published from 2016 to 2021. Publications were screened according to predetermined eligibility criteria; population-level data were extracted using standardized data fields. Publication quality was assessed according to Grading of Recommendations Assessment, Development and Evaluation (GRADE). The data were analyzed descriptively, grouped by drug class. RESULTS Sixty publications were identified, including 23 relating to comparative trials. GRADE assessment found that, of these 23 trials, 83% reported high or moderate-quality evidence. Of the publications relating to comparative trials, nine (three trials) reported favorable results: the pivotal phase 3 NAPOLI-1 trial for liposomal irinotecan; a phase 3 trial of non-liposomal irinotecan within the FOLFIRINOX regimen; and a phase 2 trial of eryaspase plus chemotherapy. CONCLUSIONS The level of unmet need for ≥2L treatment options for mPDAC remains high. Irinotecan-based regimens currently offer the greatest promise. Investigations into paradigm-changing agents and combination approaches continue.
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Affiliation(s)
| | - Teresa Macarulla
- Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
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Treatment Outcomes and Prognostic Factors of Gemcitabine Plus Nab-Paclitaxel as Second-Line Chemotherapy after Modified FOLFIRINOX in Unresectable Pancreatic Cancer. Cancers (Basel) 2023; 15:cancers15020358. [PMID: 36672308 PMCID: PMC9857205 DOI: 10.3390/cancers15020358] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/26/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
Outcomes and prognostic factors of second-line gemcitabine plus nab-paclitaxel (GnP) after modified FOLFIRINOX (mFFX) for unresectable pancreatic cancer were unclear. We retrospectively analyzed consecutive patients with unresectable pancreatic cancer treated with GnP after first-line mFFX treatment between March 2015 and March 2022 at our hospital. A total of 103 patients were included. Median overall survival (OS) from the start of first-line and second-line treatments was 14.9 months and 7.2 months, respectively. Median progression-free survival (PFS) was 3.6 months. Performance status, modified Glasgow prognostic score, and neutrophil-to-lymphocyte ratio were independently associated with OS. Our prognostic model using these parameters classifies patients into good (n = 70) and poor (n = 33) prognosis groups. Median OS and PFS were longer in the good prognosis group than in the poor prognosis group (OS: 9.3 vs. 3.8 months, p < 0.01; PFS: 4.1 vs. 2.3 months, p < 0.01). Grade 3/4 adverse events were observed in 70.9% of patients, with neutropenia being the most frequent. While GnP as second-line treatment was well-tolerated, efficacy of second-line gemcitabine plus nab-paclitaxel was notably limited, particularly in the poor prognosis group.
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Huffman BM, Basu Mallick A, Horick NK, Wang-Gillam A, Hosein PJ, Morse MA, Beg MS, Murphy JE, Mavroukakis S, Zaki A, Schlechter BL, Sanoff H, Manz C, Wolpin BM, Arlen P, Lacy J, Cleary JM. Effect of a MUC5AC Antibody (NPC-1C) Administered With Second-Line Gemcitabine and Nab-Paclitaxel on the Survival of Patients With Advanced Pancreatic Ductal Adenocarcinoma: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2249720. [PMID: 36602796 PMCID: PMC9856813 DOI: 10.1001/jamanetworkopen.2022.49720] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Treatment options are limited for patients with advanced pancreatic ductal adenocarcinoma (PDAC) beyond first-line 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX), with such individuals commonly being treated with gemcitabine and nab-paclitaxel. OBJECTIVE To determine whether NPC-1C, an antibody directed against MUC5AC, might increase the efficacy of second-line gemcitabine and nab-paclitaxel in patients with advanced PDAC. DESIGN, SETTING, AND PARTICIPANTS This multicenter, randomized phase II clinical trial enrolled patients with advanced PDAC between April 2014 and March 2017 whose disease had progressed on first-line FOLFIRINOX. Eligible patients had tumors with at least 20 MUC5AC staining by centralized immunohistochemistry review. Statistical analysis was performed from April to May 2022. INTERVENTIONS Patients were randomly assigned to receive gemcitabine (1000 mg/m2) and nab-paclitaxel (125 mg/m2) administered intravenously on days 1, 8, and 15 of every 4-week cycle, with or without intravenous NPC-1C 1.5 mg/kg every 2 weeks. MAIN OUTCOMES AND MEASURES The primary end point was overall survival (OS). Secondary end points were progression-free survival (PFS), objective response rate (ORR), and safety. Pretreatment clinical variables were explored with Cox proportional hazards analysis. RESULTS A total of 78 patients (median [range] age, 62 [36-78] years; 32 [41%] women; 9 [12%] Black; 66 [85%] White) received second-line treatment with gemcitabine plus nab-paclitaxel (n = 40) or gemcitabine plus nab-paclitaxel and NPC-1C (n = 38). Median OS was 6.6 months (95% CI, 4.7-8.4 months) with gemcitabine plus nab-paclitaxel vs 5.0 months (95% CI, 3.3-6.5 months; P = .22) with gemcitabine plus nab-paclitaxel and NPC-1C. Median PFS was 2.7 months (95% CI, 1.9-4.1 months) with gemcitabine plus nab-paclitaxel vs 3.4 months (95% CI, 1.9-5.3 months; P = .80) with gemcitabine plus nab-paclitaxel and NPC-1C. The ORR was 3.1% (95% CI, 0.4%-19.7%) in the gemcitabine plus nab-paclitaxel and NPC-1C group and 2.9% (95% CI, 0.4%-18.7%) in the gemcitabine plus nab-paclitaxel group. No differences in toxicity were observed between groups, except that grade 3 or greater anemia occurred more frequently in patients treated with gemcitabine plus nab-paclitaxel and NPC-1C than gemcitabine plus nab-paclitaxel (39% [15 of 38] vs 10% [4 of 40]; P = .003). The frequency of chemotherapy dose reductions was similar in both groups (65% vs 74%; P = .47). Lower performance status, hypoalbuminemia, PDAC diagnosis less than or equal to 18 months before trial enrollment, lymphocyte-to-monocyte ratio less than 2.8, and CA19-9 greater than 2000 IU/mL were independently associated with poorer survival. CONCLUSIONS AND RELEVANCE In this randomized clinical trial of advanced PDAC, NPC-1C did not enhance the efficacy of gemcitabine/nab-paclitaxel. These data provide a benchmark for future trials investigating second-line treatment of PDAC. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01834235.
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Affiliation(s)
- Brandon M. Huffman
- Division of Gastrointestinal Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | - Atrayee Basu Mallick
- Thomas Jefferson University/Sidney Kimmel Cancer Center, Philadelphia, Pennsylvania
| | - Nora K. Horick
- Biostatistics Center, Massachusetts General Hospital, Boston
| | - Andrea Wang-Gillam
- Washington University in St. Louis, School of Medicine, St. Louis, Missouri
| | | | | | - Muhammad Shaalan Beg
- UT Southwestern Medical Center, Dallas, Texas
- Science 37 Inc, Durham, North Carolina
| | - Janet E. Murphy
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston
| | | | | | | | | | - Christopher Manz
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | - Brian M. Wolpin
- Division of Gastrointestinal Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
| | | | - Jill Lacy
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut
| | - James M. Cleary
- Division of Gastrointestinal Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, Massachusetts
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Noel MS, Kim S, Hartley ML, Wong S, Picozzi V, Staszewski H, Kim DW, Van Tornout JM, Philip PA, Chung V, Ocean AJ, Wang‐Gillam A. A randomized phase II study of SM-88 plus methoxsalen, phenytoin, and sirolimus in patients with metastatic pancreatic cancer treated in the second line and beyond. Cancer Med 2022; 11:4169-4181. [PMID: 35499204 PMCID: PMC9678093 DOI: 10.1002/cam4.4768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/11/2022] [Accepted: 04/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This trial explores SM-88 used with methoxsalen, phenytoin, and sirolimus (MPS) in pretreated metastatic pancreatic ductal adenocarcinoma (mPDAC) METHODS: Forty-nine patients were randomized to daily 460 or 920 mg oral SM-88 with MPS (SM-88 Regimen). The primary endpoint was objective response rate (RECIST 1.1). RESULTS Thirty-seven patients completed ≥ one cycle of SM-88 Regimen (response evaluable population). Disease control rate (DCR), overall survival (OS), and progression-free survival (PFS) did not differ significantly between dose levels. Stable disease was achieved in 9/37 patients (DCR, 24.3%); there were no complete or partial responses. Quality-of-life (QOL) was maintained and trended in favor of 920 mg. SM-88 Regimen was well tolerated; a single patient (1/49) had related grade 3 and 4 adverse events, which later resolved. In the intention-to-treat population of 49 patients, the median overall survival (mOS) was 3.4 months (95% CI: 2.7-4.9 months). Those treated in the second line had an mOS of 8.1 months and a median PFS of 3.8 months. Survival was higher for patients with stable versus progressive disease (any line; mOS: 10.6 months vs. 3.9 months; p = 0.01). CONCLUSIONS SM-88 Regimen has a favorable safety profile with encouraging QOL effects, disease control, and survival trends. This regimen should be explored in the second-line treatment of patients with mPDAC. CLINICALTRIALS gov Identifier: NCT03512756.
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Affiliation(s)
- Marcus S. Noel
- Georgetown Lombardi Comprehensive Cancer CenterWashingtonDistrict of ColumbiaUSA
| | - Semmie Kim
- TYME Technologies Inc.BedminsterNew JerseyUSA
| | - Marion L. Hartley
- The Ruesch Center for the Cure of Gastrointestinal CancersWashingtonDistrict of ColumbiaUSA
| | - Steve Wong
- Sarcoma Oncology Research CenterSanta MonicaCaliforniaUSA
| | | | | | - Dae Won Kim
- The University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | | | - Philip Agop Philip
- Karmanos Cancer CenterWayne State UniversityMichiganDetroitUSA
- SWOGFarmington HillsMichiganUSA
| | | | - Allyson J. Ocean
- Weill Cornell MedicineNew York‐Presbyterian HospitalNew YorkNew YorkUSA
| | - Andrea Wang‐Gillam
- Washington University School of Medicine in St. LouisSt. LouisMissouriUSA
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Christenson ES, Lim SJ, Durham J, De Jesus-Acosta A, Bever K, Laheru D, Ryan A, Agarwal P, Scharpf RB, Le DT, Wang H. Cell-free DNA Predicts Prolonged Response to Multi-agent Chemotherapy in Pancreatic Ductal Adenocarcinoma. CANCER RESEARCH COMMUNICATIONS 2022; 2:1418-1425. [PMID: 36970054 PMCID: PMC10035498 DOI: 10.1158/2767-9764.crc-22-0343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/18/2022] [Accepted: 10/18/2022] [Indexed: 11/07/2022]
Abstract
The treatment of metastatic pancreatic ductal adenocarcinoma (PDAC) is frequently characterized by significant toxicity and rapid development of resistance to current approved therapies. More reliable biomarkers of response are needed to guide clinical decision making. We evaluated cell-free DNA (cfDNA) using a tumor-agnostic platform and traditional biomarkers (CEA and CA19-9) levels in 12 patients treated at Johns Hopkins University on NCT02324543 "Study of Gemcitabine/Nab-Paclitaxel/Xeloda (GAX) in Combination With Cisplatin and Irinotecan in Subjects With Metastatic Pancreatic Cancer." The pretreatment values, levels after 2 months of treatment, and change in biomarker levels with treatment were compared with clinical outcomes to determine their predictive value. The variant allele frequency (VAF) of KRAS and TP53 mutations in cfDNA after 2 months of treatment was predictive of progression-free survival (PFS) and overall survival (OS). In particular, patients with a lower-than-average KRAS VAF after 2 months of treatment had a substantially longer PFS than patients with higher posttreatment KRAS VAF (20.96 vs. 4.39 months). Changes in CEA and CA19-9 after 2 months of treatment were also good predictors of PFS. Comparison via concordance index demonstrated KRAS or TP53 VAF after 2 months of treatment to be better predictors of PFS and OS than CA19-9 or CEA. This pilot study requires validation but suggests cfDNA measurement is a useful adjunct to traditional protein biomarkers and imaging evaluation and could distinguish between patients who are likely to achieve prolonged responses versus those that will have early progression and may benefit from a change in treatment approach. Significance We report on the association of cfDNA with response durability for patients undergoing treatment with a novel metronomic chemotherapy regimen (gemcitabine, nab-paclitaxel, capecitabine, cisplatin, irinotecan; GAX-CI) for metastatic PDAC. This investigation offers encouraging evidence that cfDNA may prove to be a valuable diagnostic tool to guide clinical management.
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Affiliation(s)
- Eric S Christenson
- Bloomberg-Kimmel Institute, Sidney Kimmel Comprehensive Cancer Center, and The Skip Viragh Center for Pancreatic Cancer Research and Clinical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Su Jin Lim
- Bloomberg-Kimmel Institute, Sidney Kimmel Comprehensive Cancer Center, and The Skip Viragh Center for Pancreatic Cancer Research and Clinical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer Durham
- Bloomberg-Kimmel Institute, Sidney Kimmel Comprehensive Cancer Center, and The Skip Viragh Center for Pancreatic Cancer Research and Clinical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ana De Jesus-Acosta
- Bloomberg-Kimmel Institute, Sidney Kimmel Comprehensive Cancer Center, and The Skip Viragh Center for Pancreatic Cancer Research and Clinical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Katherine Bever
- Bloomberg-Kimmel Institute, Sidney Kimmel Comprehensive Cancer Center, and The Skip Viragh Center for Pancreatic Cancer Research and Clinical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel Laheru
- Bloomberg-Kimmel Institute, Sidney Kimmel Comprehensive Cancer Center, and The Skip Viragh Center for Pancreatic Cancer Research and Clinical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amy Ryan
- Bloomberg-Kimmel Institute, Sidney Kimmel Comprehensive Cancer Center, and The Skip Viragh Center for Pancreatic Cancer Research and Clinical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Parul Agarwal
- Bloomberg-Kimmel Institute, Sidney Kimmel Comprehensive Cancer Center, and The Skip Viragh Center for Pancreatic Cancer Research and Clinical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert B Scharpf
- Bloomberg-Kimmel Institute, Sidney Kimmel Comprehensive Cancer Center, and The Skip Viragh Center for Pancreatic Cancer Research and Clinical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dung T Le
- Bloomberg-Kimmel Institute, Sidney Kimmel Comprehensive Cancer Center, and The Skip Viragh Center for Pancreatic Cancer Research and Clinical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hao Wang
- Bloomberg-Kimmel Institute, Sidney Kimmel Comprehensive Cancer Center, and The Skip Viragh Center for Pancreatic Cancer Research and Clinical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Sadaka S, Iwashita T, Fujii H, Kato-Hayashi H, Ohata K, Uemura S, Shimizu M, Suzuki A. Impact of First-Line FOLFIRINOX-Induced Peripheral Neuropathy on the Efficacy of Second-Line GnP in Patients with Unresectable Advanced Pancreatic Cancer. J Clin Med 2022; 11:jcm11195895. [PMID: 36233762 PMCID: PMC9572211 DOI: 10.3390/jcm11195895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/02/2022] [Accepted: 10/03/2022] [Indexed: 11/16/2022] Open
Abstract
Modified FOLFIRINOX (mFFX) and Gemcitabine plus nab-paclitaxel (GnP) are effective first-line chemotherapies for unresectable advanced pancreatic cancer (APC); however, both lead to peripheral neuropathy (PN). Aims: To evaluate the impact of first-line mFFX-induced PN on the efficacy of second-line GnP in patients with APC. Methods: A database containing patients with APC was retrospectively analyzed to evaluate patients who received second-line GnP after first-line mFFX failure between September 2014 and January 2021. The efficacy and safety of GnP were compared between patients with PN ≥ Grade 2 (PN group) and PN ≤ Grade 1 (non-PN group) at the start of second-line GnP. Cox proportional hazards analysis was also performed to examine the effect on overall survival (OS) and time-to-treatment failure (TTF). Results: Fifty-nine patients (PN group, 18 patients; non-PN group, 41 patients) were included. Median OS and TTF in the PN versus non-PN group were 7.7 versus 5.7 months (p = 0.19) and 3.8 versus 2.7 months (p = 0.18), respectively. Multivariate analysis showed that PN (≥Grade 2) was not a significant factor affecting either OS (hazard ratio (HR) 0.66, 95% confidence interval [CI] 0.33–1.31, p = 0.24) or TTF (HR 0.71, 95% CI 0.38–1.33, p = 0.28). No significant difference was observed in the relative dose intensity of GEM or nab-PTX, and incidence of adverse events. Conclusions: mFFX-induced PN has little impact on the efficacy and safety of second-line GnP in patients with APC. Second-line GnP could be a possible treatment option regardless of the presence of PN.
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Affiliation(s)
- Shiori Sadaka
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu 501-1194, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu 501-1194, Japan
- Correspondence: ; Tel.: +81-58-230-6308; Fax: +81-58-230-6316
| | - Hironori Fujii
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu 501-1194, Japan
| | - Hiroko Kato-Hayashi
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu 501-1194, Japan
| | - Koichi Ohata
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu 501-1194, Japan
| | - Shinya Uemura
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu 501-1194, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu 501-1194, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu 501-1194, Japan
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11
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Servetto A, Santaniello A, Napolitano F, Foschini F, Marciano R, Cascetta P, Amato AR, Augurio MR, Maresca L, De Placido P, De Placido S, Formisano L, Bianco R. FOLFIRINOX or nab-paclitaxel plus gemcitabine in metastatic pancreatic adenocarcinoma: an observational study. Future Oncol 2022; 18:2643-2653. [PMID: 35608115 DOI: 10.2217/fon-2021-1142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Comparison of first-line FOLFIRINOX (FFN) and nab-paclitaxel plus gemcitabine (NabGem) in patients with metastatic pancreatic ductal adenocarcinoma. Patients & methods: The authors analyzed data from 160 patients with metastatic pancreatic adenocarcinoma receiving first-line FFN (n = 43) or NabGem (n = 117). Results: FFN and NabGem were similar in median progression-free survival (24.43 vs 26.28 weeks; hazard ratio [HR]: 0.88) and medial overall survival (47.43 vs 42.86 weeks; HR: 0.90). Of the 43 patients receiving FFN, 26 (60.4%) were treated with second-line NabGem; 14/117 (12.0%) patients receiving NabGem received second-line FFN (p < 0.0001). In the FFN → NabGem and NabGem → FFN groups, median overall survival was 51.2 and 71.6 weeks (HR: 0.69; p = 0.15). In patients receiving NabGem, second-line FFN, compared with FOLFOX/CAPOX or FOLFIRI, improved median progression-free survival 2 (25.6 vs 12.1 weeks; HR: 0.47; p = 0.0067) and median overall survival 2 (39.0 vs 19.14 weeks; HR: 0.49; p = 0.032). Conclusion: First-line FFN and NabGem promote similar clinical outcomes. Second-line FFN should be considered after NabGem.
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Affiliation(s)
- Alberto Servetto
- Department of Clinical Medicine & Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Antonio Santaniello
- Department of Clinical Medicine & Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Fabiana Napolitano
- Department of Clinical Medicine & Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Francesca Foschini
- Department of Clinical Medicine & Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Roberta Marciano
- Azienda Ospedaliera Universitaria San Giovanni di Dio Ruggi d'Aragona, Salerno, 84125, Italy
| | - Priscilla Cascetta
- Department of Clinical Medicine & Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Anna Rita Amato
- Department of Clinical Medicine & Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Maria Rosaria Augurio
- Department of Clinical Medicine & Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Lucia Maresca
- Department of Clinical Medicine & Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Pietro De Placido
- Department of Clinical Medicine & Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Sabino De Placido
- Department of Clinical Medicine & Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Luigi Formisano
- Department of Clinical Medicine & Surgery, University of Naples Federico II, Naples, 80131, Italy
| | - Roberto Bianco
- Department of Clinical Medicine & Surgery, University of Naples Federico II, Naples, 80131, Italy
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12
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Chakrabarti S, Kamgar M, Mahipal A. Systemic Therapy of Metastatic Pancreatic Adenocarcinoma: Current Status, Challenges, and Opportunities. Cancers (Basel) 2022; 14:2588. [PMID: 35681565 PMCID: PMC9179239 DOI: 10.3390/cancers14112588] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 05/19/2022] [Accepted: 05/23/2022] [Indexed: 02/01/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy characterized by nonspecific presenting symptoms, lack of a screening test, rapidly progressive clinical course, and presentation with an advanced-stage disease in the majority of patients. PDAC is essentially a systemic disease irrespective of the initial stage, as most patients with non-metastatic PDAC undergoing curative-intent treatment eventually experience metastatic relapse. Currently, cytotoxic chemotherapy remains the cornerstone of treatment in patients with advanced disease. However, the current standard treatment with multiagent chemotherapy has modest efficacy and results in median overall survival (OS) of less than a year and a 5-year OS of about 10%. The pathobiology of PDAC poses many challenges, including a unique tumor microenvironment interfering with drug delivery, intratumoral heterogeneity, and a strongly immunosuppressive microenvironment that supports cancer growth. Recent research is exploring a wide range of novel therapeutic targets, including genomic alterations, tumor microenvironment, and tumor metabolism. The rapid evolution of tumor genome sequencing technologies paves the way for personalized, targeted therapies. The present review summarizes the current chemotherapeutic treatment paradigm of advanced PDAC and discusses the evolving novel targets that are being investigated in a myriad of clinical trials.
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Affiliation(s)
- Sakti Chakrabarti
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA; (S.C.); (M.K.)
| | - Mandana Kamgar
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA; (S.C.); (M.K.)
| | - Amit Mahipal
- Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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13
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Nguyen M, Segelov E, Goldstein D, Pavlakis N, Shapiro J, Price TJ, Nagrial A, Chantrill L, Leong T, Chen J, Burge M, Karapetis CS, Chau I, Lordick F, Renouf D, Tebbutt N, Roy AC. Update on optimal management for pancreatic cancer: expert perspectives from members of the Australasian Gastrointestinal Trials Group (AGITG) with invited international faculty. Expert Rev Anticancer Ther 2022; 22:39-51. [PMID: 34739362 DOI: 10.1080/14737140.2022.2002689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/28/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Pancreatic cancer remains a challenging malignancy due to the high proportion of patients diagnosed at advanced stages and the limited treatment options. This article discusses recent evidence in the management of both localized and advanced pancreatic cancer and offers an expert opinion on current best practice. AREAS COVERED For patients with localized disease, the evidence for adjuvant chemotherapy is discussed as well as emerging neoadjuvant approaches for resectable, borderline resectable, and locally advanced disease. Advances in metastatic disease are discussed including cytotoxic chemotherapy, targeted therapies, and the role of genomic testing to identify patients with molecular alterations. Reviewed literature included journal publications, abstracts presented at major international oncology meetings, and ongoing clinical trials databases. EXPERT OPINION Pancreatic cancer is a devastating diagnosis and despite recent advances has a very poor prognosis. Only a minority of patients, 20%, are diagnosed with potentially curable disease. The shifting paradigm toward neoadjuvant therapy may improve resectability and survival rates; however, robust evidence is required. Thus far, there has only been limited progress in advanced stage disease. Genomic testing may potentially identify more treatment targets although limited to small subgroups.
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Affiliation(s)
- Mike Nguyen
- Department of Medical Oncology, School of Clinical Sciences, Monash University and Monash Health, Melbourne, Australia
| | - Eva Segelov
- Department of Medical Oncology, School of Clinical Sciences, Monash University and Monash Health, Melbourne, Australia
| | - David Goldstein
- Department of Medical Oncology, Prince of Wales Hospital, University of NSW, Sydney, Australia
| | - Nick Pavlakis
- Department of Medical Oncology, Royal North Shore Hospital, University of Sydney, Sydney, Australia
| | | | - Timothy J Price
- Department of Haematology and Oncology, The Queen Elizabeth Hospital/University of Adelaide, Adelaide, Australia
| | - Adnan Nagrial
- Department of Medical Oncology, Westmead & Blacktown Hospitals, University of Sydney, Sydney, Australia
| | - Lorraine Chantrill
- Department Medical Oncology, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Australia
| | - Trevor Leong
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, The University of Melbourne, Melbourne, Australia
| | - John Chen
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, Australia
| | - Matt Burge
- Department of Cancer Care Services, Royal Brisbane Hospital, University of Queensland, Herston, Australia
| | - Christos S Karapetis
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, Australia
| | - Ian Chau
- Department of Medicine, Royal Marsden Hospital, Institute of Cancer Research, Surrey, London, UK
| | - Florian Lordick
- University Cancer Center Leipzig and Department of Oncology, Gastroenterology, Hepatology, Pneumology and Infectious Diseases, Leipzig University Medical Center, Leipzig, Germany
| | - Daniel Renouf
- Department of Medical Oncology, BC Cancer. Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Niall Tebbutt
- Department of Medical Oncology, Olivia Newton-John Cancer Wellness and Research Centre. Austin Health, Heidelberg, Australia
| | - Amitesh C Roy
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, Australia
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14
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Lundy J, Harris M, Zalcberg J, Zimet A, Goldstein D, Gebski V, Borsaru A, Desmond C, Swan M, Jenkins BJ, Croagh D. EUS-FNA Biopsies to Guide Precision Medicine in Pancreatic Cancer: Results of a Pilot Study to Identify KRAS Wild-Type Tumours for Targeted Therapy. Front Oncol 2021; 11:770022. [PMID: 34956889 PMCID: PMC8696205 DOI: 10.3389/fonc.2021.770022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/18/2021] [Indexed: 12/27/2022] Open
Abstract
Background Pancreatic ductal adenocarcinoma (PDAC) is a leading cause of cancer death and lacks effective treatment options. Diagnostic endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsies represent an appealing source of material for molecular analysis to inform targeted therapy, as they are often the only available tissue for patients presenting with PDAC irrespective of disease stage. However, EUS-FNA biopsies are typically not used to screen for precision medicine studies due to concerns about low tissue yield and quality. Epidermal growth factor receptor (EGFR) inhibition has shown promise in clinical trials of unselected patients with advanced pancreatic cancer, but has not been prospectively tested in KRAS wild-type patients. Here, we examine the clinical utility of EUS-FNA biopsies for molecular screening of KRAS wild-type PDAC patients for targeted anti-EGFR therapy to assess the feasibility of this approach. Patients and Methods Fresh frozen EUS-FNA or surgical biopsies from PDAC patient tumours were used to screen for KRAS mutations. Eligible patients with recurrent, locally advanced, or metastatic KRAS wild-type status who had received at least one prior line of chemotherapy were enrolled in a pilot study (ACTRN12617000540314) and treated with panitumumab at 6mg/kg intravenously every 2 weeks until progression or unacceptable toxicity. The primary endpoint was 4-month progression-free survival (PFS). Results 275 patient biopsies were screened for KRAS mutations, which were detected in 88.3% of patient samples. 8 eligible KRAS wild-type patients were enrolled onto the interventional study between November 2017 and December 2020 and treated with panitumumab. 4-month PFS was 14.3% with no objective tumour responses observed. The only grade 3/4 treatment related toxicity observed was hypomagnesaemia. Conclusions This study demonstrates proof-of-principle feasibility to molecularly screen patients with pancreatic cancer for targeted therapies, and confirms diagnostic EUS-FNA biopsies as a reliable source of tumour material for molecular analysis. Single agent panitumumab was safe and tolerable but led to no objective tumour responses in this population.
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Affiliation(s)
- Joanne Lundy
- Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Molecular and Translational Science, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia.,Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
| | - Marion Harris
- Department of Oncology, Faculty of Medicine, Nursing and Health Sciences and School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - John Zalcberg
- Department of Medical Oncology, Alfred Health, Melbourne, VIC, Australia.,Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - Allan Zimet
- Department of Medical Oncology, Epworth Hospital, Melbourne, VIC, Australia
| | - David Goldstein
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia.,Department of Medical Oncology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Val Gebski
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Adina Borsaru
- Diagnostic Imaging, Monash Health, Melbourne, VIC, Australia
| | | | - Michael Swan
- Department of Gastroenterology, Monash Health, Melbourne, VIC, Australia
| | - Brendan J Jenkins
- Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Molecular and Translational Science, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
| | - Daniel Croagh
- Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia.,Department of Surgery, Epworth Healthcare, Melbourne, VIC, Australia
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15
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Bukhari N, Abdalla K, Ibnshamsa F, Alselwi W, Al-Shakir S, Alqahtani M. Exceptional Response to Second-Line Gemcitabine/Nab-Paclitaxel Chemotherapy in Patients With Metastatic Pancreatic Adenocarcinoma. Cureus 2021; 13:e18756. [PMID: 34796055 PMCID: PMC8589452 DOI: 10.7759/cureus.18756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 12/27/2022] Open
Abstract
Pancreatic cancer is an extremely lethal malignancy with the majority of patients presenting with advanced disease. Typically, fit patients with advanced unresectable disease are treated with chemotherapy, which comprises either first-line folfirinox (FNX) or gemcitabine/nab-paclitaxel (GNP) regimens based on level 1 evidence. To our knowledge, robust evidence for second-line GNP post FNX does not exist. We herein report four cases treated at our institute with second-line GNP. Amongst those were patients with durable responses lasting over a year, which is extremely rare in stage 4 pancreatic cancer.
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Affiliation(s)
- Nedal Bukhari
- Department of Medical Oncology, King Fahad Specialist Hospital, Dammam, SAU.,Department of Internal Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Khalda Abdalla
- Department of Medical Oncology, King Fahad Specialist Hospital, Dammam, SAU
| | - Fahad Ibnshamsa
- Department of Medical Oncology, King Fahad Specialist Hospital, Dammam, SAU
| | - Waleed Alselwi
- Department of Medical Oncology, King Fahad Specialist Hospital, Dammam, SAU
| | - Shakir Al-Shakir
- Department of Radiation Oncology, King Fahad Specialist Hospital, Dammam, SAU
| | - Mohammed Alqahtani
- Multiorgan Transplant Center, King Fahad Specialist Hospital, Dammam, SAU
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16
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Huh G, Lee HS, Choi JH, Lee SH, Paik WH, Ryu JK, Kim YT, Bang S, Lee ES. Gemcitabine plus Nab-paclitaxel as a second-line treatment following FOLFIRINOX failure in advanced pancreatic cancer: a multicenter, single-arm, open-label, phase 2 trial. Ther Adv Med Oncol 2021; 13:17588359211056179. [PMID: 34790261 PMCID: PMC8591648 DOI: 10.1177/17588359211056179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 10/11/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate the efficacy and safety of gemcitabine plus nab-paclitaxel (GnP) as second-line chemotherapy following first-line FOLFIRINOX treatment failure in advanced pancreatic cancer. METHODS This was a multicenter, single-arm, open-label, phase 2 trial done at three tertiary centers in South Korea from May 2018 to December 2019. Eligible patients were aged 20 years or older, had histologically confirmed advanced pancreatic ductal adenocarcinoma, and disease progression after receiving first-line FOLFIRINOX. Patients received a second-line GnP regimen as intravenous nab-paclitaxel at a dose of 125 mg/m2 and gemcitabine at a dose of 1000 mg/m2, on days 1, 8, and 15 every 4 weeks until disease progression or unacceptable toxicity. The primary outcome was survival rate at 6 months and the secondary outcomes were median progression-free survival (PFS), overall survival (OS), disease control rate (DCR), and adverse events. This study is registered with Clinicaltrials.gov. (NCT03401827). RESULTS Forty patients were enrolled in the study. The survival rate at 6 months was 72.5% [95% confidence interval (CI), 59.9-87.7], achieving superiority over prespecified assumed 6-month OS rate of 20% for best supportive care only (p < 0.001). The median PFS and OS were 5.8 months (95% CI, 4.3-8.7) and 9.9 months (95% CI, 7.5-12.4), respectively. DCR was 87.5% with six partial responses and 29 stable diseases. Grade 3 or higher treatment-related adverse events occurred in 25 (62.5%) patients with the most common being thrombocytopenia, anemia, neutropenia, peripheral neuropathy, and peripheral edema. CONCLUSION GnP demonstrated favorable efficacy with acceptable toxicity in patients with advanced pancreatic ductal adenocarcinoma after FOLFIRINOX failure.
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Affiliation(s)
- Gunn Huh
- Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
- Pancreaticobiliary Cancer Study Group of Korean Society of Gastrointestinal Cancer, Seoul, Korea
| | - Hee Seung Lee
- Pancreaticobiliary Cancer Study Group of Korean Society of Gastrointestinal Cancer, Seoul, Korea
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Ho Choi
- Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
- Pancreaticobiliary Cancer Study Group of Korean Society of Gastrointestinal Cancer, Seoul, Korea
| | - Sang Hyub Lee
- Professor, Division of Gastroenterology, Department of Internal Medicine, Seoul National University College of Medicine, Liver Research Institute, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea
- Pancreaticobiliary Cancer Study Group of Korean Society of Gastrointestinal Cancer, Seoul, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
- Pancreaticobiliary Cancer Study Group of Korean Society of Gastrointestinal Cancer, Seoul, Korea
| | - Ji Kon Ryu
- Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
- Pancreaticobiliary Cancer Study Group of Korean Society of Gastrointestinal Cancer, Seoul, Korea
| | - Yong-Tae Kim
- Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
- Pancreaticobiliary Cancer Study Group of Korean Society of Gastrointestinal Cancer, Seoul, Korea
| | - Seungmin Bang
- Pancreaticobiliary Cancer Study Group of Korean Society of Gastrointestinal Cancer, Seoul, Korea
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Eaum Seok Lee
- Pancreaticobiliary Cancer Study Group of Korean Society of Gastrointestinal Cancer, Seoul, Korea
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
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17
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Nanoliposomal irinotecan plus fluorouracil and folinic acid as a second-line treatment option in patients with metastatic pancreatic ductal adenocarcinoma: a retrospective cohort study. BMC Cancer 2021; 21:1176. [PMID: 34732161 PMCID: PMC8567553 DOI: 10.1186/s12885-021-08887-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/12/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND According to the NAPOLI-1 trial, nanoliposomal irinotecan (nal-IRI) plus fluorouracil/folinic acid (5-FU/LV) showed improved overall survival compared to fluorouracil alone for patients with metastatic pancreatic cancer who were previously treated with gemcitabine-based therapy. In that trial, Asian patients had frequent dose modification due to haematological toxicity. There has been limited information on the clinical benefits and toxicity of this regimen in real-world settings. In this study, we assessed real-world experience of nal-IRI plus 5-FU/LV in patients with advanced pancreatic cancer after gemcitabine failure. METHODS We conducted a single institution, retrospective analysis of response, survival and safety in patients who had been treated with nal-IRI with 5-FU/LV. Patients with metastatic pancreatic ductal adenocarcinoma previously treated with gemcitabine-based therapy received nal-IRI (80 mg/m2) with 5-FU/LV every 2 weeks. Kaplan-Meier analysis was performed to obtain median progression free survival and median overall survival. The hazard ratio and 95% confidence interval (CI) were estimated using a stratified Cox regression model. A multivariate Cox proportional hazards regression model was used to identify the effects of clinical factors. RESULTS Fifty-one patients received nal-IRI plus 5-FU/LV between January 2015 and December 2020. The median age was 67 years, and males were 58.8%. A total of 40 (78.4%) and 11 (21.6%) patients had received one and two lines of prior chemotherapy before enrollment, respectively. Median progression-free survival was 2.8 months (95% CI 1.8-3.7) and median overall survival was 7.0 months (95% CI 6.0-7.9). Chemotherapy doses were reduced or delayed in 33 (64.7%) patients during the first 6 weeks and median relative dose intensity was 0.87. Thirty-six (70.6%) patients experienced grade 3 or 4 adverse events, most commonly neutropenia (58.8%). Most non-haematologic adverse events were under grade 2. Since the start of first-line chemotherapy, median overall survival was 16.3 months (95% CI 14.1-18.4). CONCLUSIONS Nal-IRI plus 5-FU/LV seems to be effective, with manageable toxicities, following gemcitabine-based treatment in patients with metastatic pancreatic ductal adenocarcinoma. Nal-IRI plus 5-FU/LV following gemcitabine with nab-paclitaxel is a feasible sequential treatment option in patients with metastatic pancreatic cancer. TRIAL REGISTRATION Retrospectively registered.
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18
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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: 2] [Impact Index Per Article: 0.7] [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: 11] [Impact Index Per Article: 3.7] [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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20
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Fujii H, Koda M, Sadaka S, Ohata K, Kato-Hayashi H, Iihara H, Kobayashi R, Ishihara T, Uemura S, Iwashita T, Hayashi H, Sugiyama T, Shimizu M, Suzuki A. Anorexia, pain and peripheral neuropathy are associated with a decrease in quality of life in patients with advanced pancreatic cancer receiving outpatient chemotherapy - a retrospective observational study. J Pharm Health Care Sci 2021; 7:27. [PMID: 34334136 PMCID: PMC8327438 DOI: 10.1186/s40780-021-00210-1] [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: 11/26/2020] [Accepted: 05/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cancer chemotherapy usually improves clinical outcomes in patients with advanced pancreatic cancer (APC), but can also cause moderate-to-severe adverse events (AEs). We investigated the relationship between moderate-to-severe AEs and quality of life (QOL) in patients with APC who received outpatient chemotherapy. METHODS We recruited APC patients who received outpatient chemotherapy in Gifu University Hospital between September 2017 and December 2018. Adverse events related to chemotherapy were assessed by a pharmacist collaborating with a physician using common terminology criteria for AEs (CTCAE) ver 4.0, and QOL of patients was self-assessed by patients using the five-level EuroQol five-dimensional questionnaire (EQ-5D-5L Japanese edition 2). Associations between the EQ-5D-5L utility value and serious AEs were assessed using proportional odds logistic regression. RESULTS A total of 59 patients who received 475 chemotherapy cycles were included. The proportional odds logistic regression indicated that grade ≥ 2 anorexia, pain and peripheral neuropathy were significantly correlated with a decreased EQ-5D-5L utility value. Pharmaceutical intervention for these AEs significantly improved the patients' EQ-5D-5L utility value. CONCLUSIONS Anorexia, pain and peripheral neuropathy were significantly associated with a decrease in QOL. It is assumed that appropriate pharmaceutical intervention with particular emphasis on these AEs can improve the QOL of pancreatic cancer patients receiving outpatient chemotherapy.
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Affiliation(s)
- Hironori Fujii
- Department of Pharmacy, Gifu University Hospital, Yanagido 1-1, Gifu, 501-1194, Japan.
| | - Maaya Koda
- Laboratory of Pharmacy Practice and Social Science, Gifu Pharmaceutical University, Gifu, 501-1196, Japan
| | - Shiori Sadaka
- Department of Pharmacy, Gifu University Hospital, Yanagido 1-1, Gifu, 501-1194, Japan
| | - Koichi Ohata
- Department of Pharmacy, Gifu University Hospital, Yanagido 1-1, Gifu, 501-1194, Japan
| | - Hiroko Kato-Hayashi
- Department of Pharmacy, Gifu University Hospital, Yanagido 1-1, Gifu, 501-1194, Japan
| | - Hirotoshi Iihara
- Department of Pharmacy, Gifu University Hospital, Yanagido 1-1, Gifu, 501-1194, Japan
| | - Ryo Kobayashi
- Department of Pharmacy, Gifu University Hospital, Yanagido 1-1, Gifu, 501-1194, Japan
| | - Takuma Ishihara
- Gifu University Hospital, Innovative and Clinical Research Promotion Center, Gifu University, Gifu, 501-1194, Japan
| | - Shinya Uemura
- First Department of Internal Medicine, Gifu University Hospital, Gifu, 501-1194, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, 501-1194, Japan
| | - Hideki Hayashi
- Laboratory of Pharmacy Practice and Social Science, Gifu Pharmaceutical University, Gifu, 501-1196, Japan
| | - Tadashi Sugiyama
- Laboratory of Pharmacy Practice and Social Science, Gifu Pharmaceutical University, Gifu, 501-1196, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Hospital, Gifu, 501-1194, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, Yanagido 1-1, Gifu, 501-1194, Japan
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21
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Hayuka K, Okuyama H, Murakami A, Okita Y, Nishiuchi T, Okano K, Suzuki Y, Tsuji A. Gemcitabine Plus Nab-Paclitaxel as Second-Line Chemotherapy following FOLFIRINOX in Patients with Unresectable Pancreatic Cancer: A Single-Institution, Retrospective Analysis. Chemotherapy 2021; 66:58-64. [PMID: 34284397 DOI: 10.1159/000517244] [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] [Received: 12/14/2020] [Accepted: 05/09/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Patients with advanced pancreatic cancer have a poor prognosis. FOLFIRINOX (FFX) and gemcitabine plus nab-paclitaxel (GnP) have been established as first-line treatment, but they have not been confirmed as second-line treatment after FFX. The aim of this study was to evaluate the safety and efficacy of GnP as second-line therapy after FFX in patients with unresectable pancreatic cancer. METHODS Twenty-five patients with unresectable pancreatic cancer were enrolled. The patients were treated with GnP after FFX between September 2015 and September 2019. Tumor response, progression-free survival (PFS), overall survival (OS), and incidence of adverse events were evaluated. RESULTS The response rate, disease control rate, median PFS, and median OS were 12%, 96%, 5.3 months, and 15.6 months, respectively. The common grade 3 or 4 adverse events were neutropenia (76%) and anemia (16%). CONCLUSIONS GnP after FOLFIRINOX is expected to be one of the second-line recommendations for patients with unresectable pancreatic cancer.
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Affiliation(s)
- Kotone Hayuka
- Department of Clinical Oncology, Faculty of Medicine, Kagawa University, Takamatsu, Japan,
| | - Hiroyuki Okuyama
- Department of Clinical Oncology, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Akitsu Murakami
- Department of Clinical Oncology, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Yoshihiro Okita
- Department of Clinical Oncology, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Takamasa Nishiuchi
- Department of Clinical Oncology, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Kagawa University, Takamatsu, Japan
| | - Yasuyuki Suzuki
- Department of Gastroenterological Surgery, Kagawa University, Takamatsu, Japan
| | - Akihito Tsuji
- Department of Clinical Oncology, Faculty of Medicine, Kagawa University, Takamatsu, Japan
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22
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Lellouche L, Palmieri LJ, Dermine S, Brezault C, Chaussade S, Coriat R. Systemic therapy in metastatic pancreatic adenocarcinoma: current practice and perspectives. Ther Adv Med Oncol 2021; 13:17588359211018539. [PMID: 34285720 PMCID: PMC8264726 DOI: 10.1177/17588359211018539] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/29/2021] [Indexed: 12/25/2022] Open
Abstract
Major breakthroughs have been achieved in the management of metastatic pancreatic ductal adenocarcinoma (PDAC) with FOLFIRINOX (5-fluorouracil + irinotecan + oxaliplatin) and gemcitabine plus nab-paclitaxel approved as a first-line therapy, although the prognosis is still poor. At progression, patients who maintain a good performance status (PS) can benefit from second-line chemotherapy. To address the concern of achieving tumor control while maintaining a good quality of life, maintenance therapy is a concept that has now emerged. After a FOLFIRINOX induction treatment, maintenance with 5-fluorouracil (5-FU) seems to offer a promising approach. Although not confirmed in large, prospective trials, gemcitabine alone as a maintenance therapy following induction treatment with gemcitabine plus nab-paclitaxel could be an option, while a small subset of patients with a germline mutation of breast cancer gene (BRCA) can benefit from the polyadenosine diphosphate-ribose polymerase (PARP) inhibitor olaparib. The rate of PDAC with molecular alterations that could lead to a specific therapy is up to 25%. The Food and Drug Administration (FDA) recently approved larotrectinib for patients with any tumors harboring a neurotrophic tyrosine receptor kinase (NTRK) gene fusion, and pembrolizumab for patients with a mismatch repair deficiency in a second-line setting, including PDAC. Research focused on targeted therapy and immunotherapy is active and could improve patients' outcomes in the near future.
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Affiliation(s)
- Lisa Lellouche
- Gastroenterology and Digestive Oncology Department, Cochin Hospital, APHP. Centre, Paris, France
- Faculté de Médecine Paris Centre, Université de Paris, Paris, France
| | - Lola-Jade Palmieri
- Gastroenterology and Digestive Oncology Department, Cochin Hospital, APHP. Centre, 27 rue du faubourg St Jacques, Paris, 75014, France
- Faculté de Médecine Paris Centre, Université de Paris, Paris, 75006, France
| | - Solène Dermine
- Gastroenterology and Digestive Oncology Department, Cochin Hospital, APHP. Centre, Paris, France
- Faculté de Médecine Paris Centre, Université de Paris, Paris, France
| | - Catherine Brezault
- Gastroenterology and Digestive Oncology Department, Cochin Hospital, Paris, France
| | - Stanislas Chaussade
- Gastroenterology and Digestive Oncology Department, Cochin Hospital, APHP. Centre, Paris, France
- Faculté de Médecine Paris Centre, Université de Paris, Paris, France
| | - Romain Coriat
- Gastroenterology and Digestive Oncology Department, Cochin Hospital, APHP. Centre, Paris, France
- Faculté de Médecine Paris Centre, Université de Paris, Paris, France
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23
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Mita N, Iwashita T, Ichikawa H, Iwasa Y, Uemura S, Murase K, Shimizu M. Clinical Outcomes of Conversion Surgery after FOLFIRINOX in Patients with Unresectable Advanced Pancreatic Cancer: A Retrospective Cohort Study at a Single Center. J Clin Med 2021; 10:jcm10132848. [PMID: 34199125 PMCID: PMC8267793 DOI: 10.3390/jcm10132848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 12/29/2022] Open
Abstract
Pancreatic cancer is one of the most lethal cancers. To improve its prognosis, conversion surgery for initially unresectable advanced pancreatic cancer (UAPC) after chemotherapy has been reported in recent years. Methods: A retrospective analysis of the patients with initially UAPC underwent conversion surgery after the first-line modified FOLFIRINOX (mFX) was conducted at a single tertiary care center between January 2014 and March 2020. Results: Among 79 patients with UAPC who had mFX, 8 patients with a median age of 63 years, including 5 males (3 with locally advanced and 5 metastatic lesions), underwent conversion surgery after a median of 20 cycles of mFX. Conversion surgery was performed in 10.1% of patients (8/79) and surgical resection was successful in all with R0 resection. Postoperative major adverse events were seen in 2 patients, but no perioperative deaths were recognized. Recurrence was confirmed in 3 patients, and these 3 patients died due to cancer recurrence in 17.7, 30.6 and 57.8 months after mFX initiation. 5 patients were still alive without recurrence. The median OS in the patients who underwent conversion surgery was estimated as 65.9 months and was significantly longer than that of the patients without conversion surgery or that in the patients who had a partial response for mFX but did not have conversion surgery. The median follow-up period for the patients who had conversion surgery was 35.2 months. Conclusion: Conversion surgery achieved long-term survival in patients with UAPC who were treated with the first-line mFX, although controversy still remained.
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Affiliation(s)
- Naoki Mita
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu 501-1194, Japan; (N.M.); (H.I.); (Y.I.); (S.U.); (M.S.)
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu 501-1194, Japan; (N.M.); (H.I.); (Y.I.); (S.U.); (M.S.)
- Correspondence: ; Tel.: +81-58-2306308; Fax: +81-58-2306310
| | - Hironao Ichikawa
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu 501-1194, Japan; (N.M.); (H.I.); (Y.I.); (S.U.); (M.S.)
| | - Yuhei Iwasa
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu 501-1194, Japan; (N.M.); (H.I.); (Y.I.); (S.U.); (M.S.)
| | - Shinya Uemura
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu 501-1194, Japan; (N.M.); (H.I.); (Y.I.); (S.U.); (M.S.)
| | - Katsutoshi Murase
- Department of Digestive Surgery, Gifu University Hospital, Gifu 501-1194, Japan;
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Hospital, 1-1 Yanagido, Gifu 501-1194, Japan; (N.M.); (H.I.); (Y.I.); (S.U.); (M.S.)
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Equivalent Efficacy but Different Safety Profiles of Gemcitabine Plus Nab-Paclitaxel and FOLFIRINOX in Metastatic Pancreatic Cancer. Biomolecules 2021; 11:biom11060780. [PMID: 34067288 PMCID: PMC8224606 DOI: 10.3390/biom11060780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/20/2021] [Accepted: 05/20/2021] [Indexed: 11/17/2022] Open
Abstract
FOLFIRINOX (FFX) and gemcitabine + nab-paclitaxel (GN) are the most common chemotherapy regimens in first-line treatment of metastatic pancreatic cancer (PC). They have not been compared each other in a prospective trial, but only in retrospective studies, which can thus be affected by several biases. In order to overcome these biases, we took advantage of matching-adjusted indirect comparison (MAIC), that allows an indirect comparison by reducing cross-trial differences, and compared data from 268 patients treated with GN in a real-world setting with data from the 171 patients included in the FFX arm of the PRODIGE trial. Survival outcomes did not differ between the two populations. Overall survival was 11.1 months for both treatments (hazard ratio (HR) of FFX 1.10, 95% confidence interval (CI) 0.81–1.49; p = 0.527). Progression-free survival was 6.0 months with GN and 6.4 months with FFX (HR of FFX 1.11, 95% CI 0.82–1.50; p = 0.520). On the other hand, we observed a difference in the toxicity profiles: grade 3/4 anemia was more frequent with GN, whereas a higher occurrence of grade 3/4 vomiting and diarrhea was reported with FFX. FFX and GN show an equivalent efficacy but different safety profiles in the first-line therapy of metastatic pancreatic cancer. Searching for reliable predictive biomarkers is advised in order to improve therapeutic strategy in metastatic PC.
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25
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Patterns of Palliative Chemotherapy and Survival in Patients With Pancreatic Cancer Focusing on Age: A Nationwide Real-World Danish Registry Study. Pancreas 2021; 50:685-695. [PMID: 34016900 DOI: 10.1097/mpa.0000000000001833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES The aim of this study was to identify patterns of palliative chemotherapy (CTh) and the associated overall survival (OS) in patients with pancreatic cancer, with specific focus on age. METHODS Between May 1, 2011, and April 30, 2016, 4260 patients were registered in the Danish Pancreatic Cancer Database. The 1715 patients receiving palliative CTh were retrieved. Age was grouped into less than 70, 70 to less than 75, and 75 years or more. RESULTS Of the 1715 patients receiving first-line CTh, 586 (34%) underwent second-line CTh and 151 (9%) third-line CTh. First-line gemcitabine resulted in a significant worse survival compared with combination CTh, hazard ratio 1.51. For combination CTh, OS differed between the age groups, P < 0.01. The median OS in the less than 70 years (n = 547), 70 to less than 75 years (n = 163), and 75 years or more (n = 67) groups were 9.3, 9.6, and 7.2 months, respectively. No differences in survival were observed among patients receiving first-line gemcitabine (P = 0.35). CONCLUSIONS Our findings are useful in treatment-related decision making in patients with pancreatic cancer. A significant survival benefit was observed for all patients after first-line combination CTh. The effect of combination CTh was most prominent among patients aged less than 75 years. By age, no differences in survival were observed in those receiving gemcitabine.
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King DA, Rahalkar S, Bingham DB, Fisher GA. Pancreatic INI1-deficient undifferentiated rhabdoid carcinoma achieves complete clinical response on gemcitabine and nab-paclitaxel following immediate progression on FOLFIRINOX: a case report. J Gastrointest Oncol 2021; 12:874-879. [PMID: 34012674 DOI: 10.21037/jgo-20-478] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION INI1-deficient undifferentiated rhabdoid carcinoma is a rare pancreatic carcinoma for which the optimal treatment is unknown. Pancreatic ductal adenocarcinoma, the most common histology of pancreas cancer, is treated with combination chemotherapy in the advanced setting, a strategy supported by strong evidence in well powered studies. In patients with excellent performance status, first-line treatment usually consists of the three-drug regimen FOLFIRINOX, with the combination of gemcitabine with nab-paclitaxel, typically less toxic than the three-drug regimen, reserved for second-line therapy. Given the lack of published reports describing treatment outcomes for patients with rare forms of pancreatic cancer, the same treatment approach used for pancreatic ductal adenocarcinoma is typically employed. OBSERVATION This case describes a patient with metastatic pancreatic INI1-deficient undifferentiated rhabdoid carcinoma who was primarily resistant to FOLFIRINOX therapy but who then achieved an immediate, marked and sustained response to gemcitabine with nab-paclitaxel. CONCLUSION Given the lack of data informing on optimal management of INI1-deficient pancreatic undifferentiated rhabdoid carcinoma, and the exceptional response achieved by gemcitabine with nab-paclitaxel, this case report highlights a surprising and potentially informative anecdote. Additional studies are needed to confirm responses observed in this report which when taken together may strongly influence first-line therapy choice for this rare malignancy. Given the difficult in acquiring sufficient numbers of these rare histologies in any one institution, multi-institution collaboration in studying outcomes of rare pancreatic malignancies is likely essential.
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Affiliation(s)
- Daniel A King
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Smruti Rahalkar
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - David B Bingham
- Department of Pathology, Stanford University, Stanford, CA, USA
| | - George A Fisher
- Department of Medicine, Stanford University, Stanford, CA, USA
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27
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Yeh C, Bates SE. Two decades of research toward the treatment of locally advanced and metastatic pancreatic cancer: Remarkable effort and limited gain. Semin Oncol 2021; 48:34-46. [PMID: 33712267 DOI: 10.1053/j.seminoncol.2021.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/20/2021] [Indexed: 01/04/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy that is diagnosed at the locally advanced or metastatic stage in approximately 80% of cases. Relative to other tumor types, progress in the treatment of this disease has been painfully slow. While agents targeting DNA repair have proven successful in a subset of patients, the majority of PDACs do not exhibit validated molecular targets. Hence, conventional chemotherapy remains at the forefront of therapy for this disease. In this review, we study two decades of efforts to improve upon the gemcitabine backbone - 67 phase II and III trials enrolling 16,446 patients - that culminated in the approvals of gemcitabine/nab-paclitaxel (Gem/NabP) and FOLFIRINOX. Today, these remain gold standards for the first-line treatment of locally advanced unresectable and metastatic PDAC, while ongoing efforts focus on improving upon the Gem/NabP backbone. Because real world data often do not reflect the data of randomized controlled trials (RCTs), we also summarize the retrospective evidence comparing the efficacy of Gem/NabP and FOLFIRINOX in the first-line setting - 29 studies reporting a median overall survival of 10.7 and 9.1 months for FOLFIRINOX and Gem/NabP, respectively. These values are surprisingly comparable to those reported by the pivotal RCTs at 11.1 and 8.5 months. Finally, there is a paucity of RCT data regarding the efficacy of second-line therapy. Hence, we conclude this review by summarizing the data that ultimately demonstrate a small but significant survival benefit of second-line therapy with Gem/NabP or FOLFIRINOX. Collectively, these studies describe the long journey, the steady effort, and the myriad lessons to be learned from 20 years of PDAC trials to inform strategies for success in clinical trials moving forward.
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Affiliation(s)
- Celine Yeh
- Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Susan E Bates
- James J. Peters VA Medical Center, Bronx, NY; Columbia University Herbert Irving Comprehensive Cancer Center, New York, NY.
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Observational Study of Clinical Practice in Patients with Pancreatic Adenocarcinoma in Greece. JOURNAL OF ONCOLOGY 2020; 2020:5304516. [PMID: 33014051 PMCID: PMC7520678 DOI: 10.1155/2020/5304516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 08/14/2020] [Accepted: 09/07/2020] [Indexed: 11/21/2022]
Abstract
Background During the last decade, significant improvement was made in systemic therapy of pancreatic adenocarcinoma (PAC). The impact of this progress in everyday clinical practice has not been fully described yet. The aim of the study was to investigate the pattern followed by Greek Medical Oncologists regarding the treatment of patients with PAC. Methods This observational, noninterventional multicenter study recorded clinical data from the files of 200 active patients (alive and under treatment or follow-up) for a two-year period (November 2015 until November 2017) from 20 oncology centers around Greece. Results In total, 51 (25.5%) patients underwent radical surgical resection of PAC, and 40 (78.4%) of them received adjuvant and 1 (2.0%) neoadjuvant chemotherapy. The median time to recurrence was 7.9 months, and median overall survival (OS), 20.2 months. First-line chemotherapy was administered to 193 (96.5%) patients. The majority of patients were treated with the combination of nab-paclitaxel-gemcitabine (NPG), 5-fluorouracil, leucovorin, irinotecan, oxaliplatin (FOLFIRINOX), or gemcitabine monotherapy. Of them, 39.5% responded to the treatment. Median OS and PFS were 14.1 months and 7.0 months, respectively. Second-line treatment was administered to 112 patients. The majority received NPG, FOLFIRINOX/capecitabine, oxaliplatin, irinotecan (CAPOXIRI), or 5-fluorouracil, leucovorin, oxaliplatin (FOLFOX)/capecitabine, oxaliplatin (CAPOX). Median OS with second-line treatment was 8.6 months, and median PFS, 5.5 months. The most common chemotherapy sequences were NPG as first-line followed by FOLFIRINOX/CAPOXIRI as second-line, NPG followed by FOLFOX/CAPOX, NPG followed by other regimens, and FOLFIRINOX/CAPOXIRI followed by NPG. Conclusion This study described the significant improvement in prognosis of PAC patients receiving palliative chemotherapy and the relatively high rate of receipt of second-line chemotherapy, according to real-world data. However, due to the nonrandomized nature of the study, any comparison between different chemotherapy regimens should be regarded with caution.
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Chae H, Jeong H, Cheon J, Chon HJ, Ryu H, Kim IH, Kang MJ, Jeong JH, Ryoo BY, Kim KP, Yoo C. Efficacy and safety of second-line nab-paclitaxel plus gemcitabine after progression on FOLFIRINOX for unresectable or metastatic pancreatic ductal adenocarcinoma: multicenter retrospective analysis. Ther Adv Med Oncol 2020; 12:1758835920923424. [PMID: 32523632 PMCID: PMC7257856 DOI: 10.1177/1758835920923424] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/03/2020] [Indexed: 12/12/2022] Open
Abstract
Background: FOLFIRINOX (fluorouracil, folinic acid, irinotecan plus oxaliplatin) is an
effective standard first-line treatment option for advanced pancreatic
ductal adenocarcinoma (PDAC). There is no clear consensus on the second-line
treatment following progression on FOLFIRINOX. In this multicenter
retrospective analysis, we evaluated the efficacy and tolerability of
second-line nab-P/Gem (nab-paclitaxel and gemcitabine) after progression on
FOLFIRNOX in PDAC. Methods: Patients with unresectable or metastatic PDAC who received nab-P/Gem after
progression on FOLFIRINOX between February 2016 and February 2019 were
identified from five referral cancer centers in South Korea. Baseline
characteristics, treatment history, survival outcomes, and toxicity profile
were obtained retrospectively from medical records. Results: A total of 102 patients treated with second-line nab-P/Gem for advanced PDAC
after progression on FOLFIRINOX were included. At the time of nab-P/Gem, the
median age was 60 years, with males comprising 49.0%, and most (75.5%) had
metastatic disease. Patients received a median of three cycles (range 1–12)
of nab-P/Gem. The median overall survival (OS) and progression-free survival
(PFS) from the start of second-line nab-P/Gem therapy were 9.8 (95% CI,
8.9–10.6) and 4.6 months (3.7–5.5), respectively. A partial response was
achieved in 8.5%, and the disease control rate was 73.6%. From the start of
first-line FOLFIRIOX, the OS1+2 and PFS1+2 were 20.9
(15.7–26.1) and 13.9 (10.8–17.0) months, respectively, with a 2-year
survival rate of 45.1%. There was no treatment-related mortality and grade
⩾3 toxicity was observed in 60.2%. Conclusion: Our results showed that nab-P/Gem was an effective and tolerable second-line
treatment option in medically fit patients with advanced PDAC who progressed
on first-line FOLFIRNOX. ClinicalTrials.gov identifier: NCT04133155
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Affiliation(s)
- Heejung Chae
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, South Korea
| | - Hyehyun Jeong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, South Korea
| | - Jaekyung Cheon
- Division of Hematology and Oncology, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Hong Jae Chon
- Department of Medical Oncology, CHA Bundang Medical Center, CHA University, South Korea
| | - Hyewon Ryu
- Division of Hematology and Oncology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, South Korea
| | - Il-Hwan Kim
- Department of Oncology, Haeundae Paik Hospital, Cancer Center, Inje University College of Medicine, Busan, South Korea
| | - Myoung Joo Kang
- Department of Oncology, Haeundae Paik Hospital, Cancer Center, Inje University College of Medicine, Busan, South Korea
| | - Jae Ho Jeong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, South Korea
| | - Baek-Yeol Ryoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, South Korea
| | - Kyu-Pyo Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Changhoon Yoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
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de Jesus VHF, Camandaroba MPG, Calsavara VF, Riechelmann RP. Systematic review and meta-analysis of gemcitabine-based chemotherapy after FOLFIRINOX in advanced pancreatic cancer. Ther Adv Med Oncol 2020; 12:1758835920905408. [PMID: 32165927 PMCID: PMC7052451 DOI: 10.1177/1758835920905408] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/14/2020] [Indexed: 12/11/2022] Open
Abstract
Background There are no randomized data to guide treatment decisions for patients with advanced pancreatic adenocarcinoma following first-line FOLFIRINOX. We performed a systematic review and meta-analysis of studies using gemcitabine-based chemotherapy after FOLFIRINOX to assess treatment efficacy and toxicity. Methods We included studies published between 2011 and 2018 that evaluated the efficacy and toxicity of gemcitabine-based chemotherapy after FOLFIRINOX in patients with advanced pancreatic adenocarcinoma. We searched PubMed, Embase, Scopus, and Web of Science. Primary outcomes were objective response rate (ORR), disease control rate (DCR), any grade 3/4 toxicity rate, and progression-free survival (PFS). We used the random-effects model to generate pooled estimates for proportions. Results Sixteen studies met the eligibility criteria. Overall, ORR was 10.8%, DCR was 41.1%, and any grade 3/4 toxicity rate was 28.6%. In subgroup analyses, gemcitabine plus nab-paclitaxel was associated with superior ORR (14.4 versus 8.4%; p = 0.038) and DCR (53.5 versus 30.5%; p < 0.001) compared with single-agent gemcitabine. Median PFS ranged from 1.9 to 6.4 months and numerically favored gemcitabine plus nab-paclitaxel. Conclusions Our study suggests gemcitabine-based chemotherapy likely outperforms best supportive care after FOLFIRINOX in advanced pancreatic cancer. Also, gemcitabine plus nab-paclitaxel seems to be more active than single-agent gemcitabine (CRD42018100421).
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Affiliation(s)
- Victor H F de Jesus
- Medical Oncology Department, A.C. Camargo Cancer Center, Rua Prof. Antônio Prudente, 211, São Paulo, 01509-010, Brazil
| | | | - Vinicius F Calsavara
- Department of Epidemiology and Statistics - International Research Center (CIPE), A.C. Camargo Cancer Center, São Paulo, Brazil
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