Pancreatic adenocarcinoma

Question 1

Metastatic

• Acceptable chemotherapy combinations for patients with good performance status

Answer 1

FOLFIRINOX1 (category 1) (preferred) Gemcitabine + albumin-bound paclitaxel(category 1) (preferred)
Gemcitabine + erlotinib (category 1)
Gemcitabine + capecitabine
Gemcitabine + cisplatin (Can be considered as an alternative to FOLFIRINOX in patients with possible hereditary cancers involving DNA repair mutations.)
Fixed-dose-rate gemcitabine, docetaxel, capecitabine (GTX regimen)(category 2B) Fluoropyrimidine + oxaliplatin (category 2B) (eg, 5-FU/leucovorin/oxaliplatin or CapeOx)

Question 2

Metastatic

Acceptable monotherapy options for patients with poor performance status

Answer 2

Gemcitabine at 1000 mg/m2 over 30 minutes, weekly for 3 weeks every 28 days (category 1).
Fixed-dose-rate gemcitabine (10 mg/m2/min) may substitute for standard infusion of gemcitabine over 30 minutes (category 2B).
Capecitabine or continuous infusion 5-FU (category 2B)

Question 3

Metastatic

Second-line chemotherapy may consist of:

Answer 3

• 5-FU + leucovorin + liposomal irinotecan (category 1)(for metastatic disease previously treated with gemcitabine-based therapy)
• Gemcitabine-based therapy for those previously treated with fluoropyrimidine-based therapy
• Fluoropyrimidine-based therapy for those previously treated with gemcitabine-based therapy

Question 4

Locally Advanced

Answer 4

-Depending on performance status, mono- or combination systemic chemotherapy, may be considered as initial therapy prior to chemoradiation for appropriate patients with locally advanced, unresectable disease.
-Patients should be evaluated for recovery from hematologic and non-hematologic toxicity prior to initiation of chemoradiation.
Patients who progress with metastatic disease are not candidates for chemoradiation unless required for palliative purposes

Question 5

Adjuvant

Answer 5

• The CONKO 001 trial - resectable pancreatic adenocarcinoma

• postoperative gemcitabine as adjuvant chemotherapy versus observation
• significant improvements in disease-free survival and overall survival

• ESPAC-3 study
5-FU/leucovorin versus gemcitabine following surgery
-no significant difference in overall survival
-median survival was 23.0 months and 23.6 months

• RTOG 97-04 study

• pre and post chemoradiation gemcitabine for postoperative adjuvant treatment
• No significant differences were observed
• For patients with good performance status who relapse after receiving adjuvant therapy, FOLFIRINOX or gemcitabine + albumin-bound paclitaxel are options depending on the length of time since completion of adjuvant therapy.
• Recommended adjuvant therapy options apply to patients who did not receive prior neoadjuvant therapy. For those who received prior neoadjuvant therapy, the adjuvant therapy options are dependent on the response to neoadjuvant therapy and other clinical considerations

Question 6

Neoadjuvant

Answer 6

• There is limited evidence to recommend specific neoadjuvant regimens off-study, and practices vary with regard to the use of chemotherapy and chemoradiation. Acceptable regimens include FOLFIRINOX or gemcitabine + albumin-bound paclitaxel. Subsequent chemoradiation is sometimes included. Most NCCN Member Institutions prefer neoadjuvant therapy at a high-volume center