Dr Lim on the Treatment of Resectable and Borderline Resectable Pancreatic Cancer

Kian-Huat Lim, MD, PhD, medical oncologist, associate professor, medicine, Division of Medical Oncology, Siteman Cancer Center, the Washington University School of Medicine, discusses the current standard of care (SOC) for patients with resectable or borderline resectable pancreatic cancer.

The current SOC for patients with resectable or borderline resectable pancreatic cancer involves incorporating tumor markers and neoadjuvant chemotherapy to optimize outcomes, Lim begins. For patients with localized and seemingly resectable pancreatic cancer, one of the primary considerations is the level of tumor markers, particularly CA19-9, he explains. In such cases, neoadjuvant chemotherapy is typically administered to address these potential micrometastases before proceeding with surgery, Lim adds.

When treating patients who have borderline resectable or locally advanced pancreatic cancer, neoadjuvant chemotherapy becomes even more critical, he continues, adding that downstaging the tumor, making it more amenable to surgical resection, is the goal. This treatment phase usually spans between 4 and 6 months, Lim emphasizes.

A 2022 trial compared 2 chemotherapy regimens—FOLFIRINOX (folinic acid, fluorouracil, irinotecan, and oxaliplatin) and gemcitabine plus nab-paclitaxel—as first-line treatments for patients with localized pancreatic ductal adenocarcinoma, he expands. The study found that FOLFIRINOX resulted in higher response rates, establishing it as the preferred regimen for downstaging disease in patients who are able to sufficiently handle its effects. However, it is essential to note that both regimens are associated with unique toxicities, necessitating careful patient selection, Lim explains.

In clinical practice, FOLFIRINOX or NALIRIFOX (irinotecan liposome [Onivyde], oxaliplatin, 5-fluorouracil, and leucovorin) is often chosen for patients with locally advanced disease who are potential candidates for surgery, according to Lim. The choice between these regimens is still a matter of clinical judgment, as there is no definitive evidence favoring one over the other, Lim explains. The medical community recognizes the need for a prospective study to directly compare FOLFIRINOX with NALIRIFOX to determine the optimal choice for these patients, Lim notes. Until such data are available, oncologists will continue to rely on existing evidence and their clinical expertise to guide treatment decisions for patients with pancreatic cancer, he concludes.