Dr Lim on Treatment With FOLFIRINOX vs NALIRIFOX in Metastatic 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 what factors influence the choice between treatment with FOLFIRINOX (leucovorin, fluorouracil, irinotecan, and oxaliplatin) or NALIRIFOX (irinotecan liposome [Onivyde], oxaliplatin, 5-fluorouracil, and leucovorin) for patients with metastatic pancreatic cancer.

The distinction between NALIRIFOX and FOLFIRINOX lies primarily in the formulation of irinotecan used within the regimen. NALIRIFOX replaces the standard free form of irinotecan found in FOLFIRINOX with liposomal irinotecan, which has a longer retention time within tissues, Lim begins. Patient selection plays a critical role in determining the suitability of NALIRIFOX vs FOLFIRINOX due to differences in their toxicity profiles, he explains, adding that NALIRIFOX is associated with slightly higher incidences of nausea, vomiting, and diarrhea compared with FOLFIRINOX. Consequently, in patients prone to experiencing these adverse effects (AEs), careful consideration is needed to mitigate potential exacerbation of these toxicities, Lim notes.

One of the notable advantages of NALIRIFOX is its reduced reliance on oxaliplatin, a component known for causing neuropathy, Lim expands. By using a lower dose of oxaliplatin compared with FOLFIRINOX, NALIRIFOX may be better suited for patients with pre-existing neuropathy, those with long-term diabetes, or elderly patients who are more susceptible to neuropathic AEs, he reports. Furthermore, the decreased dose of oxaliplatin in NALIRIFOX contributes to less severe bone marrow suppression compared with FOLFIRINOX, a consideration that is particularly important in patients with compromised bone marrow function, Lim states.

Despite these nuances in toxicity and dosing, the overall outcomes with NALIRIFOX and FOLFIRINOX are comparable, he continues. Both regimens demonstrate similar overall survival rates. However, NALIRIFOX may exhibit a higher response rate, particularly in patients with locally advanced or borderline resectable disease where tumor downstaging is a critical therapeutic goal, Lim states. 

The higher response rates seen with NALIRIFOX raise questions about this regimen’s potential efficacy in downstaging tumors for surgical intervention in patients with locally advanced or borderline resectable disease, according to Lim. Further studies are needed to validate these findings and determine the regimen’s suitability in specific clinical scenarios, he concludes.