Systemic Therapy in Newly Diagnosed Pancreatic Cancer

Johanna Bendell, MD: Hello, and thank you for joining us for this OncLive Peer Exchange. The majority of patients with pancreatic adenocarcinoma are diagnosed with late-stage, unresectable tumors, a setting in which combination chemotherapy is the mainstay. Although progress has been slow, new drugs have become available, important research questions are being addressed, and treatment strategies are continuing to evolve as a result. Today’s program will focus on the recent advances in the treatment of pancreatic cancer and what they mean to the future of patient care.

My name is Johanna Bendell. I am the director of the GI Oncology Research program and associate director of the Drug Development Unit at the Sarah Cannon Research Institute. I’m joined today by some good friends: Dr. Thomas Abrams, assistant professor at the Dana Farber Cancer Institute at Harvard Medical School; Dr. George Kim, GI medical oncologist at the 21st Century Oncology and University of Florida Health Oncology in Jacksonville, Florida; Dr. Caio Rocha Lima, associate cancer center director for Translational Research at the Gibbs Cancer Center and Research Institute in Spartanburg, South Carolina; and Dr. Philip Philip, professor of oncology at the Karmanos Cancer Center at Wayne State University in Detroit. Thank you so much. I have this great panel. Thank you all for participating in this discussion, and let’s begin.

Let’s start with something easy, right? So this is your approach to systemic therapy in the newly diagnosed patient with pancreatic cancer. Now, all of a sudden, we have new chemotherapy regimens and options for these patients that are changing survival. What is your initial approach to treating these patients and what disease factors, patient-related factors, come into play? I’m going to start with Dr. Philip.

Philip A. Philip, MD, PhD, FRCP: When you have a patient who comes to you for the first time, he or she has a devastating diagnosis. So there’s a psychological element which we have to handle to start off with. We don’t want to think of patients as just objects to give chemotherapy or CT scans or blood tests. The most important thing, in my opinion, is to stabilize the patient physically and mentally. So pain control for me is very important. The other thing is issues regarding the management of biliary obstruction, if that exists. So these are things that we have to get right from the beginning.

Once the patient is stabilized, then we start thinking of what systemic treatment we’re going to give, because these patients have metastatic disease. We don’t want to delay the treatment. At the same time, we want to start them in a way that we can deliver the best treatment we have. So supporting them from the beginning will allow us to go into those more aggressive treatments that we now have. But one of the most important point I want to make, Johanna, is that we need to also consider clinical trials in those patients.

Stabilizing a patient and rushing them into a treatment nowadays is not the best way to do it, because we have to really think of clinical trials also. There are more interesting drugs coming along, and we’re going to talk about them hopefully today. But, certainly, every patient deserves that ability to be exposed to what is out there. And the clinical trials we have now, they’re based on the standard treatments plus an experimental agent. So, it’s not like they’ll be deprived of having any active treatment. That’s a very important point I want to make here.

Now, what are the options we have in terms of systemic treatment frontline? Well, at least three options. One is the gemcitabine/nab-paclitaxel combination. The other one is FOLFIRINOX. Also, we have the option of gemcitabine. Gemcitabine/erlotinib is not really an option anymore. We’re not recommending it to the patient. So, we have these three treatment modalities. Certainly in patients who have favorable performance status who are willing to undergo more combination-type treatment, we will recommend the combinations.

But there’s something here also that is important: we have to discuss this with the patients and give them the options, especially when we are trying to choose between nab-paclitaxel and FOLFIRINOX. Because the benefits of these treatments, as we will discuss maybe later on, are comparable in the majority of the patients. So, patients have to know what their options are rather than us being biased to one or the other treatment regimens. So that’s really very important.

In terms of choosing treatments, it’s obvious what we do in oncology. Performance status is a very important point that really helps us determine how aggressive to be and sometimes which treatment to choose, and the age of the patient. Because if we look at the clinical trials, the upper limit, or how old patients were in terms of the range, is also a bit different. So we don’t have, for example, evidence for how patients who are over 74 or 75 do on FOLFIRINOX.

Whether they do well or not, we don’t know, but we have a better idea with other regimens like gemcitabine or the combination with nab-paclitaxel. So age, performance status, and also organ function. It’s very important for us to stabilize the liver function, but also if it’s not normal, we have to be able to assess the situation because the treatments can be problematic. So, these would be the major factors I would look at in making a decision. But certainly, discuss with the patient, give them the options, and then see their preferences. But also give them the expectation or the goals of the treatment. That’s also very important.

Transcript Edited for Clarity