ASCO recommends the use of FOLFIRINOX in the first-line treatment of metastatic pancreatic cancer in its 2016 guidelines and 2018 Clinical Practice Guideline Update. This regimen consists of leucovorin, fluorouracil, irinotecan, and oxaliplatin. It is recommended for patients with good performance status (0 or 1) and relatively few comorbidities. ASCO qualifies this recommendation as strong and evidence-based. (Note that per NCCN guidelines the efficacy of a modified FOLFIRINOX regimen has been comparable to that of the standard regimen.)
Alternatively, these patients can be treated with gemcitabine plus nab-paclitaxel. ASCO qualifies this recommendation as strong with intermediate evidence.
For patients with a worse performance status (2) and/or who may not tolerate a more aggressive therapy but still wish to receive cancer-directed therapy, the addition of capecitabine or erlotinib to gemcitabine may be offered. ASCO qualifies this recommendation as moderate with intermediate evidence. (Note that the MPACT trial included patients with a Karnofsky score of 70 or higher, translating to an ECOG 2 with relatively few comorbidities, indicating that gemcitabine with nab-paclitaxel may be an appropriate option in these patients.) ASCO guidelines recommend that for patients with a performance status of 3 or more with poorly controlled comorbid conditions despite ongoing medical care, emphasis should be on optimizing supportive care measures. ASCO qualifies this recommendation as moderate with intermediate evidence.
ASCO guidelines also specify that all patients with pancreatic cancer should be offered information about clinical trials and palliative care, among other recommendations.
ESMO 2015 guidelines recommendations for first-line treatment of metastatic pancreatic cancer, after the relief of biliary/duodenal obstruction, malnutrition, and pain, are as follows:
In patients with good performance status (0 or 1) and bilirubin level less than 1.5 times the upper limit of normal, combination chemotherapy with either FOLFIRINOX or the combination of gemcitabine and nab-paclitaxel should be considered (I, A). ESMO qualifies this recommendation as strong and evidence-based
In patients with performance status 2 and/or bilirubin level higher than 1.5 times the upper limit of normal, monotherapy with gemcitabine should be considered (I, A). ESMO qualifies this recommendation as strong and evidence-based
In very selected patients with performance status 2 due to heavy tumor load, gemcitabine and nab-paclitaxel can be considered for best chance of response. ESMO qualifies this recommendation as strong or moderate, with more limited evidence
In patients with poor performance status (3 or 4), with significant morbidities and a very short life expectancy, only symptomatic treatment can be considered
NCCN 2018 guidelines recommendations for first-line treatment of metastatic pancreatic adenocarcinoma include:
For patients with a good performance status, a clinical trial (preferred) or chemotherapy. For poor performance status, palliative and best supportive care are recommended with consideration of a single-agent chemotherapy or palliative radiation therapy
FOLFIRINOX or gemcitabine plus nab-paclitaxel is recommended as a first-line treatment for patients with metastatic disease who have good performance status. NCCN classifies these options as category 1. Additional options may include gemcitabine plus erlotinib (category 1), gemcitabine alone (category 1), gemcitabine plus capecitabine, gemcitabine plus cisplatin (only with known BRCA1/2 mutations), fixed dose rate gemcitabine plus docetaxel and capecitabine (GTX regimen, 2B), or Fluoropyrimidine plus oxaliplatin (2B)
Gemcitabine monotherapy, or palliative therapy and best supportive care, is recommended for metastatic disease in symptomatic patients with poor performance status (category 1). Alternative options may include capecitabine (2B) and CI 5-FU (2B).
To learn more about the treatment guidelines for metastatic pancreatic cancer, read here.
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Michael J. Pishvaian. Fast Five Quiz: Test Your Knowledge of Metastatic Pancreatic Cancer Pathophysiology, Diagnosis, and Treatment - Medscape - Sep 26, 2018.