ONCAlert | 2018 ASCO Annual Meeting
Pancreatic Cancer Case Studies

Eileen M. O'Reilly, MD: The Evolution of Therapy Sequencing Strategies in Pancreatic Cancer

Eileen M. O'Reilly, MD
Published Online:Sep 09, 2016
Larry D, a 62-year-old, presented to his primary care physician with persistent pain in his epigastric region, and was later diagnosed with metastatic pancreatic cancer. 

Metastatic Pancreatic Cancer With George P. Kim, MD, and Eileen M. O'Reilly, MD: Case 1

Metastatic Pancreatic Cancer With George P. Kim, MD, and Eileen M. O'Reilly, MD: Case 1
Metastatic Pancreatic Cancer With George P. Kim, MD, and Eileen M. O'Reilly, MD: Case 2


How have therapy sequencing strategies evolved with the approval of effective therapies for patients with pancreatic cancer?

Up until relatively recently, we’ve really had an established frontline treatment with FOLFIRINOX and gemcitabine/nab-paclitaxel. We now have a second-line regimen that has received FDA approval with liposomal irinotecan and fluorouracil. Alternative options in that setting might be oxaliplatin-based therapy with 5-FU. Increasingly for patients who receive gemcitabine-based treatment upfront, they’ll be candidates for 5-FU–based therapy as a second-line, and it’s certainly logical to consider gemcitabine/nab-paclitaxel and liposomal irinotecan. Then, potentially for those that are eligible and well enough, oxaliplatin-based therapy as a third-line. That’s an example of how thinking has evolved based on the availability of regimens and based on the ability to think about sequencing in terms of treatment choices.

In contrast, patients who receive fluoropyrimidine-based therapy upfront, for example as a frontline treatment for metastatic disease, receive FOLFIRINOX, and it’s logical to consider a gemcitabine-based treatment as a second-line, though we don’t have a lot of data suggesting whether that should be a single agent or combination. We certainly have data suggesting that using both of these active regimens in sequence contributes to the totality of improvement in outcomes, and that’s a discussion point these days—how can we maximize disease control and longevity and minimize toxicity, and what’s the best way to do that as our options increase in this disease. I think we’re beginning to address some of those questions in the clinic, but we still have a lot to learn in terms of what’s the optimal strategy. I would say our choices are good, and we’re happy to have the availability of regimens and not necessarily be wedded to the fact that one combination and sequence is better than another.

Metastatic Pancreatic Cancer: Case 1

Larry D, a 62-year-old, presented to his primary care physician with persistent pain in his epigastric region, which persists throughout the night. Within the past 2 years, he has developed diabetes and experienced considerable weight loss with signs of depression. 

  • During his visit, jaundice was observed along with periumbilical subcutaneous metastases.
  • Testing revealed an elevated CA19-9 level (2293 U/ml).
  • CT scan showed a large mass on the head of the pancreas, and a subsequent biopsy showed the mass to be adenocarcinoma. Liver and local lymph note metastases were identified.

Larry went on to receive the combination of nab-paclitaxel and gemcitabine as frontline therapy for 5 months:

  • Upon progression, Larry was switched to the combination of liposomal irinotecan, fluorouracil, and folinic acid. Treatment failure occurred after 2.5 months.
  • Larry received FOLFOX as a third-line treatment.
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