ONCAlert | 2018 ASCO Annual Meeting
Pancreatic Cancer Case Studies

Eileen M. O'Reilly, MD: The Nab-Paclitaxel/Gemcitabine Regimen in Frontline Standard of Care

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


Has the frontline standard of care shifted toward the nab-paclitaxel/gemcitabine regimen?

We really have two major choices for people with a good performance status, either FOLFIRINOX or gemcitabine or nab-paclitaxel. I would say that there has been a change in approach to this disease. Both options are now well-recognized and I would say widely utilized, but given that we have an emerging standard in a second-line setting, increasingly people are thinking, "What choices should we use upfront to maximize the sequence options over time?" To a degree, that probably is biasing the community towards gemcitabine and nab-paclitaxel. There’s been a very steady uptake here and that may also be impacted upon by patients’ increasing comforts with this regimen. It has some attractions. It’s a weekly regimen as opposed to FOLFIRINOX, which is bi-weekly and requires a mediport. Patients have a home infusion, which for some can be inconvenient and awkward, so that is a factor in terms of choices.

The other factors that influence people’s choices would be issues of alopecia, more with one regimen than with the other. Issues of neuropathy may bias towards one regimen versus the other. A very common scenario is patients who have elevated LFTs, and we’re waiting for an improvement in liver function following stent placements. That, at least initially, curtails the use of certain drugs until the liver function improves, and that might sway us to use one regimen versus the other in a modified format initially.

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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