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ONCAlert | ESMO 2018 Congress
Pancreatic Cancer Case Studies

George P. Kim, MD: The Nab-Paclitaxel/Gemcitabine Regimen in Frontline Standard of Care

George P. Kim, 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?

I think the standard of care has shifted to the gemcitabine/nab-paclitaxel frontline approach. And, getting back to the NCCN guidelines, that does make sense. What’s happening is that we have two approved drugs and the gemcitabine/nab-paclitaxel, if given upfront, can logically be changed to an irinotecan-based treatment, the Onivyde nanoparticle liposomal irinotecan. It makes sense to use that sequence because you avoid some of the neuropathy that can carry over. The NAPOLI regimen or the nal-IRI regimen has no neuropathy associated with it. It also has a very low rate of thrombocytopenia, which is another reason that patients come off of frontline gemcitabine/abraxane. So it makes sense from an efficacy standpoint but also in the types of toxicities, the reasons the patients come off of first-line treatment to go from one regimen to the next.

Alternatively, if you choose the FOLFIRINOX regimen upfront, it makes very little sense to then give nanoparticle liposomal irinotecan as second-line treatment. You can’t really go from FOLFIRINOX to the nal-IRI regimen because you’re still using the irinotecan. That raises questions about resistance. Alternatively, again, you can try to go to gemcitabine/abraxane, but the problem there is the neuropathy and thrombocytopenia that is encountered in the frontline interferes with the ability to give meaningful treatment in the second-line with the nab-paclitaxel/gemcitabine. That’s why more people are using gemcitabine-based treatment upfront.

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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