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Factors Determining Frontline Therapy Selection for Pancreatic Cancer

Published Online: May 17,2016
A multitude of factors contribute to the selection of frontline treatment for patients with advanced pancreatic cancer, specifically in regard to selecting first- and second-line therapies. Moreover, these factors may differ between clinical trials and real-world experience.

To explore the multiple factors, a study looked at the effectiveness and supportive care utilization associated with first-line treatment with nab-paclitaxel/gemcitabine or FOLFIRINOX for patients with metastatic pancreatic cancer.8 In this retrospective cohort study, data were selected from an electronic medical record platform involving patients throughout the United States. This analysis provided real-world data to support decision-making, including sequencing, in an era of expanding second-line options.

The main objectives of the analysis were to determine time to treatment discontinuation (TTD), database persistence (a proxy for survival), adverse events, supportive care before and during chemotherapy, proportion of patients receiving second-line therapy, time to next treatment, and duration of first- and second-line treatment.

Data were assessed for 122 patients treated with first-line nab-paclitaxel and gemcitabine and 80 treated with FOLFIRINOX. Patients treated with nab-paclitaxel/gemcitabine were significantly older (67.0 vs 61.4 years; P <.001) but, otherwise, the groups were similar.

The median TTD was 3.4 months with nab-paclitaxel/gemcitabine and 3.8 months with FOLFIRINOX. Database persistence also did not differ between the two groups, at 8.6 months for both arms.

FOLFIRINOX was associated with a higher incidence of all-grade adverse events (95% vs 84%) and significantly greater prophylactic use of G-CSF and other supportive care medications (TABLE). In the FOLFIRINOX arm, 39% of patients utilized an average of 4.41 doses of G-CSF per patient per 100 days. With nab-paclitaxel/gemcitabine, just 8% utilized G-CSF an average of 2.02 doses per patient per 100 days (P <.01). Additionally, a significantly greater number of patients required erythropoiesis-stimulating agents in the FOLFIRINOX arm (0.9 vs 0.13 doses per 100 patient days; P <0.01).

TABLE. Number of Doses Per Patient Per 100 Days

  Nab-paclitaxel Plus Gemcitabine FOLFIRINOX P Value
Antiemetic 6.94 6.30 .057
ESA 0.9 0.13 <.01
G-CSF 2.02 4.41 <.01
Steroids 7.89 5.79 <.01
Abbreviations: ESA, erythropoiesis-stimulating agents; G-CSF, granulocyte-colony stimulating factor 

Approximately one-third of patients initially treated with nab-paclitaxel/gemcitabine received 5-FU–based second-line treatment, and about half of the FOLFIRINOX group received second-line gemcitabine-based regimens. Duration of treatment in second-line was similar between the groups (about 8.5 months). Database persistence was 12.7 months for the nab-paclitaxel/gemcitabine group and 9.3 months with the FOLFIRINOX group, a difference that did not achieve statistical significance (P = .48).

When considering the overall cost of care, supportive care and other considerations should be taken into account. With this in mind, nab-paclitaxel and gemcitabine could be the most cost-effective option for the first-line treatment of patients with metastatic pancreatic cancer, according to a recent health resources management study.9

In the study, the costs and clinical outcomes of nab-paclitaxel/gemcitabine versus erlotinib plus gemcitabine were assessed using drug cost per cycle multiplied by the median cycles delivered from clinical trials. The comparison included the cost of the drugs and expenses related to administering the therapy and managing adverse events of grade 3/4 severity. These costs were based on 4 months of therapy for nab-paclitaxel/gemcitabine versus 3.9 months for erlotinib/gemcitabine.

In this comparison, the costs associated with the nab-paclitaxel regimen were $24,984 versus $23,044 with erlotinib. When considering the respective survival advantages, the nab-paclitaxel arm showed a $15,522 per life year benefit versus the erlotinib group. 

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Factors Determining Frontline Therapy Selection for Pancreatic Cancer
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