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

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.

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.