George P. Kim, MD: The Evolution of Therapy Sequencing Strategies in Pancreatic Cancer

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

We didn’t used to strategize. We didn’t used to think when the patient came in newly diagnosed with metastatic pancreatic cancer that we had to sequence and that we had to think about toxicities and what the outcomes would be with each of the regimens. So now we are, we think, if I give FOLFIRINOX upfront, what can I use in the second-line and the third-line?

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.