Locally Advanced Pancreatic Cancer: Optimizing Treatment

John Marshall, MD:We have no idea what to do with a patient if they’ve gotten preoperative chemotherapy, radiation, and surgery and now have no evidence of disease. We have no idea what to do with that patient. We do know that patient has a pretty high probability of relapse. They’re probably not cured. They might be but probably not. So, we want to give more chemotherapy. Now, let’s say we have a patient who got FOLFIRINOX preoperatively, then chemoradiation. Well, we know that one of the best adjuvant drugs is gemcitabine. Should we now give a little adjuvant gemcitabine? My bias would be yes, we should, and in fact, gemcitabine/capecitabine is the standard doublet that one uses postoperatively. Even though they’ve already got fluoropyrimidine preoperatively, I would probably give them a little more adjuvant therapy postoperatively based on no data—only risk and concern, if you will. But we don’t know what to do there.

I think an appropriate thing could be to stop and observe. An appropriate step could be gemcitabine with some capecitabine if you haven’t given it already. What if you gave gemcitabine/nab-paclitaxel preoperatively? Well, that’s a different story now, particularly if you gave a little capecitabine during your radiation. You’ve given those drugs. Should you give some more afterward? I would still probably say yes, if the patient was doing OK. If their overall performance status was good postoperatively and they were doing OK, their scans were negative, I would probably tack on a little more adjuvant therapy.

Taking care of a patient with pancreas cancer is both a joy and a challenge. It takes a lot. It really requires people on the home front, so it’s really nice if there’s a significant other or child—it’s always the daughter, it’s never the son—who is there to help support the patient. You need that. On our side, we need a lot, too. Not only do we need the doctor who’s driving treatment, but you need all the nursing crew, the infusion suite, and palliative care professionals. Nutrition is a big deal here because these people are sick. They very often have pain and no appetite, so they’re losing weight. Where these tumors are often difficult is around digestion. Patients have malabsorption. They often have biliary stents. They’re tricky to take care of, and you really need some experience and an understanding of the mechanism of all of that to support a patient. It takes a village, both on the patient side and on our side, to manage that patient best.

Our case, a 64-year-old woman, gets preoperative chemotherapy for her locally advanced pancreas cancer and is one of the lucky ones. She has a nice response and consolidates that with a little chemoradiation and surgery. She comes back with no new evidence of disease—maybe cured but probably not—considering further adjuvant therapy. If we think back on the years before, when this was an incurable disease, we’re just going to give this patient a chemotherapy approach. This is nice progress. We, of course, are frustrated. We want more with pancreas cancers. We want more medicines. We want better outcomes. We want earlier detection if we could get it, but to go from where we were to where we are is true progress.

Transcript edited for clarity.

May 2017

• A 64-year-old female was diagnosed with locally advanced pancreatic adenocarcinoma and referred for consultation at a high-volume center
• CT with contrast showed a 2.8-cm mass in the pancreatic body, invading the common hepatic, celiac, and splenic arteries, with abutment more than 180° to the superior mesenteric artery (SMA) but no encasement
• Staging laparoscopy showed no distant metastasis; peritoneal washing cytology showed no malignant cells
• She received FOLFIRINOX followed by capecitabine and concurrent RT

December 2017

• Six months after the initial treatment, the tumor size had decreased to 1.2 cm, and abutment to the main artery was diminished but still detectable
• She underwent distal pancreatectomy with celiac artery resection
• Histopathology showed fibrous changes around the celiac artery; Evans grade IIb
• No evidence of residual tumor at the periphery; R0