Advancing Outcomes in Metastatic Pancreatic Cancer - Episode 6
George Kim, MD:The patient has been treated with second-line therapy consisting of 5-FU/Nal-IRI, and now we need to think about what other treatments are available. I think we should go back to the very beginning; we always have to think about experimental clinical trials which are really going to pave the opportunity to advance the field, and hopefully will continue to improve survival outcomes while maintaining patient’s quality of life. In this setting, it’s always reasonable to consider an experimental clinical trial. Certainly, that’s a consideration in the frontline and second-line setting. For this patient, you would consider that. Alternatively, the patient has not been treated with a -platin, so, in this situation, you might introduce oxaliplatin (Eloxatin) either as FOLFOX. You could also use cisplatin; there is some very interesting data combining nab-paclitaxel/gemcitabine/cisplatin as a 3-drug regimen which had very interesting results. Other opportunities include maybe capecitabine, oral 5-FU; although there’s limited data with that agent.
All along we really need to continue to focus on supportive care. Palliative medicine may become more important in this setting. Managing the patient’s symptoms, again, trying to be positive, in terms of the psychologic status of the patient. But we do have some other available treatment options. Another consideration is what we said earlier, is this aBRCApatient? Well, certainly, if that’s true, you’re going to try to get a PARP inhibitor. Is this a patient that has a MSI-high or defective mismatch repair status? Will they benefit from checkpoint inhibitors?
The other thing that I’m a proponent of, is rebiopsy clinics; meaning does the cancer change during our treatment? Is there more expression of targetable mutation as the patient has gone through the spectrum of therapies that we can take advantage of? Getting molecular analysis, and getting tissue may be important. I know the insurance companies don’t like that, but getting more tissue to see whether the cancer has changed, may be important in terms of deciding additional treatments. But by the book, I think a -platin is the most appropriate available therapy for this individual.
Transcript edited for clarity.
A 57-Year-Old Man With Abdominal Pain and Unexplained Weight Loss