Supportive Care for Advanced Pancreatic Cancer

George Kim, MD:The patient progresses and has symptoms that are characteristic of when they initially presented—changes in their appetite, weight loss, pain, and jaundice. We really have to be active, again, reengaging the patient and managing the symptoms. We have to perhaps intensify our efforts to have them increase their appetite. So, appetite stimulants are very important. Your Megace, your Marinol, some of these agents that are helpful in stimulating their appetite. We have to make sure that it’s not just nausea that’s causing their appetite to be diminished. We have to really make sure that they’re taking their antiemetics and that they’re using them on an appropriate schedule, and that it’s meaningful.

We also have to review some of what they’re eating. We have to make sure that they are getting good, meaningful nutrients. Starches are great. Proteins, meat, fish, and chicken are all still very important. Obviously, they’re managing their glucose levels. We may want to be a little loose in that regard, letting the glucose levels ride a little bit above more stringent levels. And so, again, we have to reengage the patient, make sure that they’re continuing with the management recommendations that we made in the very beginning. This patient also should be reevaluated in regards to, is the biliary stent functioning? The patient still has a performance status of 1. We want to make sure that patients with good performance status, 0 and 1’s, receive second-line treatment. In this instance, it’s appropriate for them to receive ONIVYDE, the nanoparticle liposomal irinotecan. The trial looked at patients with ECOG performance statuses of 0 and 1.

I think it’s very important in today’s practice that we get supportive care. Oncologists are very, very busy in the community managing several different diseases and several different new drugs, all with very broad considerations. So, palliative medicine in this instance has become very important. They enable us to really focus on what the patient is experiencing and how symptoms can be managed. There’s also psychosocial support, which is critical for these patients, many of whom have depression, and so palliative medicine is very helpful. And just having good primary medical care—not to wall off the primary care doctor who has been with the patient for years taking care of them before they even developed cancer—having them remain engaged is very important.

We consider the treatment options for this patient using the standards: gemcitabine and Abraxane and FOLFIRINOX. But we really have to consider whether this patient had an opportunity to participate in research and in experimental trials. Our treatments are more active than they were years ago, but we still have a lot of work to do. And so, when we were considering what options are available for our patient with advanced disease, we really have to go back and think about trying to find them an experimental trial so we can advance the field. That’s very important.

Our patient has progressed on second-line treatment. Now we’ve run out of treatment options, and that’s another opportunity for patients to participate in experimental trials such as phase I studies. They’re dedicated to pancreas cancer disease and to pancreas cancer patients. So, in that situation, we can have an opportunity for research and patients can have an opportunity to access drugs that may provide benefit in the future.

Other approaches are some of the genetic, molecular analyses work that can be done. Patients may have a specific mutation that may be actionable and targetable. And in that instance, there’s the great work done with PanCAN and the KnowYourTumor program where they actually perform molecular analyses of the tumor, try to identify a targetable mutation, and, again, hopefully allow the patient to continue to benefit from intervention and prolong time.

Transcript edited for clarity.

March 2016

• A 63-year-old Caucasian male was admitted to the hospital from the emergency room with symptoms of epigastric pain that radiated toward the back, abdominal distention, vomiting, and jaundice
• Laboratory tests:
  • Bilirubin and liver enzymes; elevated
  • CBC values WNL
  • Hepatitis B, & C testing, negative
  • CEA: 34.2 ng/mL; CA 19-9 > 12000 U/mL
• Performance status, 1
• CT reveals 3.5 cm × 3.7 cm mass in the head of the pancreas and multiple liver nodules; also, indicates an obstruction of the bile duct
• Ultrasound-guided percutaneous needle biopsy of a liver metastases shows adenocarcinoma histology
• The patient undergoes biliary stent placement based on endoscopic retrograde cholangiopancreatogram (ERCP) findings
• Diagnosis: stage IV pancreatic cancer with liver metastasis
• The patient was started with treatment on gemcitabine andnab-paclitaxel
• CT with contrast after two treatment cycles showed marked shrinkage of the pancreatic lesion and liver nodules.
• CT after 6 cycles showed stable disease

November 2016

• The patient reports symptoms of rapid weight loss, abdominal pain, dark urine, and jaundice; he has declining functional status and is often bedridden
• Systemic therapy is under consideration