Treatment for Metastatic Pancreatic Cancer

George Kim, MD:The prognosis for this specific patient is that we have treatments that are meaningful and helpful, something that we didn’t have even 5 to 7 years ago. Obviously, the patient has stage 4 cancer, whether it be pancreas cancer, lung cancer, or colon cancer. It’s an advanced setting and our treatments are really to palliate and prolong time.

So, the prognosis, based on it being stage 4, is a concern and can be considered poor. But we’ve got to get over that nihilism of pancreas cancer in particular. We are still benefiting patients with our treatments. We are still getting patients to important anniversaries, birthdays, and births of grandchildren. These are very important events in the lives of our patients, and also in the survivors of their family. Their family members are very important events that still can be achieved by prolonging time and maintaining quality, even though the prognosis is poor.

For this patient, obviously, there is metastatic disease. And so, we start thinking of systemic treatments and chemotherapy, and that will help the patient. Our goals and our patients’ goals are to maintain and preserve quality of life. We want to maintain their dignity. We want to prolong time. We want to give them more time that they may not have had in prior eras when we didn’t have as active chemotherapy. And then, there are patients’ concerns regarding side effects: “What is the impact of the chemotherapy on my quality of life? Am I going to be sick in the bed without any quality of life, coming to the doctor every week, or am I going to be able to function, go to work, be able to go on vacation, and spend time with my family?” These are all very important endpoints that patients have told us are important to them, and it’s our responsibility to provide those outcomes.

The treatment options for this patient—as we discussed, he does have metastatic disease, he is not a resection candidate—we need to treat the whole extent of the tumor burden. So, chemotherapy in this setting is appropriate. In 2017, chemotherapy involves 1 of 2 regimens. There is the Abraxane, or nab-paclitaxel, with gemcitabine combination. And then, there is the FOLFIRINOX regimen. Gemcitabine combined with Abraxane was shown to be superior to gemcitabine alone in terms of overall survival. The toxicities are known and are well-managed. FOLFIRINOX also has been shown to provide a survival advantage over gemcitabine alone. Remember that we’re using full-dose 5-FU, full-dose leucovorin, and full-dose oxaliplatin and irinotecan. So, it may be a more intense regimen, but those are the 2 standards that are useful or that can be considered for our patient.

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