Key points to consider when determining the best treatment for advanced metastatic pancreatic cancer

FAQ Library published on August 7, 2017
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Tanios Bekaii-Saab, MD, FACP
Co-Leader, Gastrointestinal Cancer Program
Mayo Clinic Cancer Center
Senior Associate Consultant
Division of Hematology and Oncology
Mayo Clinic
Phoenix, Arizona
Key points to consider when determining the best treatment for advanced metastatic pancreatic cancer

Welcome to Partners in Pancreatic Cancer. I am Dr. Tanios Bekaii-Saab. I am frequently asked, “When determining the best treatment approach for patients with advanced metastatic pancreatic cancer, what are the key points that community providers should think about?” This question is very relevant to most community providers who do not frequently see pancreatic cancer patients. It is very important to understand that, over the last decade, we have done some significant improvements in treating pancreatic cancer. It does not seem that it has caught up with most of the other cancers we work with. Nonetheless, if we look at the 5-year survival of patients with pancreatic cancer overall, it went from 4%, closer to 8%, close to 10%. For four decades, we have been stuck in the single digits for 5-year survival, and we are now moving into the double digits hopefully soon. There are differences to be made. For metastatic pancreatic cancer patients, we know that they present with a lot of symptoms, pain, nausea, weight loss. A lot of these symptoms can be quite significant. When we think about patients with advanced metastatic pancreatic cancer, we think primarily of two things. One, we want to prolong their life, but we also want to make them feel better. Chemotherapy is primarily palliative. Patients actually do benefit from chemotherapy, not just in terms of their survival but also in terms of feeling better. If the chemotherapy works, which it does now in more than 50% to 70% of the patients, ie, shrinking the tumor or stabilizing its growth, the patients tend to feel better. That is a sizable number of patients. The survival curve has been shifting continuously closer to a year at the median. For some patients that had translated into survival of 2 years, and 5% of the patients actually are surviving 3, 4, 5 years or plus. That may not seem like a lot, but it sure beats 0%, which we have been stuck with for many years with gemcitabine alone. I think the key here is to understand that, one, we are able to make a bigger difference in those patients’ survival and, two, we have more treatment options available. In the first line, we have FOLFIRINOX, gemcitabine, and nab-paclitaxel. In the second line, we have 5-FU/MM-398 or nanoliposomal irinotecan. We also have possibly gemcitabine as a single agent.  Then in the third line, for some patients, we may have oxaliplatin as an option. Overall, we are creating more options for these patients. You really have to think about that patient that comes to your clinic. What are we looking to achieve? We want to prolong their survival, we want to make them feel better. We have different options. We have the option of growing what I call the old kitchen sink approach, which essentially means that we put all these three drugs together, 5-FU, irinotecan, and oxaliplatin. On the other hand, we have another approach which is a little bit more sequenced with gemcitabine and nab-paclitaxel followed by nanoliposomal irinotecan followed by perhaps oxaliplatin. There is also the importance of considering clinical trials. All of these patients should be considered, if possible and if feasible, and if a study is accessible, for a clinical trial. Although we have made a difference and chemotherapy seems to have improved outcomes, clinical trials continue to be a very important lifeline for those patients, and hopefully will continue leading us toward the right path in improving outcomes. Again, think about palliation, prolonging survival and clinical trials; also think about exposing most of the patients who are eligible for treatment sequentially, if possible.

The last point, when you are thinking about who should be treated and who should perhaps not be actively treated, at the time of presentation decide which patients could be considered for palliative care and comfort care. This remains, unfortunately, about 10% to 15% of our patients with pancreatic cancer, who still present at the point where they are not treatable; those patients typically have a performance status of 3 or 4, so they are quite debilitated. Some of them present essentially on stretchers or in the hospital with very bad disease. Those patients probably will not benefit from treatment, should not get any active treatment and should be considered for palliative care. Fortunately, for the rest, we should definitely consider them for treatment since they do seem to benefit from such, and this individualized strategy will make a lot of sense. So, thank you for viewing this activity.

Last modified: June 22, 2017
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