What is the best sequencing approach for second-line therapy when using FOLFIRINOX in the first line?

FAQ Library published on September 12, 2018
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Tanios Bekaii-Saab, MD, FACP
Professor
Mayo Clinic College of Medicine and Science
Program Co-Leader, Gastrointestinal Cancer
Mayo Clinic Cancer Center
Medical Director, Cancer Clinical Research Office
Section Chief and Vice-Chair
Division of Hematology/Oncology
Mayo Clinic
Phoenix, Arizona
What is the best sequencing approach for second-line therapy when using FOLFIRINOX in the first line?

Welcome to Partners in Pancreatic Cancer. I am Dr. Tanios Bekaii-Saab.

Today, I would like to discuss the best sequencing approach for second-line therapy when using FOLFIRINOX in the first line. FOLFIRINOX in the first line is indicated based on a large phase 3 study comparing it to gemcitabine. We use it primarily in its modified form, getting rid of the bolus 5-FU and the leucovorin and cutting down on the dose of the irinotecan often in some regimens. Despite the modifications, it tends to be quite the tough regimen in most patients. But its level of benefit, at least according to the published studies, tends to be quite significant over gemcitabine for this disease with very few options. The limiting factor with FOLFIRINOX in the first line is that second-line therapy is difficult to define as there is very little prospective data, at least with gemcitabine-based regimens, specifically gemcitabine/nab-paclitaxel, but there is certainly some retrospective data as well. The prospective data tends to be very limited, very small, and there are very few attempts to study the question. Another challenge with FOLFIRINOX is the neuropathy that can rise because of the oxaliplatin and the utilization of nab-paclitaxel which has its neurotoxic potential following FOLFIRINOX with a platinum-based compound. For those patients who go through FOLFIRINOX have very little toxicities, do not have any residual neuropathy. Gemcitabine and nab-paclitaxel may seem as the natural fit for second line. For those patients who may have had a tough time with neutropenia, who may have some significant neuropathy, may want to consider gemcitabine and capecitabine. In this group of patients, a biweekly regimen of gemcitabine/nab-paclitaxel would be significantly preferred given the fact that the toxicity is lesser and it’s more likely that those patients will be able to tolerate an every-other-week regimen than a weekly regimen. For the majority of the patients who are still able and capable to get chemotherapy in the second line following FOLFIRINOX failure, my first choice would be biweekly gemcitabine and nab-paclitaxel, and then second choice would be gemcitabine plus capecitabine or other therapies, especially in the presence of residual neuropathy. Thank you for viewing this activity.

Last modified: August 13, 2018
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