Eileen M. O'Reilly, MD: Options for Patient Going Forward

What are the options for this patient going forward? Do you recommend a third-line therapy?

It’s good that we’re discussing this because the third-line is not a setting where we have an established standard of care. But it’s also, and this is the good news, an increasing discussion that we have in the clinic because more and more patients are well enough to go on to receive a second-line therapy and also be considered for a third-line therapy, where performance status permits. I mean, this ideally is a clinical trial setting because that’s how we’re going to define what we should be doing in this setting. And there are some trials being developed in this space.

For now, outside of a trial setting, it will depend on what people have had in terms of their prior therapy. So, for example, if we take an individual who’s received gemcitabine/nab-paclitaxel frontline, went on to receive the NAPOLI-1 regimen second-line with liposomal irinotecan, well then we would consider logically, based on available tools, using oxaliplatin-based therapy third-line. In contrast, for a patient, perhaps, who had received neoadjuvant FOLFIRINOX and then their disease progressed, we might choose gemcitabine/nab-paclitaxel as their second-line treatment, although frontline for metastatic disease and then liposomal irinotecan could be third-line. If that patient remained well enough, we might actually recycle some of the drugs that were used earlier in the disease phase.

We’re getting into less and less data there as we go down the sequencing pathway, but I think it’s good that we’re discussing this optic and that we’re now making a decision based on what’s available second and third-line but at least thinking about how can we utilize all the tools to get the best outcome for a given individual.

Metastatic Pancreatic Cancer: Case 2

Henry R was diagnosed with adenocarcinoma in the body of the pancreas when he was 64 years old, following rapid weight loss, abdominal pains, and the development of venous thrombosis.

• At diagnosis, measurable distant lymph node, liver, and lung metastases were observed
• His CA19-9 level was 2760 U/ml and his concentration of albumin was 28 g/L. His ECOG performance status was 1.

Upfront treatment was administered with nab-paclitaxel and gemcitabine, which lasted for 4months:

• At the time of progression, pain levels had increased interfering with daily activity and raising the ECOG performance status to a 2.
• At this point, second-line therapy was initiated with liposomal irinotecan, fluorouracil, and folinic acid.