Metastatic Pancreas Cancer: Beyond Second-Line Treatment

George Kim, MD:The patient has been treated with second-line therapy consisting of 5-FU/Nal-IRI, and now we need to think about what other treatments are available. I think we should go back to the very beginning; we always have to think about experimental clinical trials which are really going to pave the opportunity to advance the field, and hopefully will continue to improve survival outcomes while maintaining patient’s quality of life. In this setting, it’s always reasonable to consider an experimental clinical trial. Certainly, that’s a consideration in the frontline and second-line setting. For this patient, you would consider that. Alternatively, the patient has not been treated with a -platin, so, in this situation, you might introduce oxaliplatin (Eloxatin) either as FOLFOX. You could also use cisplatin; there is some very interesting data combining nab-paclitaxel/gemcitabine/cisplatin as a 3-drug regimen which had very interesting results. Other opportunities include maybe capecitabine, oral 5-FU; although there’s limited data with that agent.

All along we really need to continue to focus on supportive care. Palliative medicine may become more important in this setting. Managing the patient’s symptoms, again, trying to be positive, in terms of the psychologic status of the patient. But we do have some other available treatment options. Another consideration is what we said earlier, is this aBRCApatient? Well, certainly, if that’s true, you’re going to try to get a PARP inhibitor. Is this a patient that has a MSI-high or defective mismatch repair status? Will they benefit from checkpoint inhibitors?

The other thing that I’m a proponent of, is rebiopsy clinics; meaning does the cancer change during our treatment? Is there more expression of targetable mutation as the patient has gone through the spectrum of therapies that we can take advantage of? Getting molecular analysis, and getting tissue may be important. I know the insurance companies don’t like that, but getting more tissue to see whether the cancer has changed, may be important in terms of deciding additional treatments. But by the book, I think a -platin is the most appropriate available therapy for this individual.

Transcript edited for clarity.

A 57-Year-Old Man With Abdominal Pain and Unexplained Weight Loss

• A 57-year-old man was referred from his primary care clinician with complaints of persistent pain in his upper abdomen that radiate to his back
• History
  • Former smoker (35 years, quit 5 years ago)
  • Was obese (BMI 29.0), but began losing weight despite not changing his eating habits
  • Reports feeling “tired” despite regular sleep habits
  • Treated for DVT 8 months ago
  • Hypertension controlled on medication, impaired glucose tolerance
  • Family history: mother alive with type 2 diabetes, father died (MI)
• Clinical evaluation
  • CT reveals mass in head of pancreas with metastases in liver and blood vessels
  • CA19-9 level: 55 times upper limit of normal
  • ECOG PS: 1
• Diagnosis: unresectable metastatic pancreatic cancer
• Patient began treatment with IV nab-paclitaxel (125 mg/m²) plus IV gemcitabine (1000 mg/m²) on days 1, 8 and 15 of a 28-day cycle
  • Experienced grade 3 neutropenia; did not require growth factors
  • Had mild peripheral neuropathy that did not progress or require dose adjustment
• At 6 months, patient progressed and received second-line treatment with liposomal irinotecan in combination with 5-FU/LV