J Cancer 2018; 9(11):1978-1988. doi:10.7150/jca.23716 This issue


From First Line to Sequential Treatment in the Management of Metastatic Pancreatic Cancer

Andrés Muñoz Martín1✉, Manuel Hidalgo2, Rafael Alvarez3, Virginia Arrazubi4, Joaquina Martínez-Galán5, Mercedes Salgado6, Teresa Macarulla7, Alfredo Carrato8

1. Dpt. Medical Oncology, Hospital Universitario Gregorio Marañón, Madrid, Spain;
2. Div. Medical Oncology, Beth Israel Deaconess Medical Center, Boston, USA;
3. Centro Integral Oncológico Clara Campal, Hospital Universitario HM Sanchinarro, Madrid, Spain
4. Dpt. Medical Oncology, Complejo Hospitalario de Navarra, Pamplona, Spain;
5. Dpt. Medical Oncology, H.U. Virgen de las Nieves, Complejo Hospitalario de Granada, Granada, Spain;
6. Dpt. Medical Oncology, Complejo Hospitalario Universitario de Orense, Orense, Spain;
7. Dpt. Medical Oncology, Hospital Vall d´Hebrón, Barcelona, Spain;
8. Dpt. Medical Oncology, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERONC, Madrid, Spain

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Martín AM, Hidalgo M, Alvarez R, Arrazubi V, Martínez-Galán J, Salgado M, Macarulla T, Carrato A. From First Line to Sequential Treatment in the Management of Metastatic Pancreatic Cancer. J Cancer 2018; 9(11):1978-1988. doi:10.7150/jca.23716. Available from https://www.jcancer.org/v09p1978.htm

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The current management of patients with metastatic pancreatic ductal adenocarcinoma (mPDAC) is based on systemic chemotherapy. The results of the MPACT and PRODIGE clinical trials have demonstrated that the combination of nab-paclitaxel and gemcitabine (GEM) as well as FOLFIRINOX regimen result in improvement in overall survival when compared to GEM alone. Treatment guidelines now recommend either one of these two regimens as first line treatment for fit patients with mPDAC. Because no head-to-head comparison between the two regimens exists, the selection of one versus the other is based on clinical criteria. The design and eligibility criteria of these two clinical trials are dissimilar, making the results of the MPACT trial more applicable to the general population of patients with mPDAC. In addition, the combination of nab-paclitaxel and GEM is better tolerated and easier to administer in clinical practice than FOLFIRINOX. Furthermore, when the regimens are studied in comparable patient populations the efficacy results are very similar. Nanoliposomal irinotecan plus 5FU has recently demonstrated a significant increase in efficacy rates after a GEM-based treatment. Importantly, treatment of mPDAC should now be considered as a continuum care for patients who are fit, with second and even third line treatments. Different sequential treatment algorithms are proposed based on available data. In retrospective studies, patients who were managed with GEM-based regimens followed by fluoropyrimidine-based regimens appear to have the most favorable outcome.

Keywords: pancreatic cancer, metastatic disease, chemotherapy, nab-paclitaxel + gemcitabine, FOLFIRINOX, sequential treatment