A C-change in Adjuvant Pancreas Cancer?
A C-change in Adjuvant Pancreas Cancer?
Hi. It's John Marshall for Medscape. Happy summer. I hope it's going great. It's a beautiful day here in Washington, DC. We have finally broken the heat and it is lovely. The Nationals cannot win a game, but I was on the Jumbotron last night, so I am very excited about that. In fact, one of my patients texted me and said, "Was that you on the Jumbotron?" I said, "Yeah, of course it was me. I am very cool."
What is going on in pancreas cancer? I think this is very exciting stuff that is happening all of a sudden. We are doing it with not a lot of targeted fancy stuff but with traditional drugs. First, we have the story about FOLFOXIRI beating gemcitabine, and that is great. It is good that we have moved the bar. Response rate is 30% and there is survival benefit and the like, but it is a spicy meatball and we have to dose-modify and dose-adjust. You can't give tons of cycles of that stuff. Then comes nab-paclitaxel plus gemcitabine, which also showed an improvement over gemcitabine alone with a survival advantage response rate improvement that, although not quite as good as with FOLFOXIRI, was certainly decent. Instantly, we saw in the United States a huge rise in the use of nab-paclitaxel plus gemcitabine in metastatic pancreas cancer. That is all good and positive, but what I want to focus on is adjuvant chemotherapy for pancreas cancer.
We do many Whipple procedures here, so I see a lot of patients who are now facing adjuvant treatment. Of course, the current standard of care is gemcitabine, but is anybody paying attention to the big study that was put out by the Japanese at ASCO® this year, suggesting that oral fluoropyrimidine in the form of S-1 vs gemcitabine actually won? Prolonged oral 5-FU (5-fluorouracil) beat gemcitabine. We have oral capecitabine. Should we be changing our adjuvant therapy on the basis of this Japanese study? I am not hearing a lot of ripple out there in the gastrointestinal cancer blogosphere, and I am not sure why that is, because this is clearly a positive study. I know we like to see more than 1 study for this kind of thing, but it suggests that oral fluoropyrimidines are a good idea. If I were faced with pancreas cancer tomorrow, which would I take -- gemcitabine or oral fluoropyrimidine? I'm a little challenged on that answer.
What we are doing here at Georgetown University and what others are doing is combining. I am seeing nab-paclitaxel plus gemcitabine being used. I am seeing people fiddle with FOLFOXIRI in the adjuvant setting. What I am personally doing is combining these efforts by giving some gemcitabine followed by capecitabine -- maybe as a chronic therapy, a chronic maintenance-like approach. I don't think we really know what the right answer is. Cooperative group studies are looking at erlotinib. I think the answer is going to be prolonged 5-FU.
I like the Japanese study. I think we should be paying more attention to it and I think we need to embrace it, test it again, and make sure that it is the right thing to do. I call upon our GI cancer leaders in the cooperative group world to embrace this design and trial and quickly get this up and running so we can test it in our patient population. It is a nice, easy regimen and had a nice outcome in one study. Let's see if we can replicate it in a study over here and change the standard of care for this terrible disease. I'm John Marshall for Medscape. Have a great summer.
Hi. It's John Marshall for Medscape. Happy summer. I hope it's going great. It's a beautiful day here in Washington, DC. We have finally broken the heat and it is lovely. The Nationals cannot win a game, but I was on the Jumbotron last night, so I am very excited about that. In fact, one of my patients texted me and said, "Was that you on the Jumbotron?" I said, "Yeah, of course it was me. I am very cool."
What is going on in pancreas cancer? I think this is very exciting stuff that is happening all of a sudden. We are doing it with not a lot of targeted fancy stuff but with traditional drugs. First, we have the story about FOLFOXIRI beating gemcitabine, and that is great. It is good that we have moved the bar. Response rate is 30% and there is survival benefit and the like, but it is a spicy meatball and we have to dose-modify and dose-adjust. You can't give tons of cycles of that stuff. Then comes nab-paclitaxel plus gemcitabine, which also showed an improvement over gemcitabine alone with a survival advantage response rate improvement that, although not quite as good as with FOLFOXIRI, was certainly decent. Instantly, we saw in the United States a huge rise in the use of nab-paclitaxel plus gemcitabine in metastatic pancreas cancer. That is all good and positive, but what I want to focus on is adjuvant chemotherapy for pancreas cancer.
We do many Whipple procedures here, so I see a lot of patients who are now facing adjuvant treatment. Of course, the current standard of care is gemcitabine, but is anybody paying attention to the big study that was put out by the Japanese at ASCO® this year, suggesting that oral fluoropyrimidine in the form of S-1 vs gemcitabine actually won? Prolonged oral 5-FU (5-fluorouracil) beat gemcitabine. We have oral capecitabine. Should we be changing our adjuvant therapy on the basis of this Japanese study? I am not hearing a lot of ripple out there in the gastrointestinal cancer blogosphere, and I am not sure why that is, because this is clearly a positive study. I know we like to see more than 1 study for this kind of thing, but it suggests that oral fluoropyrimidines are a good idea. If I were faced with pancreas cancer tomorrow, which would I take -- gemcitabine or oral fluoropyrimidine? I'm a little challenged on that answer.
What we are doing here at Georgetown University and what others are doing is combining. I am seeing nab-paclitaxel plus gemcitabine being used. I am seeing people fiddle with FOLFOXIRI in the adjuvant setting. What I am personally doing is combining these efforts by giving some gemcitabine followed by capecitabine -- maybe as a chronic therapy, a chronic maintenance-like approach. I don't think we really know what the right answer is. Cooperative group studies are looking at erlotinib. I think the answer is going to be prolonged 5-FU.
I like the Japanese study. I think we should be paying more attention to it and I think we need to embrace it, test it again, and make sure that it is the right thing to do. I call upon our GI cancer leaders in the cooperative group world to embrace this design and trial and quickly get this up and running so we can test it in our patient population. It is a nice, easy regimen and had a nice outcome in one study. Let's see if we can replicate it in a study over here and change the standard of care for this terrible disease. I'm John Marshall for Medscape. Have a great summer.