Phase II study of leucovorin, 5-fluorouracil and gemcitabine for locally advanced and metastatic pancreatic cancer (FOLFUGEM 2)

The reversible reproductive toxicity of 5-fluorouracil in mice

5-Fluorouracil (5-FU) is a "cytotoxic" drug used for cancer chemotherapy, which inhibits cells division via affecting DNA synthesis. Although being widely used for cancer treatment, 5-FU has non-negligible side effects. In the present study, the effects of 5-FU on oocyte and early embryonic development were investigated. Multiple intraperitoneal administration of 5-FU (50 mg/kg/day) in female mice resulted in small ovarian size and reduced number of corpus luteum in the ovary, and lead to ovulation failure. However, these defects could be recovered after one week. In vitro experiments further indicated that exposure to 5-FU inhibited oocytes maturation and reduced developmental potential of pre-implantation embryos. Our data suggested that 5-FU has negative impact on ovarian function, oocyte and early embryonic development, but the adverse effect could be reversed after withdrawal of 5-FU administration.

The combination of curcumin and 5-fluorouracil in cancer therapy

5-Fluorouracil (5-FU) alone or in combination with other therapeutic drugs has been widely used for clinical treatment of various cancers. However, 5-FU-based chemotherapy has limited anticancer efficacy in clinic due to multidrug resistance and dose-limiting cytotoxicity. Some molecules and genes in cancer cells, such as nuclear factor kappa B, insulin-like growth factor-1 receptor, epidermal growth factor receptor, cyclooxygenase-2, signal transducer and activator of transcription 3, phosphatase and tensin homolog deleted on chromosome ten and Bcl-2 etc. are related to the chemoresistance and sensitivity of cancer cells to 5-FU. The activation of these molecules and genes expressions in cancer cells will be increased or decreased with long-term exposure of 5-FU. Curcumin has been found to be able to negatively regulate these processes. In order to overcome the problems of 5-FU, curcumin has been used to combine with 5-FU in cancer therapy.

Systemic therapy for metastatic pancreatic adenocarcinoma

Systemic treatment of metastatic pancreatic adenocarcinoma achieves only modest benefits, with evidence indicating a survival advantage with 5-fluorouracil (5-FU) over best supportive care alone, and further advantage of single-agent gemcitabine over 5-FU. There are very few regimens better than single-agent gemcitabine despite multiple trials of cytotoxic and targeted agents. The addition of a platinum agent has improved response rate but not survival. The addition of erlotinib has improved survival but only by a small margin. The use of gemcitabine in multidrug regimens containing one or more of: a platinum agent; fluoropyrimidine; anthracycline; and taxane has demonstrated advantages in response rate, progression-free survival and, in one randomized study, overall survival. After gemcitabine failure, second-line therapy with oxaliplatin and 5-FU provides a further survival advantage. Further advances depend upon the current and future clinical trials investigating enhanced delivery of current agents, new agents and novel modalities, improved supportive care, and treatment more tailored to the individual patient and tumour.

Impact of chemoradiotherapy after disease control with chemotherapy in locally advanced pancreatic adenocarcinoma in GERCOR phase II and III studies

PURPOSE

The management of locally advanced (LA) pancreatic cancer patients remains controversial. To select patients who could benefit from chemoradiotherapy (CRT), the therapeutic strategy used by the Groupe Coopérateur Multidisciplinaire en Oncologie (GERCOR) consisted of initial chemotherapy (CT) for at least 3 months. The decision to administer CRT or continue CT in nonprogressive patients was the investigator's choice.

PATIENTS AND METHODS

Retrospective analysis of outcome in 181 patients with LA pancreatic cancer (76 women and 105 men; mean age, 61 years; range, 37 to 85 years) enrolled onto prospective phase II and III GERCOR studies was performed to compare the survival of patients who received CRT with that of patients who continued CT alone.

RESULTS

Median progression-free survival (PFS) and overall survival (OS) times for the 181 patients were 6.3 and 11.4 months, respectively. Fifty-three patients (29.3%) had metastatic disease after 3 months of CT and were not eligible for CRT. Among the 128 remaining patients (70.3%) who had no disease progression and who were, therefore, eligible for CRT, 72 (56%) received CRT (group A), whereas 56 (44%) continued with CT (group B). The two groups were balanced for initial characteristics (performance status, sex, age, and type of CT), as well as for induction CT results. In groups A and B, the median PFS times were 10.8 and 7.4 months, respectively (P = .005), and the median OS times were 15.0 and 11.7 months, respectively (P = .0009).

CONCLUSION

These results suggest that, after control of disease by initial CT, CRT could significantly improve survival in patients with LA pancreatic cancer compared with CT alone. A prospective phase III study is ongoing to evaluate this strategy.

Locally advanced pancreatic cancer: current therapeutic approach

Even though pancreatic cancer accounts for only 2% of all cancer diagnoses in the U.S., it is the fourth-leading cause of cancer death and one of the most difficult malignancies to manage. Because of the usually late onset of symptoms, only 10%-15% of patients present with resectable disease, whereas the remaining 85%-90% present with locally advanced unresectable or metastatic disease. Despite a lack of consistent evidence from previous clinical trials, chemotherapy in addition to radiation therapy is the most commonly used approach in treating locally advanced pancreatic cancer. The most appropriate chemotherapy in combination with radiation is still debatable between 5-fluorouracil and gemcitabine, and novel trends to prevent resistance and enhance efficacy incorporate biologically targeted agents. This paper reviews the current management options, controversies, and ongoing and future directions for the treatment of locally advanced adenocarcinoma of the pancreas.

Cytotoxic Chemotherapy for Pancreatic Cancer

Chemotherapy remains the mainstay of treatment for pancreatic cancer as most patients present with advanced disease, which precludes locoregional treatment. However, the efficacy of chemotherapy is limited. Gemcitabine is the only agent that improves symptoms and confers a modest survival advantage. Many combination therapy regimens have been studied in phase II settings. Eleven randomised phase III trials have been conducted to compare gemcitabine-containing regimens with gemcitabine monotherapy since gemcitabine became available clinically. The combination of gemcitabine plus capecitabine has demonstrated a survival advantage over gemcitabine, whereas gemcitabine plus oxaliplatin and gemcitabine plus cisplatin have shown improved progression-free survival or time to tumour progression but failed to demonstrate a survival advantage over gemcitabine. The search for effective therapy for advanced pancreatic cancer continues. Gemcitabine in combination with cytotoxic agents or molecular targeted agents hold promise.