SEOM clinical guidelines for the treatment of pancreatic cancer

Pancreatic cancer (PC) is one of the main causes of cancer-related death in the United States and Europe. Due to its poor long-term survival, all patients with PC should undergo a comprehensive evaluation by a Multidisciplinary Tumor Committee to establish the best therapeutic strategy. Pathologic PC diagnosis should be made according to the latest WHO classification of malignant tumours and an accurate staging is crucial to assess resectability, determine the extension and, in some cases, reestablish biliary flow. For patients with localised resectable disease the standard treatment option is radical pancreatic resection. The aim of resection is to obtain microscopically negative margins (R0) and also to resect the drainage lymph nodes. In those cases diagnosed with locally advanced unresectable or metastatic PC, palliative bypass of intestinal or biliary obstruction followed by chemotherapy or chemoradiation remains the main palliative treatment option. Since 1997, gemcitabine monotherapy has been considered the standard of care for advanced PC. In recent years new chemotherapy combinations and targeted agents have demonstrated significant antitumoral activity, increasing the armamentarium that can be used against this lethal disease.

Gemcitabine and oxaliplatin combination chemotherapy for patients with refractory pancreatic cancer

OBJECTIVE

The aim of this study was to investigate the effect of gemcitabine and oxaliplatin combination chemotherapy on refractory pancreatic cancer.

METHODS

Patients with advanced pancreatic cancer refractory to gemcitabine and S-1 were treated with gemcitabine 1,000 mg/m² over 30 min and oxaliplatin 85 mg/m² over 120 min on days 1 and 15. Treatment was repeated every 4 weeks and tumor response was assessed every two cycles by RECIST version 1.0.

RESULTS

Twenty-two patients with pathologically confirmed pancreatic cancer were enrolled. The treatment was administered as a second-line chemotherapy in eighteen patients (82%) and as a third-line chemotherapy in four patients (18%). Tumor response did not occur in any of the cases. Thirteen patients demonstrated stable diseases, and the disease control rate was 59%. Median overall survival and time to progression were 6.8 months (95% CI, 2.8-11.5) and 2.6 months (95% CI, 1.5-3.8), respectively. Median overall survival from the first-line chemotherapy was 22.7 months (95% CI, 14.8-24.4). The major grade 3/4 adverse events included neutropenia (14%), anorexia (23%), and peripheral neuropathy (14%).

CONCLUSIONS

Gemcitabine and oxaliplatin combination chemotherapy was tolerable but had limited activity in patients with advanced pancreatic cancer in a refractory setting.

Impact of S-1 in patients with gemcitabine-refractory pancreatic cancer in Japan

OBJECTIVE

We investigated the impact of S-1 on the prognosis of patients with gemcitabine-refractory pancreatic cancer.

METHODS

A total of 108 patients with gemcitabine-refractory pancreatic cancer were divided by the time of S-1 introduction in our institution: 47 patients who experienced progressive disease before February 2005 (pre-S-1 group) and 61 patients showed progressive disease after February 2005 (post-S-1 group). Introduction rates of second-line chemotherapy and survival were compared. Prognostic factors for residual survival were analyzed using the Cox proportional hazards model.

RESULTS

Introduction rates of second-line chemotherapy were 12.8% in the pre-S-1 group and 45.9% in the post-S-1 group. Second-line chemotherapy was administered to 34 patients: 29 using S-1, 4 using 5-fluorouracil-based chemoradiation and 1 using 5-fluorouracil. The objective response rate, progression-free survival and overall survival for second-line chemotherapy with S-1 were 17.2%, 2.5 and 7.7 months, respectively. By the introduction of S-1 in our institution, residual survival was prolonged from 3.1 months in the pre-S-1 group to 6.7 months in the post-S-1 group (P < 0.001). Overall survival from the initiation of gemcitabine was 8.8 months in the pre-S-1 group and 11.3 months in the post-S-1 group (P = 0.013). Multivariate analysis identified the post-S-1 group (hazard ratio, 0.43; P = 0.001), gender, performance status, liver metastasis, and lactate dehydrogenase and C-reactive protein levels at progressive disease for gemcitabine to be prognostic factors for residual survival.

CONCLUSIONS

The introduction of S-1 might improve the prognosis of patients with gemcitabine-refractory pancreatic cancer.

Second- and third-line chemotherapy in patients with metastatic pancreatic adenocarcinoma: feasibility and potential benefits in a retrospective series of 117 patients

BACKGROUND

Chemotherapy is effective in metastatic pancreatic adenocarcinoma (PAC), but the benefits of second- and third-line chemotherapy remain unclear.

METHODS

We studied all patients followed consecutively for metastatic PAC, and registered at our institution between 1997 and 2006. We retrospectively analyzed the following data in terms of chemotherapy: tumor response; time to tumor progression (TTP) for each line; and overall survival (OS). Efficacy of second-line regimens was assessed using the growth modulation index (GMI).

RESULTS

Out of 117 patients, 99 (85%) received at least one line of chemotherapy, 53 (45%) received two lines and 24 (21%) had three or more lines. Median OS was 6.7 months for all 117 patients, 1.8 months for 18 patients who never received chemotherapy, 4.6 months for 46 patients who received one-line chemotherapy and 11.5 months for 53 patients who received at least two lines. Median OS from the beginning of the second-line was 4.7 months. The GMI demonstrated beneficial effects of second-line treatment on disease progression, with a GMI greater than 1.33 in 57% (30/53) of patients.

CONCLUSION

More than half the patients with metastatic PAC progression while receiving one-line chemotherapy achieved better disease control on receiving two lines of treatment.

Second-line therapy for advanced pancreatic cancer: a review of the literature and future directions

Whereas first-line chemotherapy (CT) with single-agent gemcitabine or gemcitabine-based combinations provides a proven benefit in patients with locally advanced or metastatic pancreatic cancer (PC), the role of salvage CT after gemcitabine-failure is not well-established and to date no regimen has emerged as preferred in this setting. Several clinical trials have investigated the efficacy and toxicity-profile of second-line CT and indicated that selected patients may obtain significant benefit from it, also with regard to survival. However, definitive results from large randomized phase III studies are still lacking, and the evidence for clinical benefit of salvage CT is based on small phase II trials that evaluated different treatment schedules in heterogeneous populations. The main goal of this paper is reviewing this topic.

Gemcitabine in the treatment of metastatic pancreatic cancer

Gemcitabine (2 ,2 -difluorodeoxycytidine) is a deoxycytidine-analog antimetabolite with broad activity against a variety of solid tumors and lymphoid malignancies. It was approved as standard of care in patients with pancreatic cancer one decade ago, based primarily on improvement in clinical benefit response such as pain reduction, improvement in Karnofsky performance status and increase in body weight. This article gives an overview of the pharmacodynamics and pharmacokinetics of gemcitabine, highlights the clinical activity of gemcitabine and summarizes the treatment options in metastatic pancreatic cancer with focus on gemcitabine-based chemotherapy. The emerging role of combinations of gemcitabine with novel targeted agents, including small-molecule inhibitors and other investigational drugs, is also discussed.

The role of second-line chemotherapy after gemcitabine failure in patients with advanced pancreatic cancer

Systemic chemotherapy with single-agent gemcitabine or a gemcitabine-based regimen still remains a standard of care for the treatment of patients with locally advanced and metastatic pancreatic cancer. To date, no standard treatment approach for patients that show progressive disease during gemcitabine therapy is defined. Several clinical trials have evaluated the safety and efficacy of second-line chemotherapy after gemcitabine failure in this patient population. Based on the currently available data, there is increasing evidence that selected patients may derive clinical benefit from salvage chemotherapy, also with regard to survival. However, results from large randomized Phase III trials are still lacking and therefore no evidence-based treatment recommendation can be given for patients with advanced pancreatic cancer after failure of first-line gemcitabine.