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Marschner N, Hegewisch-Becker S, Reiser M, von der Heyde E, Bertram M, Hollerbach SH, Kreher S, Wolf T, Binninger A, Chiabudini M, Kaiser-Osterhues A, Jänicke M. FOLFIRINOX or gemcitabine/nab-paclitaxel in advanced pancreatic adenocarcinoma: A novel validated prognostic score to facilitate treatment decision-making in real-world. Int J Cancer 2023; 152:458-469. [PMID: 36053905 PMCID: PMC10087956 DOI: 10.1002/ijc.34271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/30/2022] [Accepted: 07/20/2022] [Indexed: 02/01/2023]
Abstract
There is no prospective, randomised head-to-head trial comparing first-line FOLFIRINOX and gemcitabine/nab-paclitaxel in advanced pancreatic cancer. We assess real-world effectiveness and quality of life (QoL) of both regimens using a new prognostic score. This analysis includes 1540 patients with advanced pancreatic cancer from the prospective, clinical cohort study Tumour Registry Pancreatic Cancer separated into learning (n = 1027) and validation sample (n = 513). The Pancreatic Cancer Score (PCS) was developed using multivariate Cox regression. We compared overall survival (OS) and time to deterioration (TTD) for longitudinal QoL between first-line FOLFIRINOX (n = 407) and gemcitabine/nab-paclitaxel (n = 655) according to patients' prognostic risk, after inverse probability of treatment weighting (IPTW) by propensity score analysis. The PCS includes nine independent prognostic factors for survival: female sex, BMI ≥24/unknown, ECOG performance status ≥1, Charlson comorbidity index ≥1, tumour staging IV/unknown at primary diagnosis, liver metastases, bilirubin >1.5× upper limit of normal (ULN), leukocytes >ULN and neutrophil-to-lymphocyte ratio ≥4. Median OS of the validation sample was 11.4 (95% confidence interval [CI]: 10.4-14.4), 8.5 (95% CI: 6.8-9.6) and 5.9 months (95% CI: 4.0-7.4) for favourable- (0-3 risk factors), intermediate- (4-5 factors) and poor-risk group (6-9 factors), respectively. After IPTW, only poor-risk patients had significantly longer median OS and TTD of overall QoL with FOLFIRINOX (OS: 6.9 months, 95% CI: 3.9-13.3; TTD: 10.6 months, 95% CI: 2.0-14.1) vs gemcitabine/nab-paclitaxel (OS: 4.0 months, 95% CI: 2.8-4.8; TTD: 4.1 months, 95% CI: 2.4-4.5). Our novel PCS may facilitate treatment decisions in clinical routine of advanced pancreatic cancer, since only poor-risk, but not favourable-risk patients, seem to benefit from intensified treatment with FOLFIRINOX.
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Affiliation(s)
- Norbert Marschner
- Praxis für Interdisziplinäre Onkologie & Hämatologie, Freiburg, Germany
| | | | - Marcel Reiser
- PIOH-Praxis Internistische Onkologie und Hämatologie, Köln, Germany
| | | | - Mathias Bertram
- Hämatologisch Onkologischer Schwerpunkt Dres. Müller-Hagen/Bertram/Graefe/Kollegen, Hamburg, Germany
| | | | - Stephan Kreher
- Hämatologisch-Onkologische Schwerpunktpraxis Bad Liebenwerda, Bad Liebenwerda, Germany
| | - Thomas Wolf
- BAG, Gemeinschaftspraxis Hämatologie-Onkologie, Dresden, Germany
| | - Adrian Binninger
- Clinical Epidemiology and Health Economics, iOMEDICO, Freiburg, Germany
| | | | | | - Martina Jänicke
- Clinical Epidemiology and Health Economics, iOMEDICO, Freiburg, Germany
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Lebenthal JM, Zheng J, Glare PA, O'Reilly EM, Yang AC, Epstein AS. Prognostic value of the Memorial Sloan Kettering Prognostic Score in metastatic pancreatic adenocarcinoma. Cancer 2021; 127:1568-1575. [PMID: 33471374 DOI: 10.1002/cncr.33420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/13/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The Memorial Sloan Kettering Prognostic Score (MPS), a composite of the neutrophil-lymphocyte ratio (NLR) and albumin, is an objective prognostic tool created as a more readily available alternative to the Glasgow Prognostic Score. A prior analysis of patients with metastatic pancreatic adenocarcinoma (mPDAC) suggested that the MPS may predict survival, although it did not control for clinically relevant factors. METHODS MPS scores were calculated for patients with mPDAC treated at Memorial Sloan Kettering Cancer Center from January 1, 2011, to December 31, 2014. An MPS scale of 0 to 2 was used: 0 for an albumin level ≥ 4 g/dL and an NLR ≤ 4 g/dL, 1 for either an albumin level < 4 g/dL or an NLR > 4 g/dL, and 2 for an albumin level < 4 g/dL and an NLR > 4 g/dL. Performance status, antineoplastic therapy, presence of thromboembolism (TE), radiation therapy, and metastatic sites were also analyzed. The associations with overall survival were examined with time-dependent Cox proportional hazards regression analyses. RESULTS A multivariate model revealed that higher MPS scores at diagnosis (hazard ratio for MPS of 2 vs MPS of 0, 1.41; 95% confidence interval, 1.13-1.76), liver metastases, radiation therapy, hospital admissions, TE, and performance status were associated with worse overall survival. The median overall survival for patients with MPS scores of 0, 1, and 2 were 12.9, 9.0, and 5.4 months, respectively. CONCLUSIONS The MPS, an easily calculated composite of the NLR and albumin, is an objective tool that may predict survival in mPDAC independently of performance status, disease characteristics, and cancer therapy. LAY SUMMARY The Memorial Sloan Kettering Prognostic Score (MPS) is a new scoring system that incorporates markers of inflammation found in individuals' blood at the diagnosis of metastatic pancreatic cancer. Data suggest that the MPS may help to determine prognosis.
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Affiliation(s)
- Justin M Lebenthal
- Weill Cornell Medical Center, New York, New York.,Memorial Sloan Kettering Cancer Center, New York, New York
| | - Junting Zheng
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul A Glare
- Department of Pain Medicine, University of Sydney Medical Center, Sydney, New South Wales, Australia
| | - Eileen M O'Reilly
- Weill Cornell Medical Center, New York, New York.,Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew C Yang
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew S Epstein
- Weill Cornell Medical Center, New York, New York.,Memorial Sloan Kettering Cancer Center, New York, New York
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Long-lasting response to third-line chemotherapy in metastatic pancreatic cancer. Porto Biomed J 2020; 5:e65. [PMID: 33299946 PMCID: PMC7722404 DOI: 10.1097/j.pbj.0000000000000065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 03/29/2020] [Indexed: 01/05/2023] Open
Abstract
At diagnosis, approximately 50% of cases of adenocarcinoma of the pancreas are metastasized and 5-year survival is only 2.9%. We reported a case of a 63-year-old woman with pancreatic adenocarcinoma with multiple hepatic and intra-abdominal metastases that progressed on 2 lines of chemotherapy. She has been under treatment with third-line chemotherapy for 19 months with stable disease and excellent performance status. She has an overall survival of 29 months. There are just a few cases of metastatic disease with long survival described in the literature. The functional status and the good tolerance to treatment may be determinants of prognosis.
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Macarulla Mercadé T, Chen LT, Li CP, Siveke JT, Cunningham D, Bodoky G, Blanc JF, Lee KH, Dean A, Belanger B, Wang-Gillam A. Liposomal Irinotecan + 5-FU/LV in Metastatic Pancreatic Cancer: Subgroup Analyses of Patient, Tumor, and Previous Treatment Characteristics in the Pivotal NAPOLI-1 Trial. Pancreas 2020; 49:62-75. [PMID: 31856081 PMCID: PMC6946097 DOI: 10.1097/mpa.0000000000001455] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 11/04/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The NAnoliPOsomaL Irinotecan (NAPOLI-1) study (NCT01494506) was the largest global phase 3 study in a post-gemcitabine metastatic pancreatic adenocarcinoma (mPAC) population (N = 417). The subanalyses reported here investigated the prognostic effect of tumor characteristics and disease stage, prior treatment characteristics, baseline patient characteristics on survival outcomes in NAPOLI-1, and whether liposomal irinotecan (nal-IRI) + 5-fluorouracil/leucovorin (5-FU/LV) benefited patients with mPAC across subgroups. METHODS Post hoc analyses were performed in the NAPOLI-1 population (4 across tumor characteristics and disease stage, 6 across prior treatment characteristics, and 4 across patient baseline characteristics). Survival outcomes were estimated by Kaplan-Meier analysis and patient safety data were evaluated. RESULTS Mortality and morbidity risk was lower on nal-IRI+5-FU/LV treatment across subgroups. Exceptions were patients who had received prior nonliposomal irinotecan and those who had undergone prior Whipple procedure (overall survival hazard ratio = 1.25 and 1.23, respectively). Decreased appetite, liver metastases, and number of measurable metastatic lesions seemed to be prognostic of survival in this population. Subgroup safety data were generally comparable with those in the overall NAPOLI-1 safety population. CONCLUSIONS A diverse population of patients with mPAC that progressed on gemcitabine-based therapy benefited from nal-IRI+5-FU/LV versus 5-FU/LV, potentially helping guide treatment decisions for challenging cases.
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Affiliation(s)
- Teresa Macarulla Mercadé
- From the Vall d'Hebron University Hospital (HUVH) and Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Li-Tzong Chen
- National Institute of Cancer Research, National Health Research Institutes
- Department of Internal Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan
| | - Chung-Pin Li
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital
- National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Jens T. Siveke
- Division of Solid Tumor Translational Oncology, West German Cancer Center, University Hospital Essen
- German Cancer Consortium (DKTK, partner site Essen) and German Cancer Research Center, DKFZ, Heidelberg, Germany
| | - David Cunningham
- The Royal Marsden NHS Foundation Trust, London and Surrey, United Kingdom
| | - György Bodoky
- Department of Oncology, Szent László Hospital, Budapest, Hungary
| | | | - Kyung-Hun Lee
- Department of Internal Medicine and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Andrew Dean
- St. John of God Hospital, Subiaco, Western Australia, Australia
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Shi S, Yu X. Selecting chemotherapy for pancreatic cancer: Far away or so close? Semin Oncol 2018; 46:39-47. [PMID: 30611527 DOI: 10.1053/j.seminoncol.2018.12.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 01/26/2018] [Accepted: 12/19/2018] [Indexed: 02/06/2023]
Abstract
Pancreatic cancer is a lethal disease with a very poor prognosis. In contrast to treatments for many other tumor types, cytotoxic agents are still the first-line drugs for pancreatic cancer in both the palliative and adjuvant settings. Some progress has been made in recent years, but most large phase 3 studies have not shown significant improvements in survival. Because the available drugs and regimens are limited in both type and effect, the selection of chemotherapy based on clinicopathologic characteristics may be consequential for pancreatic cancer. In the present report, we focused on 7 landmark clinical trials for pancreatic cancer. We observed that FOLFIRINOX (oxaliplatin, irinotecan, fluorouracil, and leucovorin) and NG (nab-paclitaxel and gemcitabine), 2 first-line regimens, exerted opposite effects on metastatic pancreatic cancer patients with different baseline carbohydrate antigen 19-9 (CA19-9) levels. This suggested that not only the performance status but possibly also CA19-9 levels should be considered when making a therapeutic choice for patients with advanced pancreatic cancer. Moreover, we found that patients with a diagnosis of pancreatic cancer who have undergone a surgical resection with a negative margin (R0) may benefit more from fluorouracil and/or oral prodrugs of fluorouracil-based adjuvant therapy than from gemcitabine. Conversely, gemcitabine or gemcitabine-based regimens may be more effective for patients with a positive resection margin (R1). Based on these findings, we propose flowcharts for selecting chemotherapy for both advanced and resected pancreatic cancer. Furthermore, we present possible mechanisms and interpretations underlying the selection of chemotherapy for pancreatic cancer and propose the tumor burden as a key variable in this process. Regardless of the possible bias and exact treatment selection process, this study offers an opportunity to improve patient outcomes by using agents currently used in the therapy of pancreatic cancer. Although these conclusions are based on indirect evidence, we provide insights and possibilities to drive the selection of chemotherapy for pancreatic cancer.
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Affiliation(s)
- Si Shi
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Pancreatic Cancer Institute, Fudan University, Shanghai, China.
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Aarnink A, Richard C, Truntzer C, Vincent J, Bengrine L, Vienot A, Borg C, Ghiringhelli F. Baseline splenic volume as a surrogate marker of FOLFIRINOX efficacy in advanced pancreatic carcinoma. Oncotarget 2018; 9:25617-25629. [PMID: 29876012 PMCID: PMC5986639 DOI: 10.18632/oncotarget.25424] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 04/27/2018] [Indexed: 12/15/2022] Open
Abstract
Background The FOLFIRINOX regimen is the standard first-line treatment for advanced pancreatic adenocarcinoma (aPDAC). However, because of its potential toxicity, predictive biomarkers could help clinical decision-making. Methods A cohort of 97 aPDAC patients treated with first-line FOLFIRINOX were studied. The association between splenic volume and progression-free survival (PFS) and overall survival (OS) was evaluated using univariate and multivariable Cox analyses. The external validation cohort was composed of 117 patients treated with Gemcitabine and 52 patients treated with FOLFIRINOX. Results In the training cohort, the splenic volume of 97 patients was measured at baseline and at the end of therapy. The spleen size increased in 81% of patients, with at least a 50% increase in 27% of patients. Baseline splenomegaly predicted PFS (HR 1.812, 95% CI = [1.036–3.169]; p = 0.03) and OS (HR 1.983, 95% CI = [1.085–3.624]; p = 0.02) in the training cohort. These results were then validated in an external cohort of patients who were treated with FOLFIRINOX excluding those in the control cohort who were treated with gemcitabine. In a multivariate model based on the CoxBoost method, the following were selected as predictive markers of FOLFIRINOX efficacy (AUC = 0.81): performance status, liver metastasis, baseline Ca199 and CEA levels and baseline splenomegaly. The predictive ability of the model was validated in the external cohort that was also treated with FOLFIRINOX. Conclusions Baseline splenomegaly is a predictive marker of a poor response to FOLFIRINOX in aPDAC and remained predictive when associated with other clinical variables.
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Affiliation(s)
- Anne Aarnink
- Department of Medical Oncology, Center Georges Francois Leclerc, Dijon, France
| | - Corentin Richard
- Platform of Transfer in Oncology, Besançon University Hospital, Besançon, France
| | - Caroline Truntzer
- Platform of Transfer in Oncology, Besançon University Hospital, Besançon, France
| | - Julie Vincent
- Department of Medical Oncology, Center Georges Francois Leclerc, Dijon, France
| | - Leila Bengrine
- Department of Medical Oncology, Center Georges Francois Leclerc, Dijon, France
| | - Angélique Vienot
- Department of Medical Oncology, Besançon University Hospital, Besançon, France
| | - Christophe Borg
- Department of Medical Oncology, Besançon University Hospital, Besançon, France.,University of Bourgogne-Franche-Comté, Besançon, France
| | - Francois Ghiringhelli
- Department of Medical Oncology, Center Georges Francois Leclerc, Dijon, France.,Platform of Transfer in Oncology, Besançon University Hospital, Besançon, France.,INSERM, Unit 1231, Besançon, France.,University of Bourgogne-Franche-Comté, Besançon, France
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