Treatment practices for metastatic pancreatic cancer: Can we deliver an appropriately efficacious and safe regimen in Indian patients?

Real-world dose reduction of standard and modified FOLFIRINOX in metastatic pancreatic cancer: a systematic review, evidence-mapping, and meta-analysis

Background

FOLFIRINOX, used in metastatic pancreatic cancer (MPC), is highly efficacious but also toxic. Various dose modifications for FOLFIRINOX have been introduced to reduce toxicity. However, these studies lack a unified pattern for 'planned' dose modification, and the 'actually administered' dose varied more.

Objective

To map a 10-year trend for 'planned' and 'actual' doses of FOLFIRINOX and investigate the clinical outcomes according to dose modification.

Data sources and methods

A comprehensive systematic literature search was conducted from January 2011 to September 2021. All studies for FOLFIRINOX as first-line treatment in MPC were considered. Selected studies were firstly classified according to prospective versus retrospective research, secondly standard versus modified FOLFIRINOX, and thirdly 'planned' versus 'actual' dose. For evidence-mapping for the trend of dose modification, we developed a web-based interactive bubble-plot program (www.RDI-map.com). Objective response rate (ORR) and hematologic toxicity were set as endpoints for the comparison of clinical outcomes according to dose modification.

Results

A total of 37 studies were identified for evidence-mapping (11 prospective and 26 retrospective studies). There were 12 different types of 'planned' dose modification in FOLFIRINOX ranging 75-100% oxaliplatin, 75-100% irinotecan, 0-100% 5-fluorouracil (5-FU) bolus, and 75-133% 5-FU continuous injection. The 'actual' dose further decreased to 54-96%, 61-88%, 0-92%, and 63-98%, respectively. For the standard versus modified FOLFIRINOX, the ORR was 28.2% (95% CI: 22.5-33.9%) and 33.8% (95% CI: 30.3-37.3%), respectively (p = 0.100), and the incidence of febrile neutropenia was 11.6% (95% CI: 0-16.0%) and 5.5% (95% CI: 0-8.9%), respectively (p = 0.030).

Conclusions

RDI-map.com enables multifactorial evidence-mapping for practical FOLFIRINOX dose reduction. The pattern of dose modification was not consistent across studies, and there was a significant gap between the 'planned' and 'actual' doses. Modified FOLFIRINOX showed similar efficacy to the standard regimen with reduced incidence of febrile neutropenia.

Systemic therapy in pancreatic ductal adenocarcinomas (PDACs)-basis and current status

A major shift in the approach to the management of pancreatic ductal adenocarcinomas (PDACs) has been the recognition of the systemic nature of the disease even in clinically and radiologically limited disease stages. The recalcitrant nature of PDAC is intrinsically related to the lack of therapeutic targets and dense surrounding stroma that limits the activity of currently available chemotherapeutic options. However, research is increasingly focusing on intensifying systemic management options in PDAC, resulting in gradual improvements in survival. Currently effective chemotherapeutic regimens like modified 5-fluorouracil-leucovorin-irinotecan-oxaliplatin and gemcitabine-nab-paclitaxel have improved outcomes in resectable and advanced PDAC. An increasing use of these regimens has also resulted in greater conversion of borderline resectable and locally advanced cancers to resection, though the most effective approach in this subgroup is yet to be identified. The current review presents an outline of the basic systemic nature of PDAC and current options of systemic therapy, predominantly chemotherapy .

Neoadjuvant therapy for pancreas cancer: Global perspective and optimal care pathways in low to middle-income countries

Surgery remains the only curative intent treatment modality for localized pancreatic adenocarcinoma. Even in those who can undergo successful margin negative resection, the ability to deliver adjuvant chemotherapy is suboptimal for various reasons, resulting in poor outcomes. The delivery of "standard of care" intensive modern neoadjuvant therapies can be challenging in low to-middle-income countries (LMICs) with limited resource. This article reviews the constraints in delivering neoadjuvant therapies in LMICs and strategies to improve its implementation.

Irreversible electroporation after induction chemotherapy versus chemotherapy alone for patients with locally advanced pancreatic cancer: A propensity score matching analysis

BACKGROUND

Locally advanced pancreatic cancer (LAPC) is a devastating disease and irreversible electroporation (IRE) is a non-thermal ablation method that is especially suitable for the treatment of LAPC. This study aimed to compare the long-term survival of LAPC patients after induction chemotherapy followed by IRE and chemotherapy alone.

METHODS

From August 2015 to August 2017, a total of 132 patients with LAPC were identified. The oncological outcomes of these two treatments were analyzed by propensity score matching (PSM) analysis.

RESULTS

Before PSM analysis, patients with LAPC had better overall survival (OS) and progression-free survival (PFS) after induction chemotherapy followed by IRE than those who received chemotherapy alone (2-year OS rates, 57.9% vs 19.8%, P < 0.001; 2-year PFS rates, 31.4% vs 9.3%, P < 0.001). The baseline clinicopathological factors were balanced between the 2 groups through PSM analysis. Even after PSM, the OS and PFS rates of patients after induction chemotherapy followed by IRE treatment were superior to those of patients who received chemotherapy treatment alone (2-year OS rates, 57.9% vs 18.1%, P < 0.001; 2-year PFS rates, 31.4% vs 7.1%, P < 0.001). Multivariate Cox regression analysis indicated that chemotherapy plus IRE was a significant prognostic factor for both OS and PFS in patients of both the whole cohort and the matched cohort.

CONCLUSIONS

Induction chemotherapy followed by IRE provided better OS and PFS than chemotherapy alone for patients with LAPC. This combination method may be a more suitable treatment for patients with LAPC.