Metastatic Pancreatic Cancer After FOLFIRINOX or GN: When First-Line Treatment No Longer Controls Disease (ECOG PS 0–1)
Clinical scenario
This protocol addresses patients with metastatic pancreatic cancer who have an ECOG performance status of 0–1 and a serum bilirubin level below 1.5 times the upper limit of normal — and whose first-line systemic treatment has been exhausted.
Previous line — when first-line chemotherapy fell short
Initial treatment with first-line systemic chemotherapy (FOLFIRINOX or GN) was evaluated every 8–12 weeks based on clinical status, CA 19-9 trajectory, and imaging. When those evaluations no longer support continuation of the current line, the second-line step is indicated.
Next step — second-line approach
Second-line systemic chemotherapy is available for eligible patients. The appropriate regimen depends on which first-line therapy was received and on the patient’s current performance status and comorbidity profile. The full selection algorithm is in the structured protocol.
References
DOI: 10.1016/j.annonc.2023.08.009
In patients with ECOG PS 0-1 and bilirubin level <1.5 times the ULN, two regimens should be considered: FOLFIRINOX [I, A; ESMO-MCBS v1.1 score: 5] or GN [I, A; ESMO-MCBS v1.1 score: 3].
In patients with, or who have recovered to, ECOG PS 0-1 and who have been pretreated with a gemcitabine-based regimen, nanoliposomal irinotecan-5-FU-LV (EMA and FDA approved in metastatic PC) can be considered [I, B; ESMO-MCBS v1.1 score: 3].
After FOLFIRINOX treatment, GN (not EMA or FDA approved as second-line therapy) or gemcitabine alone may be offered to patients with ECOG PS 0-1 and a favourable comorbidity profile [III, C].
Oxaliplatin-based second-line treatment (mFOLFOX6 or OFF) remains controversial but may be considered as an alternative in patients with ECOG PS 0-2 if not given previously [II, C].
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