Treatment
Recommendation 3.6
➤ Fluorouracil plus oxaliplatin may be considered as second-line
therapy for patients who meet all of the following criteria: first-line
treatment with gemcitabine plus NAB-paclitaxel, an ECOG PS of 0
to 1, a relatively favorable comorbidity profile, patient preference
and a support system for aggressive medical therapy, and access to
chemotherapy port and infusion pump management services (Moderate
recommendation; IC-B-L).
Qualifying statement. A phase III trial comparing mFOLFOX6 with FU + LV
demonstrated a higher rate of grade 3 or 4 adverse events and significantly reduced
OS within the mFOLFOX6 arm of the trial. However, previous phase III data have
demonstrated a benefit with the OFF regimen compared with FU + LV. Considering
the inconsistency of these results, although fluorouracil plus nanoliposomal irinotecan is
preferred, the Expert Panel continues to support the use of fluorouracil plus oxaliplatin as
an option where the availability of fluorouracil plus nanoliposomal irinotecan is limited
or where residual toxicity from first-line therapy or comorbidities preclude the use of
fluorouracil plus nanoliposomal irinotecan.
Recommendation 3.7 (Updated)
➤ Gemcitabine or fluorouracil can be considered as second-line therapy
for patients who have either an ECOG PS of 2 or a comorbidity profile
that precludes more aggressive regimens and who wish to pursue
cancer-directed therapy (the addition of nab-paclitaxel to gemcitabine or
nanoliposomal irinotecan to 5-fluorouracil may be offered in this setting,
with proactive dose and schedule adjustments to minimize toxicities)
(Moderate recommendation; IC-B-L).
Recommendation 3.8
➤ No data are available to recommend third-line (or greater) therapy with
a cytotoxic agent. Clinical trial participation is encouraged (Moderate
recommendation; IC-B-L).
Palliative Care
Recommendation 4.1
➤ Patients with metastatic pancreatic cancer should have a full
assessment of symptom burden, psychological status, and social
supports as early as possible, preferably at the first visit. In most
cases, this assessment will indicate a need for a formal palliative care
consult and services (Strong recommendation; EB-B-I).
Treatment of Pain and Symptoms
Recommendation 5.1
➤ Patients with metastatic pancreatic cancer should be offered
aggressive treatment of the pain and symptoms of the cancer and/or
the cancer-directed therapy (Strong recommendation; EB-B-I).
