75 year old female, ECOG PS 1, type 2 DM, remote history of breast cancer with recent diagnosis of pancreatic adenocarcinoma, T3N0M0, elevated CA 19-9, no evidence of distant metastasis. Based on surgical oncology evaluation, she was deemed to have resectable disease, but preference was for neoadjuvant chemotherapy prior to consideration of surgery. Given good PS, I have considered both modified FOLFIRINOX as well as gemcitabine/nab-paclitaxel as appropriate regimens either in a perioperative manner or as induction x 6 months. What would be your preferred approach and regimen? In light of SWOG S1505 data demonstrating improved pathological responses, resectability and equivalent survival between the 2 regimens, would you consider Gem/Nab-paclitaxel given the favorable toxicity profile?
I would actually suggest trial if there is one available or if patient can go to a center with resectable study. One great study for this situation is the Alliance A021806 study which evaluates upfront surgery vs neoadjuvant FFX followed by surgery. another example we have is a study with Gem/Abraxane followed by window of opportunity immunotherapy with/w/o FAK inhibitor. I favor this options especially for high CA 19-9. both G/A and MFFX are reasonable if no trial options or if you want to do neoadjuvant. If patient is more like a 75 going on 80 do G/A and for SWOG1505. additionally recent NORPACT-1 study, despite its limitations showed no benefit to neoadjuvant mFFX. if patient very robust 75 but biologically 65 do mFFX. There is equipoise in this space. Thus study is best option.
