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Do you use modified FOLFIRINOX preferentially over gem/nab-paclitaxel for first line metastatic pancreatic cancer patients?

Patient characteristics would unarguably be a deciding factor, but outside of these how would you approach the situation?
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What is your preferred first line treatment for metastatic pancreatic cancer?

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3 Answers
Mednet MemberInvited Expert
Medical Oncology · Medical College of Wisconsin
Answered on
Over and beyond patient characteristics, I prioritize mfolfirinox in pancreatic ductal adenocarcinoma patients with (i) known somatic or germ line alterations in DNA Damage Repair genes and (ii) in patients with a high likelihood of such alterations based on clinical/family history (if somatic or germ line testing data are pending or not available). 
 
While there are no other predictive biomarkers (other than DNA Damage repair gene alterations) to select mfolfirinox over gemcitabine + abraxane, there are evolving data suggesting that transcriptomic signatures and/or surrogates may eventually be helpful in serving as predictive biomarkers.
Mednet Member
Medical Oncology
Answered on

We utilize modified folfirinox in all patients with PS 0-1, offer gemzar plus Abraxane for PS 2, and add cisplatin to gemzar plus Abraxane to all who are BRCA positive or “BRCA like.”

Mednet Member
Medical Oncology · Siri Onclogy and hematology Infusion Service
Answered on

I have always used modified FOLFIRINOX in pancreatic cancer.  If the patients is PS 2 or worse doses can be further reduced and increased with improved PS like the REDOS trial.There are many references as to the equal effectiveness of FOLFIRINOX at reduced doses to full unrealistic doses.

I personally think the most toxic component is is the irinotecan and never in pancreatic or colon give above 100 mg/m2.

With this modified dose and 20% reduction of other drugs I have many patients remain on therapy past 6 cycles and several into a third year or more.

Data I think suggests it is more active in the metastatic setting and certainly in the recent reported adjuvant study. I do not have to delay therapy and make decisions early decisions regarding mutational results.

I think a more important question will be, is maintenance modified FOLFIRINOX equal or superior to the expense of maintenance PARP inhibitor in a platinum sensitive patient, assuming cumulative toxicities do not enter into equation.