In what situations, if any, would you recommend NALIRIFOX over FOLFIRINOX for first-line treatment of patients with unresectable pancreatic cancer?

Given the currently available information, I would not use NALIRIFOX instead of mFOLFIRINOX in any situation.

My reasons for this are:

1. mFOLFIRINOX has been the standard of care for the treatment of metastatic and unresectable pancreatic cancer in patients who can tolerate this regimen for over a decade (see Conroy et al., PMID 21561347). The NAPOLI-3 study, recently presented at ASCO GI '23, does not offer any compelling evidence to suggest that NALIRIFOX is superior to mFOLFIRINOX.
2. Based on calc...

Fully agree with answers/comments above that with current evidence I cant see any scenario where I would use NALIRIFOX instead of FOLFIRINOX.

There is no difference in neurotoxicity or response rate. Neurotoxicity was underreported in final publication and response rate overestimated due to lack of BICR. Please see below.

Neurotoxicities were under reported in NAPOLI-3 trial (see difference in neurotox reported in oral presentation at ASCO 2023 vs final report in paper). Also see excellent metanal...

This question relates to "unresectable" pancreas cancer. The NAPOLI-3 trial included previously untreated patients with metastatic cancer. At a median follow-up of 16.1 months, median overall survival was 11.1 months with Nalirifox compared to 9.2 months with nab-paclitaxel and gemcitabine. However, concerning was the incidence of diarrhea 20.3% with Nalifirox vs 4.5% with nab-paclitaxel and gemcitabine. This toxicity must be weighed against the almost two-month improvement in OS which makes me ...