What are the ASCO guidelines for second-line treatment of metastatic pancreatic cancer?

Updated: Oct 02, 2020
  • Author: Tomislav Dragovich, MD, PhD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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Answer

Treatment options after first-line therapy:

  • In patients with tumors harboring NTRK fusions, treatment with larotrectinib or entrectinib is recommended.
  • The programmed death–1 immune checkpoint inhibitor pembrolizumab is recommended as second-line therapy for patients who have tested positive for mismatch repair-deficient or microsatellite instability-high tumors.
  • In patients who have a germline BRCA1 or BRCA2 mutation and who have received first-line platinum-based chemotherapy without disease progression for at least 16 weeks, options for continued treatment include chemotherapy or the poly (ADP-ribose) polymerase (PARP) inhibitor olaparib.

Gemcitabine plus nab-paclitaxel may be offered as second-line therapy to patients who meet all of the following criteria:

  • First-line treatment with FOLFIRINOX
  • ECOG performance status 0-1
  • Relatively favorable comorbidity profile
  • Patient preference and a support system for aggressive medical therapy

Fluorouracil plus nanoliposomal irinotecan, or fluorouracil plus irinotecan when the former combination is unavailable, is preferred as a second-line therapy for patients who meet all of the following criteria:

  • First-line treatment with a gemcitabine-based regimen
  • ECOG performance status 0-1
  • Relatively favorable comorbidity profile
  • Patient preference and a support system for aggressive medical therapy
  • Access to chemotherapy port and infusion pump management services

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
  • ECOG performance status 0-1
  • Relatively favorable comorbidity profile
  • Patient preference and a support system for aggressive medical therapy
  • Access to chemotherapy port and infusion pump management services

Gemcitabine or fluorouracil can be considered as second-line therapy for patients who have either an ECOG performance status 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 fluorouracil may be offered, with proactive dose and schedule adjustments to minimize toxicities).

No data are available to recommend third-line or further therapy with a cytotoxic agent. Clinical trial participation is encouraged.


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