Many years ago I was consulted by a psychiatrist in his late 60’s who had pancreatic cancer. The cancer was inoperable, but he felt well. My advice – don’t take chemotherapy. The only drug we had then for treating pancreatic cancer was 5-fluorouracil (5-FU) and it was useless for treating this disease. I told him he would have more bad effects than good ones. He didn’t listen and went to another oncologist who provided his chemotherapy.
Now I would advise him differently. New drugs have come along that can improve the outcome, although pancreatic cancer remains, with rare exceptions, a fatal disease. About 15 years ago, a new drug, called gemcitabine came along and in well-controlled trials, proved better than no treatment in improving survival and quality of life. And few side effects.
Still, the benefit was small with only a couple of month’s extension of life. Adding other drugs to the gemcitabine didn’t make a big difference. The outlook for living longer than a few months with pancreatic cancer wasn’t great.
Now a report in the May 12 issue of the New England Journal of Medicine provides hope for a better outcome for patients with inoperable pancreatic cancer. The investigators, who were French, compared treatment with gemcitabine to treatment with a combination of drugs known by the acronym FOLFIROFOX (oxaliplatin, 5-FU, irinotecan, leucovorin).
I would consider their results amazing. Only half the gemcitabine-treated patients lived seven or more months. But, in the FOLFIROFOX group, half made it past the eleven-month mark, a life extension of 4 months. This is a remarkable achievement in such a fatal disease. Still, most patients in the FOLFIROFOX group saw their cancer begin to grow after 7 months and almost all had died by the end of two years. This is clearly not a cure, but the outlook is a lot better than when I saw that psychiatrist.
A couple of cautions. First, because the new treatment had several drugs and was clearly more “aggressive”, there were more side effects. But these weren’t that severe and the researchers reported that the quality of life of these patients was not impaired and in fact, improved with the treatment. Second, the patients were all in good physical condition and able to carry on most if not all of their every day functions. The treatment is not for people whose physical status has deteriorated.
So, if I were practicing today, I would have recommended FOLFIROFOX to the psychiatrist.
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4 comments:
A small point but it's FOLFIRINOX. Interesting that this was done in Europe with no US centres.
What this study seems to suggest is that pancreatic cancer patients can be treated successfully with a "combination" of drugs. There is a tactic of using biopsied cells to predict which cancer treatments will work best for the patient, by taking pieces of live "fresh" tumor tissue, applying different chemotherapy treatments to it, and examining the results to see which drug or combination of drugs does the best job killing the tumor cells.
Thus, a pancreatic cancer patient can be treated successfully with a combination of drugs commonly used to fight lung, pancreatic, breast, and colorectal cancers. The tactic can report prospectively to a physician specifically which chemotherapy agent would benefit a cancer patient. There are a number of drugs that could hold benefit for the patient with pancreatic cancer, including Tarceva (erlotiinib), Camptosar (irinotecan) and a number of novel combinations.
But both Sutent and Afinitor double the amount of time that cancers remain in check, compared with placebos, according to two studies in today's New England Journal of Medicine. That's significant, because patients with advanced disease live a median of only about two years. However, this comes from population studies, but responses to any population-based protocol occurs in the minority of individual patients.
It is unclear why some patients respond to these interventions while others fail. This reinforces the need for cancer therapies to be individualized. It remines us that it is the good outcome of the patient not the therapy applied that constitute successful therapy.
Cancer of the pancreas is a condition in which malignant (cancerous) cells are formed in the tissues of the pancreas.
Nearly 32,000 Americans were diagnosed with pancreatic cancer last year. Since detected so often in later stages, this malignancy five-year survival rate is less than 5 per cent.
This comment isn't meant for posting to the blog, but just as a thank you for sharing your knowledge and insights. I have a friend with stage 4B pancreatic cancer, currently on Folfirinox. I've been searching for complementary ways to make his treatment more effective and less toxic. I did more than a bit of obsessive goggling in the weeks following his diagnosis, and if you would like, I'll be happy to e-mail you a PDF of the abstracts I've pulled (primarily focusing on phytochemicals but also including prescription drugs such as Metformin and Chloroquine and new trials using metronomic chemotherapy). I see many possibilities but unfortunately little available money for researching the bioavailability and synergistic effects of many of these phytochemicals in clinical trials. Best, Brenda
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