A blog about research, awareness, prevention, treatment and survivorship of Breast Cancer and all cancers, including targeted scientific research and a grassroots approach to increase screening for cancer, especially in the low income and under-insured population of El Paso, Texas, with a view to expand this new health care model to many other 'minority' populations across the United States and beyond
Tuesday, April 30, 2013
Dr. Susan M. Nedza Case Study
A 52 year old gentleman was diagnosed with stage IV
pancreatic cancer with liver and lung metastases. His initial therapy
included FOLFIRINOX, a 5-FU based combination with irinotecan,
leucovorin and oxaliplatin. Imaging studies showed disease progression
after 3 months of treatment. The oncologist is now requesting
bevacizumab (Avastin), and plans to add it to the current regimen.
Pancreatic cancer is a highly lethal malignancy, with a 5
year overall survival rate of 5%. In the setting of metastatic disease,
this cancer is uniformly fatal, with a median survival of approximately
6 months. Treatment has been used primarily as a palliative measure,
for clinical benefit and symptom improvement.
Gemcitabine has been the backbone of pancreatic cancer
treatment since 1996, and multiple combinations have been studied since
that time. Unfortunately, very few treatments have led to a significant
improvement in overall survival. A recent exception has been the use
of gemcitabine in combination with nab-paclitaxel (Abraxane®
). The MPACT trial, which compared this combination with
single agent gemcitabine, showed an increase in overall survival with
combination therapy (8.5 months vs. 6.7 months).
A randomized, phase III trial (PRODIGE) published in 2011
evaluated the combination (FOLFIRINOX) versus single agent gemcitabine
in patients with metastatic pancreatic cancer and good performance
status. Combination therapy demonstrated significant improvement in
progression-free survival and median overall survival, but with
significantly greater toxicity than gemcitabine alone. This regimen has
been added to the National Comprehensive Cancer Network (NCCN)
guidelines as a category 1 recommendation for first-line treatment of
metastatic pancreatic cancer in patients with good functional status.
The introduction of bevacizumab (Avastin®) has
been groundbreaking in cancer treatment, demonstrating efficacy in
colorectal cancer and lung cancer, among others. Side effects are
considered to be generally mild, with high blood pressure and mild
nosebleeds among the most common. Though rare, Avastin® has also been linked to gastrointestinal perforation, thrombosis, and fatal hemorrhage.
With respect to pancreatic cancer, however, randomized phase III studies of gemcitabine in combination with Avastin®
have failed to demonstrate improvements in overall survival,
progression-free survival, or overall response rates. Furthermore,
there was a significant increase in hypertension and proteinuria, though
no toxic deaths were reported.
In our case, the patient has received a 5-FU-based regimen
with disease progression. To date, there have been no published
studies demonstrating the efficacy or safety of adding Avastin® to this
regimen. Because of its efficacy in other tumor types and some activity
demonstrated in Phase I/II trials, this drug is often requested
Current consensus opinion would recommend either
gemcitabine/gemcitabine combination or a 5FU-based regimen for
first-line treatment. Upon progression, NCCN recommends a change to a
regimen with a different backbone. In the case presented, changing to a
gemcitabine-based regimen would be the recommended approach. Current
evidence does not support the use of bevacizumab (Avastin®) for
In cases such as this, a pathways program can guide the
ordering physician in selecting an evidence-supported approach and
discourage continuation of a failing regimen. We believe that providing
physicians with advanced cancer treatment decision support will
translate into improved, cost-effective care.
Learn more about AIM’s Integrated Oncology Solution here.
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