In patients treated with the standard palliative treatment gemcitabine (GEM), median survival still remains only 6 months. Over the last several years, many trials have been designed combining GEM with various other drugs to treat chemo-naive patients, with the aim to improve overall survival. Unfortunately, none of the GEM-based combinations studied so far have reached that objective, with the exception of GEM plus Erlotinib, which showed a slight increase in OS to 6.4 months. However, some trials – mainly those using platinum based combinations – have shown an increase in response rate and time to progression.However, there are still no guidelines or recommendations for selecting treatment for patients progressing after GEM therapy; nor are there any reports of regimens with demonstrated activity that would enable one to justify one approach over another.
Folfox is an appropriate second line regimen in this situation. There is a trial: Randomized Phase II Study of FOLFOX Versus FOLFIRI.3 in Gemcitabine-Refractory Pancreatic Cancer, NCT00786006. The trial shows that Folfox is the default, if not the standard option in this situation. The investigators were to evaluate the efficacy and safety of FOLFOX or FOLFIRI combination chemotherapy as second-line salvage chemotherapy in patients with advanced pancreatic carcinoma. The results were just published in abstract form. Both FOLFOX and FOLFIRI were tolerated with manageable toxicity, offering modest activity as second-line treatment of patients with advanced or metastatic pancreatic cancer, previously treated with gemcitabine. NCCN lists Folfox as well.
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