Metastatic pancreatic cancer: a new clinical practice guideline

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The guideline will help clinicians determine the appropriate treatment of patients with metastatic pancreatic cancer.
The guideline will help clinicians determine the appropriate treatment of patients with metastatic pancreatic cancer.

The American Society of Clinical Oncology has released a clinical practice guideline to help clinicians determine the appropriate treatment of patients with metastatic pancreatic cancer and to help them advise patients and their families about how to access and use palliative care services.

An expert panel developed the clinical practice guideline recommendations, published in the Journal of Oncology Practice, using a systematic review of the medical literature. The researchers note that the clinical course of pancreatic cancer is generally aggressive with potential for substantial deterioration in quality of life. “Therefore,” the authors wrote, “palliative care to focus on distressing symptoms and quality of life is an important adjunct in the management of this condition.”

A summary of the key recommendations is as follows:

Recommendation 1

A multiphase computed tomography scan of the chest, abdomen, and pelvis should be performed to assess the extent of the disease, and other staging studies should be performed as dictated by symptoms (intermediate quality of evidence, strong recommendation).
Clinicians should carefully evaluate baseline performance status, symptom burden, and comorbidity profile of patients with metastatic pancreatic cancer (intermediate quality of evidence, strong recommendation).
Clinicians should discuss the goals of care, patient preferences, and support systems with patients diagnosed with metastatic pancreatic cancer and his or her caregivers (intermediate quality of evidence, strong recommendation).
Multidisciplinary collaboration to formulate treatment plans and disease management for patients with metastatic pancreatic cancer should be the standard of care (intermediate quality of evidence, strong recommendation).
Patients with pancreatic cancer should be offered information about clinical trials, including therapeutic trials in all lines of treatment as well as palliative care, biorepository/biomarker, and observational studies (intermediate quality of evidence, strong recommendation).

Recommendation 2

Leucovorin, fluorouracil, irinotecan, and oxaliplatin are recommended for patients who meet the following criteria: Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1, favorable comorbidity profile, patient preference and support system for aggressive medical therapy, and access to chemotherapy port and infusion pump management services (intermediate quality of evidence, strong recommendation).
Gemcitabine plus NAB-paclitaxel is recommended for patients with an ECOG performance status 0 or 1, a relatively favorable comorbidity profile, and patient preference and support system for relatively aggressive medical therapy (intermediate quality of evidence, strong recommendation).
Gemcitabine alone is recommended for patients with either an ECOG performance status of 2 or with a comorbidity profile that precludes more aggressive regimens who wish to pursue cancer-directed therapy. Capectiabine or erlotinib may also be added in this setting (intermediate quality of evidence, moderate recommendation).
Patients with an ECOG performance status ≥3 or with poorly controlled comorbid conditions should be offered cancer-directed therapy on a case-by-case basis (intermediate quality of evidence, moderate recommendation).

Recommendation 3

Gemcitabine plus NAB-paclitaxel can be used as a second-line therapy for patients who meet the following criteria: first-line treatment with leucovorin, fluorouracil, irinotecan, and oxaliplatin, ECOG performance status 0 or 1, favorable comorbidity profile, preference and support system for aggressive medical therapy (low quality of evidence, moderate recommendation).
Fluorouracil plus oxaliplatin, irinotecan, or nanoliposomal irinotecan can be offered as a second-line therapy for patients who meet the following criteria: first-line treatment with gemcitabine plus NAB-paclitaxel, ECOG performance status 0 or 1, favorable comorbidity profile, preference and support system for aggressive medical therapy, and chemotherapy port and infusion pump management (low quality of evidence, moderate recommendation).
Gemcitabine or fluorouracil can be considered as second-line therapy for patients with either an ECOG performance status of 2 or with a comorbidity profile precluding more aggressive regimens and who wish to pursue cancer-directed therapy (low quality of evidence, moderate recommendation).
Third-line therapy with a cytotoxic agent is not recommended as a third-line therapy. Clinical trial participation is encouraged (low quality of evidence, moderate recommendation).

Recommendation 4

Patients with metastatic pancreatic cancer should undergo a full assessment of symptom burden, psychological status, and social supports as early as possible, preferable at the first visit. In most cases the assessment will indicate a need for formal palliative care consult and services (intermediate quality of evidence, strong recommendation).

Recommendation 5

Clinicians should offer patients aggressive treatment of the pain and symptoms of metastatic pancreatic cancer or the cancer-directed therapy (intermediate quality of evidence, strong recommendation).

Recommendation 6

Patients receiving active cancer-directed therapy outside a clinical trial should undergo imaging to assess first response at 2 to 3 months from the initiation of therapy. Clinical assessment during visits for cancer-directed therapy should supplant imaging assessment thereafter. The routine use of positron emission tomography scans for management of patients with pancreatic cancer is not recommended, and CA 19-9 is not considered a substitute for imaging for assessing treatment response (low quality of evidence, strong recommendation).
No data are available regarding the duration of cancer-directed therapy. An ongoing discussion of goals of care and assessment of treatment response and tolerability should guide decisions to continue or terminate cancer-directed therapy (low quality of evidence, strong recommendation).

Reference

  1. Sohal D, Mangu PB, Laheru D. Metastatic pancreatic cancer: American Society of Clinical Oncology clinical practice guideline summary. J Oncol Pract. 2017;13(4):261-264. doi:10.1200/JOP.2016.017368
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