There has never been a more promising time for pancreatic cancer treatment.
After years of nearly no advancements and bleak outlooks, researchers and clinicians are now using a form of chemotherapy that can significantly change the way we look at and treat the disease.
Folfirinox combines four types of chemotherapy — 5-fluorouracil, leucovorin, irinotecan and oxaliplatin — the strongest combination chemotherapy for pancreatic cancer. These drugs destroy quickly dividing cells, including cancer cells, and shrinks tumors enough to allow surgeons to operate on patients who were previously deemed inoperable.
While Folfirinox is not the “magic bullet” to eliminate pancreatic cancer, it serves as the first time some type of therapy has even worked at all, offering hope to thousands of people with pancreatic cancer. The National Cancer Institute estimates 56,770 new cases in 2019. More than 45,500 will die — 7.5 percent of all cancer-related deaths.
Folfirinox is used to treat advanced pancreatic cancer that has spread or can’t currently be surgically removed. This is offered when tumors metastasize to the liver, making it impossible to cure.
Previously, if the tumor didn’t shrink (called down-staging), you didn’t operate due to number of veins and arteries nearby. The pancreas hugs major blood vessels, which keep the liver and the intestine alive.
Folfirinox has been highly successful, using a protocol in which surgery is performed as long as the tumor does not grow during treatment. Surgeons can safely excise them. Although on imaging the tumors may look the same, at surgery, the tumors may have little or no residual cancer in the specimen. Folfirinox’s 55-month survival in less advanced cancers is longer than the typical 31-month survival.
Should chemotherapy begin before or after surgery? It depends on the situation. There is growing sentiment that neoadjuvant (before primary treatment) upfront chemotherapy for pancreas cancer is inching closer to becoming the standard of care. While more surgical oncologists are using it upfront, a clinical trial hasn’t yet confirmed this belief.
For example, a patient who needs a Whipple procedure — a complex operation that removes the head of the pancreas, gallbladder, duodenum and the bile duct — won’t get chemotherapy until two months after surgery due to surgery’s long recovery. If you’re diagnosed today with pancreas cancer, you can have a big operation and, on average, you won’t have any systemic therapy for two months. Metastatic, systemic disease is usually fatal. So, the idea of getting some chemotherapy in before a patient undergoes surgery is very attractive.
Administering Folfirinox pre-surgery can also test to see if the patient responds to it. Otherwise you lose critical time doing the surgery and subsequent chemotherapy for six months, which most likely wasn’t going to work for their cancer anyway.
Upfront chemotherapy is valuable for patients that have vascular involvement or locally aggressive tumors. Folfirinox showed a better response rate than gemcitabine — the standard treatment — and Abraxane. The tumors are more apt to shrink or pull off the blood vessels.
Individualized medicine is the future and Folfirinox could be a part of a menu of treatments to minimize pancreas cancer.
Research presented at the June 2018 American Society of Clinical Oncology meeting showed that patients with surgically removed pancreatic cancer who received Folfirinox lived a median of 20 months longer and were cancer-free nine months longer than those who received gemcitabine.
Historically, 85 percent of pancreatic cancer patients are considered inoperable. Too many, including the public, surgeons and oncologists, think the disease is a death sentence. Folfirinox helps change that narrative. And we can now significantly move the needle in the right direction.
William Nealon, MD, is codirector of Northwell’s Comprehensive Pancreas Cancer and Disease Center, one of the nation’s most groundbreaking programs in treating pancreatic conditions, including chronic and acute pancreatitis, type 3C diabetes and pancreatic cancer. He is also vice chair and chief of Northwell Health’s gastrointestinal, colorectal and pancreatic surgery.