ASCO issues ‘more structured guideline’ for metastatic pancreatic cancer
ASCO released updated recommendations that incorporate new evidence related to second-line therapy for patients with metastatic pancreatic cancer who progressed on or experienced intolerable toxicity during first-line therapy.
The recommendations — issued earlier this year — incorporate research published since the society released its initial guidelines in 2016.
“With this most recent update, ASCO has offered a much more structured guideline. There is an order of preference for treatment and it is a useful tool for clinicians,” Davendra P.S. Sohal, MD, MPH, assistant professor of medicine and director of the clinical genomics program at Taussig Cancer Institute at Cleveland Clinic and a HemOnc Today Next Gen Innovator, said during an interview.
HemOnc Today spoke with Sohal — who led the ASCO guideline panel — about why the guideline update was necessary and the key elements that were added.
Question: Can you provide background on the initial guideline issued a couple years ago?
Answer: The first ASCO-issued guidelines on metastatic pancreatic cancer came out in 2016. ASCO’s goal is to always provide disease-specific guidelines in a structured format. The key points of the guideline at that time were that all patients should be able to join clinical trials as available, and that all patients should receive best supportive palliative care in addition to chemotherapy. Specific chemotherapy recommendations also were made.
Q: Why was it necessary to update the guidelines 2 years later?
A: The need for this update was twofold. First, there were a couple studies published in the second-line setting that were in conflict of each other, so we had to alter the guidelines to factor this in. The second component was that immunotherapy — specifically the anti-PD-1 antibody pembrolizumab (Keytruda, Merck) — was approved for use in a subset of patients, and we wanted to include this in the most recent update.
Q: Can you elaborate on what has been added as part of this update?
A: The specific recommendation updates are as follows: In the second-line setting, 5-FU with nanoliposomal irinotecan (Onivyde, Merrimack Pharmaceuticals) is the preferred regimen, but if it is not available, then 5-FU plus irinotecan can be used. We did not discard oxaliplatin as an option, but we qualified its recommendation by saying that different studies have conflicting results on the efficacy of 5-FU plus oxaliplatin, so we did not endorse it as prominently as we did in the 2016 guideline. The second point was that all patients considering second-line therapy should be offered microsatellite instability (MSI) testing, which then leads to the option of using immunotherapy in the second-line setting. Although the proportion of patients who qualify for this is small, the efficacy of pembrolizumab for MSI-high tumors is so remarkable that it leads us to test it.
Q: Can you describe the importance of this update?
A: For the longest time, we did not have anything specific in the second-line setting in pancreatic cancer. There were two regimens in the first-line setting, but for the second-line setting, we would just pick from whatever was leftover. Now, there are more data; thus, our guidelines are more specific as to what should be tested for the order of preference when using chemotherapy or immunotherapy in the second-line therapy setting.
Q: Can you discuss the need for new and more effective therapies for patients with metastatic pancreatic cancer ?
A: Patient outcomes remain rather poor. Pancreatic cancer is the only cancer where outcomes have not changed significantly. For the past 50 years, median OS has remained less than 1 year in the metastatic setting. Clinical trials remain key, and this is how progress has been made. Not only are clinical trials needed that are testing a drug, but ancillary studies and supportive care trials also are needed. – by Jennifer Southall
Sohal D SA, et al. J Clin Oncol. 2018;doi:10.1200/JCO.2018.78.9636.
For more information:
Davendra P.S. Sohal, MD, MPH, can be reached at Taussig Cancer Institute, Cleveland Clinic, 9500 Euclid Ave., CA5, Cleveland, OH 44195; email:firstname.lastname@example.org.
Disclosure: Sohal reports no relevant financial disclosures.