The treatment of locally advanced pancreatic cancer: DISCUSSION (Part 2)

In: Pancreatic cancer

23 Jul 2012

There were no randomized studies of chemotherapy and/or radiation compared with supportive care alone. Although studies of chemotherapy or immunotherapy for the treatment of metastatic pancreatic cancer enrolled patients with locally advanced disease, none reported the results of treatment separately for patients with locally advanced disease. Consequently, chemotherapy alone, radiotherapy alone and immunotherapy cannot be recommended routinely for patients with locally advanced disease.

There are a number of ongoing North American trials examining the use of chemotherapy alone and/or combination chemoradiotherapy treatment in pancreatic cancer. Several of these studies (protocol identification numbers CAN-NCIC-PA3, CWRU-010224M, and CPMC-IRB-8544) list quality of life as an outcome of interest, and this information will be made available upon publication.

DSG consensus process

The Gastrointestinal Cancer DSG reached consensus on the draft guideline recommendations, with the following item being discussed. Because the evidence for radiation is relatively weak, there was discussion around whether treatment with gemcitabine alone should be presented as an equally acceptable alternative. The only randomized data on gemcitabine is the study by Burris et al, which demonstrated that gemcitabine improves symptoms and modestly improves survival compared with 5-FU as single-agent chemotherapy in patients with locally advanced or metastatic pancreatic cancer. These patients were symptomatic, had a life expectancy of at least 12 weeks, and a Karnofsky performance status of at least 50% (equivalent to an ECOG performance status of less than three). This randomized trial is discussed in detail in another guideline developed by the Gastrointestinal Cancer DSG, which concludes that gemcitabine is a reasonable treatment option for patients with locally advanced or metastatic pancreatic cancer. Twenty-six per cent of the patients included in the randomized trial by Burris et al had locally advanced disease but they were not reported separately, and attempts to obtain the original data on these patients were unsuccessful. However, because the overall results detected a benefit with gemcitabine, the Gastrointestinal Cancer DSG inferred that patients with locally advanced disease unable to undergo radiation may be appropriately treated as having metastatic disease.

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