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World J Gastroenterol. Dec 14, 2016; 22(46): 10124-10130
Published online Dec 14, 2016. doi: 10.3748/wjg.v22.i46.10124
Dilemma of first line regimens in metastatic pancreatic adenocarcinoma
Marwan Ghosn, Tony Ibrahim, Tarek Assi, Elie El Rassy, Hampig Raphael Kourie, Joseph Kattan
Marwan Ghosn, Tony Ibrahim, Tarek Assi, Elie El Rassy, Hampig Raphael Kourie, Joseph Kattan, Department of Oncology, Faculty of Medicine, Saint Joseph University, Beirut 166830, Lebanon
Author contributions: Kattan J initiated the review; Ghosn M, Ibrahim T and Assi T performed the review, analyzed the data and wrote first draft; Ghosn M, El Rassy E, Kourie HR and Kattan J, reviewed and commented on the paper; all authors provided final approval for the content.
Conflict-of-interest statement: To the best of our knowledge, no conflict of interest exists.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Marwan Ghosn, MD, Department of Oncology, Faculty of Medicine, Saint Joseph University, Alfred Naccache, Beirut 166830, Lebanon. marwanghosnmd@yahoo.com
Telephone: +961-3-226842 Fax: +961-1-613397
Received: August 21, 2016
Peer-review started: August 25, 2016
First decision: September 5, 2016
Revised: September 23, 2016
Accepted: October 30, 2016
Article in press: October 31, 2016
Published online: December 14, 2016
Processing time: 113 Days and 22.3 Hours
Abstract

Pancreatic cancer is one of the deadliest cancers, ranking fourth among cancer-related deaths. Despite all the major molecular advances and treatment breakthroughs, mainly targeted therapies, the cornerstone treatment of metastatic pancreatic cancer (mPC) remains cytotoxic chemotherapy. In 2016, more than 40 years after the introduction of gemcitabine in the management of mPC, the best choice for first-line treatment has not yet been fully elucidated. Two main strategies have been adopted to enhance treatment efficacy. The first strategy is based on combining non-cross resistant drugs, while the second option includes the development of newer generations of chemotherapy. More recently, two new regimens, FOLFIRINOX and gemcitabine/nab-paclitaxel (GNP), have both been shown to improve overall survival in comparison with gemcitabine alone, at the cost of increased toxicity. Therefore, the best choice for first line therapy is a matter of debate. For some authors, FOLFIRINOX should be the first choice in patients with an Eastern Cooperative Oncology Group score (0-1) given its lower hazard ratio. However, others do not share this opinion. In this paper, we review the main comparison points between FOLFIRINOX and GNP. We analyze the two pivotal trials to determine the similarities and differences in study design. In addition, we compare the toxicity profile of the two regimens as well as the impact on quality of life. Finally, we present studies revealing real life experiences and review the advantages and disadvantages of possible second-line therapies including their cost effectiveness.

Keywords: Review; Metastatic pancreatic cancer; FOLFIRINOX; Gemcitabine/nab-paclitaxel; Pivotal trials

Core tip: This paper is a mini-review that compares the design of the two pivotal trials studying the role of FOLFIRINOX and gemcitabine/nab-Paclitaxel in the management of metastatic pancreatic cancer. It also analyzes the effects these regimens have on toxicity profile, quality of life, real life experiences, choice of second-line therapy and cost.