Cheung WY, et al. ASCO GI 2018:476

A real-world multicentre study of first- and second-line treatment patterns and outcomes in advanced pancreatic cancer in Canada

Background

FOLFIRNOX (folinic acid, fluorouracil, irinotecan, and oxaliplatin), gemcitabine, and gemcitabine plus nab-paclitaxel (GN) are available treatment options for locally advanced (LAPC) and metastatic (MPC) pancreatic cancer in Canada. However, they have not been compared to each other in head-to-head trials. As a result, treatment selection and outcomes in the first- and second-line setting remain poorly characterized. At ASCO GI 2018, Cheung and colleagues presented findings on treatment patterns and outcomes in patients with advanced pancreatic cancer (APC) from a real-world, multicentre study.1

Study design

  • Data from four tertiary, eight regional, and 28 community hospitals in Canada were pooled.
  • The study included patients with LAPC and MPC, diagnosed from 2014 onwards, who received at least one prior line of systemic therapy.
  • The objectives of the study were:
    • To evaluate predictors of first-line treatment choice in APC; and
    • To examine the relationship between treatment sequence and overall survival (OS) in a real-world population of patients with APC from different centres across Canada.

Key findings

  • A total of 302 patients were identified, with a median age of 63 years.
  • Baseline characteristics and treatment patterns are presented in Table 1.
  • FOLFIRINOX and GN were given at similar rates (44% and 41%, respectively), while gemcitabine monotherapy was less common (15%) in the first line.
  • GN was the preferred multi-agent therapy in patients with poorer Eastern Cooperative Oncology Group performance status (ECOG PS; 66% with ECOG PS 2+ vs. 21% with ECOG PS 0; p = 0.001).
  • GN was also the preferred multi-agent therapy in more recently diagnosed cases (63% in patients diagnosed in 2016 vs. 25% in those diagnosed in 2014; p = 0.001).
  • First-line treatment selection was not influenced by other baseline characteristics such as age, sex, tumour location, or locally advanced versus metastatic disease.
  • A total of 107 patients proceeded to subsequent therapies, where the majority had received FOLFIRINOX as first-line treatment (66.4%).
  • For patients receiving second-line therapy, the most common treatment sequence was FOLFIRINOX followed by GN (47.7%).
  • Patients who underwent second-line therapy had better median OS than those who did not (14.2 months vs. 7 months; p = 0.001). (Figure 1)
  • After adjusting for confounders, receipt of first-line multi-agent therapy followed by second-line non–cross-resistant regimens continued to signify a better survival when compared to other treatment sequences. (Figure 2)
    • When receiving FOLFIRINOX first, HR = 0.42 (95% CI: 0.24–0.74); and
    • When receiving GN first, HR = 0.49 (95% CI: 0.36–0.68).

Table 1. Baseline characteristics and treatment patterns

Figure 1. Overall survival with one vs. two lines of systemic therapy

Figure 2. Overall survival by treatment sequence

Key conclusions

  • Approximately one third of patients with APC went on to receive second-line therapy, highlighting the feasibility of second-line trials.
  • Use of first-line, multi-agent therapy followed by second-line, non–cross-resistant regimens represent a reasonable treatment strategy for APC in the real world.

Reference: 1. Cheung WY, Spratlin JL, Tang PA, et al. A real world multicenter study of first (1L) and second (2L) line treatment patterns and outcomes in advanced pancreatic cancer (APC). J Clin Oncol (ASCO GI Annual Meeting) 2018;36(Suppl): abstr 476.