HJNO Jan/Feb 2023

HEALTHCARE JOURNAL OF NEW ORLEANS I  JAN / FEB 2023 55 Janeiro Goffin, MD Medical Oncologist Terrebonne General | Mary Bird Perkins Cancer Center called “laparoscopy” will be done by surgi- cal oncology to get more information about the location and size of the cancer. Treatment Treating pancreatic adenocarcinoma should always be evaluated with a multi- disciplinary team by hematology/oncol- ogy, surgical oncology, pathology, radia- tion oncology, and molecular/genetics to decide the best treatment. Clinical trials are always encouraged. Below is a general ap- proach to how we usually treat pancreatic adenocarcinoma. Resectable (stage I-II) Surgical oncology usually does a “Whip- ple” procedure followed by adjuvant che- motherapy. The regimens used are modi- fied FOLFIRINOX or gemcitabine plus capecitabine. Then the oncologist can start the surveillance phase. Borderline resectable (stage III) Usually, treatment starts with neoad- juvant chemotherapy with regimens like modified FOLFIRINOX or gemcitabine plus paclitaxel protein-bound, then we restage with CT scans and CA 19-9. Surgical oncol- ogy will determine if you are a candidate for surgery. Suppose surgery is done and cancer is not left behind. In that case, you will likely receive adjuvant chemotherapy with the regimens stated in stage I-II disease and start the surveillance phase. If, after surgery, cancer is left behind with a positive surgical margin (R1 resec- tion), then your oncologist will likely use a radiation and chemotherapy combina- tion. Chemotherapy used with radiation is capecitabine or continuous infusion of 5FU; after that, your oncologist typically starts the surveillance phase. For example, if you have a germline mu- tation in BRCA1/2, you can be a candidate for a target therapy pill called Olaparib. In addi- tion, if you have this mutation or PALB2 mu- tation, you can be a candidate for a targeted therapy pill called rucaparib. Other target- ed therapy pills available in the market are Larotrectinib and Entrectinib, these medica- tions usually control the cancer well, but you have to have a mutation called NTRK gene fusion. Unfortunately, this mutation is rare. Another form of treatment is immuno- therapy with pembrolizumab. In order to start this medication, your cancer has to be MSI-H, dMMR, or tumor mutational burden score equal to or more than 10 mut/Mb. Supportive care Pancreatic cancer usually obstructs the biliary ducts, causing elevated bilirubin lev- els and hepatic dysfunction. If this happens, a gastroenterologist will do an ERCP and put a stent in the biliary ducts to improve these issues so you can start treatment. Oncologists and palliative care physicians will manage pain. Sometimes the oncologist refers to interventional radiology to block the nerves of the pancreas to improve pain. Sometimes this pain is associated with gas- trointestinal obstruction, so your oncologist might call a surgeon for further evaluation and management. A nutritionist will manage weight loss. Pancreatic enzymes will be prescribed to help absorb fat, andmedications will control nausea and vomiting. Pancreatic cancer mortality is high and usually found in the terminal stage. When this happens, we usually recommend the best supportive care with hospice/pallia- tive care. n Following neoadjuvant chemotherapy, if surgical oncology determines that you are not a surgical candidate, your options would likely be systemic therapy with hematology/ oncology with or without radiation with ra- diation oncology. Description of surveillance phase Surveillance phase is the phase when you are done with your treatment and the oncologist will monitor the possibility of the cancer coming back. Monitoring will be done with blood work and scans. Surveil- lance is usually every three to six months for two years, then every six to 12 months or as clinically indicated: history and physical exam for symptom assessment, blood work including CA 19-9 and CT chest, abdomen and pelvis with IV contrast. Unresectable or metastatic disease (stage IV) Stage IV disease is not curable and termi- nal and is a chronic disease, so you will need to be in treatment for life. Depending on the performance status and age of the patient, the oncologist will decide on treatment. If the patient is fit, we recommend a pal- liative chemotherapy regimen named modi- fied FOLFIRINOX. If the patient is not fit, we usually recommend a palliative chemo- therapy regimen called gemcitabine plus paclitaxel protein-bound. If the patient is frail and elderly but wants treatment, we recommend single-agent chemotherapy with gemcitabine. Apatient that responds well after four to six months on these regimens starts “main- tenance therapy.” Maintenance therapy in- cludes capecitabine or modified schedules of original regimens. Other lines of therapy after these are based on genetic and molecu- lar studies that your oncology might order.