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Editorial Pancreatic Cancer Raising the Bar in Advanced Pancreatic Cancer Sharlene Gill University of British Columbia, British Columbia Cancer Agency, Vancouver, Canada P ancreatic cancer remains one of our greatest clinical challenges. In the last 5 years we have witnessed the introduction of new agents into our armamentarium, which has fortunately translated into incremental improvements in overall survival. We have level 1 evidence for the use of FOLFIRINOX and nab-paclitaxel in the first-line setting; however, the generalizability of randomized studies in the second-line setting has been less compelling. The use of oxaliplatin and 5-fluorouracil (5FU) post-gemcitabine progression was shown to improve survival in the CONKO-003 trial but failed to do so in the PANCREOX trial. Nano-liposomal irinotecan in combination with 5FU in pre-treated patients yielded an improved survival in the NAPOLI-1 trial, presenting an option in this setting. However, these trials were largely conducted in an era of first-line gemcitabine monotherapy, which is no longer a standard practice. Better evidence with contemporary first-line regimens is needed in order to define the optimal post-progression strategy in advanced pancreatic cancer. Keywords Pancreatic cancer, second-line, post progression, advanced disease Disclosure: Sharlene Gill has nothing to declare in relation to this article. No funding was received in the publication of this article. This article is a short opinion piece and has not been submitted to external peer reviewers. Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit. Received: March 18, 2017 Published Online: May 12, 2017 Citation: Oncology & Hematology Review, 2017;13(1):19–20 Corresponding Author: Sharlene Gill, University of British Columbia, British Columbia Cancer Agency, 600 West 10th Avenue, Vancouver, BC V5Z4E6, Canada. E: sgill@bccancer.bc.ca TOU CH MED ICA L MEDIA The challenge of treating pancreatic cancer is exemplified by its high case fatality—for the estimated 53,000 people who will be diagnosed with pancreatic cancer in the US in 2017, over 43,000 will die of the disease. 1 Due to the typically late presentation of pancreatic cancer, only 15–20% are considered resectable with the remaining majority deemed to be advanced with either locally advanced or distant metastatic disease. Chemotherapy remains the backbone of treatment for advanced pancreatic cancer. It has now been 20 years since gemcitabine has been established as the preferred first-line approach with the demonstration of superiority over 5-fluorouracil (5FU) based on an improvement in clinical benefit response and a modest improvement in survival. 2 In 2011, we learned that the combination of infusional 5FU, irinotecan, and oxaliplatin (FOLFIRINOX) significantly improved survival in the first-line setting when compared with gemcitabine, with a median overall survival of 11.1 months compared with 6.8 months. 3 Two years later, the multinational Metastatic Pancreatic Adenocarcinoma Clinical Trial (MPACT) reported a median survival of 8.5 months with the addition of nab-paclitaxel to gemcitabine when compared with 6.7 months using gemcitabine alone (p<0.0001). 4 As a result, we now have more efficacious options to offer for suitably selected patients in the first-line setting. Meanwhile, the options for patients post-progression remained limited. In 2014, Oettle and colleagues published the results of the German Charité Onkologie 003 (CONKO-003) phase III trial which evaluated the efficacy of second-line oxaliplatin in combination with 5FU and folinic acid (FF) versus FF alone. 5 In this study, patients with progression on first-line gemcitabine monotherapy were randomized 1:1 to receive weekly infusional FF for 4 of every 6 weeks (n=84), or the same with the addition of oxaliplatin 85 mg/m 2 intravenously on weeks 1 and 3, herein referred to as the OFF regimen (n=76). Despite the intended 1:1 randomization, there was an unexplained imbalance of subject numbers across the arms—77 patients were allocated to OFF with one exclusion, and 91 patients were allocated to FF with seven exclusions. After a median follow-up of 54.1 months, CONKO-003 demonstrated a median survival of 5.1 months in the OFF group versus 3.3 months in the FF group (p=0.10). The Canadian PANCREOX phase III trial attempted to validate the efficacy of oxaliplatin in this second-line setting by comparing the combination with infusional FF administered in the more commonly used biweekly modified (m)FOLFOX6 schedule (n=54) and biweekly infusional FF per the de Gramont schedule (n=54). 6 No improvement was seen in the primary endpoint of progression-free survival with a median of 3.1 months versus 2.9 months (p=0.99). Interestingly, median survival favored the infusional FF arm (6.1 months versus 9.9 months, p=0.02). Importantly, the withdrawal rate due to adverse events in the absence of progression was much greater for the mFOLFOX6 arm (20% versus 2%). 19