Thoughts on FOLFIRINOX

A 50 year old female comes to see you with recently diagnosed metastatic pancreatic adenocarcinoma. She is surprisingly asymptomatic, and aside from a few slight elevations in AST and alkaline phosphatase, labs are largely normal. Her performance status is excellent (ECOG PS 0). What would you do? For me, with the recent Conroy study presented at ASCO last year showing that FOLFIRINOX was superior to gemcitabine for first-line treatment of metastatic pancreatic cancer, the answer is FOLFIRINOX. However, I am seeing lots of pancreas cancer patients from the community who are still getting gemcitabine. I presume this is because of concern about the FOLFIRINOX regimen and its possible toxicities.

World experts in pancreas cancer have admitted at conferences their concern about the toxicity of this regimen – potentially even before they had regularly used it. And, I'll admit, essentially joining FOLFOX and FOLFIRI seemed scary to me, too. But now that I have some experience using FOLFIRINOX, I think some of that concern can be abated. I do treat everyone with maximal antiemetic support and G-CSF to help with the neutropenia. I see the patients very frequently until I am sure the doses of chemo I am using "agree" with them. And, of course, patient selection is key here. Patients I would potentially treat with FOLFIRINOX would have to meet the strict enrollment criteria of the Conroy study: PS 0 or 1, normal LFTs, normal renal and bone marrow function and biopsy-proven pancreatic adenocarcinoma. What do you think of FOLFIRINOX? How has your experience been?