Second line in pancreatic cancer: Resuming our experience and looking for prognostic factors
Authors: B. Anton, F. Longo Muñoz, D. Gutierrez Abad, M. De Torres Olombrada, I. Juez Martel, B. Losada Vila, J. Letéllez, J. Guerra Martínez, A. Fernñandez Román
Journal: Annals of Oncology (2018)

Introduction: Pancreatic tumours are a systemic disease with early metastatic spread and poor survival rates. In the past years we have experienced a transition where FOLFIRINOX and Gemcitabine plus NAB-paclitaxel have settled as first line therapy. There is some controversy about second line, with no standard regimen. The challenge of using more than one systemic treatment is based on patients' clinical conditions since they are not always fit to withstand a systemic treatment. Most of studies described and stratify patients according to the presence of metastases, performance status or progression free survival to first-line. Clearly those patients with better nutritional status, lower burden of disease or less comorbidity hope to present better response to chemotherapy in terms of lower toxicity, although this does not always translate into tumour response. We review the patients with pancreatic cancer in our working area last 10 years that have received second-line systemic chemotherapy (including locally advanced or metastatic), describe survival according to different therapies and assess clinical markers that can be related to best tolerance and prognosis. Methods: We selected all patients with pancreatic tumours (n = 108) diagnosed since January 2007 until December 2017 and selected all that have received SECOND LINE chemotherapy. We search at clinical history notes about tumor stage, location, performance status (ECOG), tumour stage, biliary stent, albumin and Ca 19.9 rates, radiotherapy and thromboembolic disease. These factors are chosen based on published literature and clinical criteria. Primary end point: Median survival (Kaplan Meier estimation) based on chemotherapy regimens, stratify by most frequent therapies and monotherapy (capecitabine or gemcitabine) and doublet (FOLFOX or gemcitabine plus nab-paclitaxel). Secondary end point: we practiced both uni and multivariate analysis between tumor location, ECOG, Ca19.9 level, thrombosis and previous radiotherapy. Results: Gemcitabine plus nab-paclitaxel first and FOLFOX are two systemic therapies with acceptable tolerance in symptomatic patients with better survival in our database. Our Kaplan-Meier estimation shows discrete benefit initially although those patients with response to monotherapy, especially with gemcitabine, can have extended survival (Figures 4, 5 and table 2). However, our population do not show improved survival with doublet in terms of overall survival(figure 5) although it is noted that FOLFOX and gemcitabine plus nab-paclitaxel presented benefit initially. The characteristics at the first table are consistent with the literature (gender equality, thromboembolic events near 30%, performance status at the beginning of second line 0 and 1 and any patient being treated with ECOG3) (Table 1). We carried out both uni and multivariate analysis in this case. Only performance status (ECOG) seems to have in our population prognostic reflection with survival. It is determined that if we increase ECOG, it is more likely to use monotherapies. Conclusion: Gemcitabine plus nab-paclitaxel is a systemic treatment well-tolerated as second-line chemotherapy in our database with optimal responses in terms of overall survival. Chemotherapy based in doublet does not improved overall survival in our population although there seems to be some clinical benefit at the beginning of second-line. ECOG status is a strong prognostic factor in or database which correlates with better survival rates.