title: Dilemma of first line regimens in metastatic pancreatic adenocarcinoma.
abstract: Pancreatic cancer is one of the deadliest cancers, ranking fourth among cancer-related deaths. Despite all the major molecular advances and treatment breakthroughs, mainly targeted therapies, the cornerstone treatment of metastatic pancreatic cancer (mPC) remains cytotoxic chemotherapy. In 2016, more than 40 years after the introduction of gemcitabine in the management of mPC, the best choice for first-line treatment has not yet been fully elucidated. Two main strategies have been adopted to enhance treatment efficacy. The first strategy is based on combining non-cross resistant drugs, while the second option includes the development of newer generations of chemotherapy. More recently, two new regimens, FOLFIRINOX and gemcitabine/nab-paclitaxel (GNP), have both been shown to improve overall survival in comparison with gemcitabine alone, at the cost of increased toxicity. Therefore, the best choice for first line therapy is a matter of debate. For some authors, FOLFIRINOX should be the first choice in patients with an Eastern Cooperative Oncology Group score (0-1) given its lower hazard ratio. However, others do not share this opinion. In this paper, we review the main comparison points between FOLFIRINOX and GNP. We analyze the two pivotal trials to determine the similarities and differences in study design. In addition, we compare the toxicity profile of the two regimens as well as the impact on quality of life. Finally, we present studies revealing real life experiences and review the advantages and disadvantages of possible second-line therapies including their cost effectiveness.
authors.affiliation: Marwan Ghosn, Tony Ibrahim, Tarek Assi, Elie El Rassy, Hampig Raphael Kourie, Joseph Kattan, Department of Oncology, Faculty of Medicine, Saint Joseph University, Beirut 166830, Lebanon.
authors.forename: Marwan
authors.initials: M
authors.lastname: Ghosn
authors.affiliation: Marwan Ghosn, Tony Ibrahim, Tarek Assi, Elie El Rassy, Hampig Raphael Kourie, Joseph Kattan, Department of Oncology, Faculty of Medicine, Saint Joseph University, Beirut 166830, Lebanon.
authors.forename: Tony
authors.initials: T
authors.lastname: Ibrahim
authors.affiliation: Marwan Ghosn, Tony Ibrahim, Tarek Assi, Elie El Rassy, Hampig Raphael Kourie, Joseph Kattan, Department of Oncology, Faculty of Medicine, Saint Joseph University, Beirut 166830, Lebanon.
authors.forename: Tarek
authors.initials: T
authors.lastname: Assi
authors.affiliation: Marwan Ghosn, Tony Ibrahim, Tarek Assi, Elie El Rassy, Hampig Raphael Kourie, Joseph Kattan, Department of Oncology, Faculty of Medicine, Saint Joseph University, Beirut 166830, Lebanon.
authors.forename: Elie
authors.initials: E
authors.lastname: El Rassy
authors.affiliation: Marwan Ghosn, Tony Ibrahim, Tarek Assi, Elie El Rassy, Hampig Raphael Kourie, Joseph Kattan, Department of Oncology, Faculty of Medicine, Saint Joseph University, Beirut 166830, Lebanon.
authors.forename: Hampig Raphael
authors.initials: HR
authors.lastname: Kourie
authors.affiliation: Marwan Ghosn, Tony Ibrahim, Tarek Assi, Elie El Rassy, Hampig Raphael Kourie, Joseph Kattan, Department of Oncology, Faculty of Medicine, Saint Joseph University, Beirut 166830, Lebanon.
authors.forename: Joseph
authors.initials: J
authors.lastname: Kattan
mesh_terms: D000230:Adenocarcinoma / Q000188:drug therapy* / Q000556:secondary; D000418:Albumins / Q000008:administration & dosage; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D002166:Camptothecin / Q000008:administration & dosage / Q000031:analogs & derivatives; D003841:Deoxycytidine / Q000008:administration & dosage / Q000031:analogs & derivatives; D064420:Drug-Related Side Effects and Adverse Reactions; D005472:Fluorouracil / Q000008:administration & dosage; D006801:Humans; D000077146:Irinotecan; D002955:Leucovorin / Q000008:administration & dosage; D009944:Organoplatinum Compounds / Q000008:administration & dosage; D000077150:Oxaliplatin; D017239:Paclitaxel / Q000008:administration & dosage; D010190:Pancreatic Neoplasms / Q000188:drug therapy* / Q000473:pathology; D011788:Quality of Life; D016896:Treatment Outcome; D000093542:Gemcitabine
chemical_list: C520255:130-nm albumin-bound paclitaxel; D000418:Albumins; D009944:Organoplatinum Compounds; D000077150:Oxaliplatin; D003841:Deoxycytidine; D000077146:Irinotecan; D017239:Paclitaxel; D002955:Leucovorin; D005472:Fluorouracil; D002166:Camptothecin; D000093542:Gemcitabine
keywords: FOLFIRINOX; Gemcitabine/nab-paclitaxel; Metastatic pancreatic cancer; Pivotal trials; Review