Treatment of Advanced Pancreatic Cancer

Pancreatic cancer, a rare disease, is projected to be the third leading cause of cancer death in Canada in 2020,1 which is an increase from fourth leading cause of cancer death in 2017.2 It also has a devastatingly low five-year net survival rate of 8%, especially when compared to other cancers, such as prostate cancer with 93%, breast cancer with 88%, and bladder cancer with 75%.3

The disease can take a long time to develop and often displays no symptoms in its early stages. There are also no effective early diagnostic tests. As a result, most individuals discover they have pancreatic cancer in its later stages, often when it has severely progressed, such as when a tumour has advanced and invaded nearby organs (known as metastasis). At this point, patients could experience abdominal pain, back pain, yellowing of the skin, weakness, loss of appetite, digestive problems, including nausea, vomiting, diarrhea, and flatulence, as well as sudden onset of diabetes or glucose intolerance, and unintentional weight loss. Left untreated, pancreatic cancer can rapidly progress to a terminal illness.

Unfortunately, there are only a few treatments available that can prolong patient survival when the disease has progressed to either metastatic or locally advanced (when the disease remains in the organ but invades nearby areas such as tissues and lymph nodes).4 Given these characteristics, it is no surprise that pancreatic cancer is also known as the silent killer.

Treatments

With pancreatic cancer often caught late, its treatments focus on containing the disease. They can include surgery, radiation, and various chemotherapy drugs. There has been development in research and innovation on palliative treatments for advanced pancreatic cancer but they still present limited efficacy in survival rates among patients (with most showing extension of survival by only a few months) and only some patients remain well enough to continue or move to other therapies.2 Unfortunately, there is no standard of care for patients with disease progression after first-line therapy. When patients fail these drugs, additional treatment options are severely lacking, representing a significant unmet need.

Onivyde®

Irinotecan liposome (Onivyde®) is a new drug available for patients with locally advanced, unresectable, or metastatic pancreatic cancer. Patients must first be treated with a gemcitabine-based therapy (i.e., Gemzar®) before they can take Onivyde®.5 Gemcitabine (Gemzar®) is an anti-cancer chemotherapy drug used to treat locally advanced and metastatic pancreatic cancer and it has shown improvements in survival rates by approximately 5-6 months.4 It is usually administered as a first-line therapy by itself or in combination with paclitaxel (Abraxane®), another chemotherapy drug for pancreatic cancer delivered by intravenous infusion.6

Onivyde® presents considerable improvements in survival rates, and particularly in survival without progression of the disease. Most importantly, this new treatment gives patients additional options for a disease that is difficult to diagnose and treat, and is plagued with a high mortality rate.

A person receives Onivyde® by intravenous infusion and must then take combination therapy of 5-fluorouracil (Fluorouracil Injection) and leucovorin calcium (Lederle Leucovorin®) every two weeks. Clinical guidelines also recommend for treatment to cease if the disease progresses or patients experience unacceptable toxicity.4 Onivyde® is not recommended for patients who were previously treated with FOLFIRINOX, which is a combination therapy of various chemotherapy drugs that can be highly toxic.

This new drug also does not replace other combination therapies that contain irinotecan. Please consult your healthcare provider for more information and to find out if this treatment option is viable for your disease stage and medication history.

Despite advancements for pancreatic cancer, the Gastrointestinal Society is committed to advocating for further research in developing early diagnosing tools as it is vital for patients to receive a timely diagnosis, leading to better survival rates and patient outcomes. Regrettably, Onivyde® is not yet covered on any oncology public formularies in Canada.

Popular Jeopardy! gameshow host, Alex Trebek, revealed in 2019 that he was diagnosed with stage 4 pancreatic cancer. “I wish I had known sooner that the persistent stomach pain I experienced prior to my diagnosis was a symptom of pancreatic cancer,” he notes in a short video.7 Regrettably, Alex Trebek passed away from pancreatic cancer on November 8, 2020.


First published in the Inside Tract® newsletter issue 215 – 2020
1. Brenner D et. al. Projected estimates of cancer in Canada in 2020. CMAJ. 2020;192(9): E199-E205.
2. Ellison L. Health at a Glance Age-specific patterns in the incidence of, and survival from, pancreatic cancer in Canada. Statistics Canada page. Available at https://www150.statcan.gc.ca/n1/pub/82-624-x/2017001/article/14799-eng.htm. Accessed 2020-08-11.
3. Canadian Cancer Statistics Advisory Committee. Canadian Cancer Statistics 2019. Canadian Cancer Society. Available at: https://www.cancer.ca/~/media/cancer.ca/CW/publications/Canadian%20Cancer%20Statistics/Canadian-Cancer-Statistics-2019-EN.pdf. Accessed 2020-08-12.
4. pan-Canadian Oncology Drug Review. Final Clinical Guidance Report Irinotecan Liposome (Onivyde®) for Metastatic Pancreatic Cancer. 2018. Available at: https://www.cadth.ca/sites/default/files/pcodr/pcodr_irinotecan_liposome_onivyde_mpc_fn_cgr.pdf. Accessed 2020-08-15.
5. pCODR Expert Review Committee (pERC). Final Recommendation. 5 January 2018. Available at: https://www.cadth.ca/sites/default/files/pcodr/pcodr_irinotecan_liposome_onivyde_mpc_fn_rec.pdf. Accessed 2020-08-15.
6. Drug Formulary nab-PACLitaxel Patient Info Sheet. Cancer Care Ontario. 2019. Available at: https://www.cancercareontario.ca/en/drugformulary/drugs/infosheet/44106. Accessed 2020-08-15.
7. Mundell EJ. Alex Trebek on Cancer: ‘I Wish I Had Known Sooner.’ WebMD page. Available at: https://www.webmd.com/cancer/pancreatic-cancer/news/20191031/i-wish-i-had-known-sooner-alex-trebek-issues-psa-on-pancreatic-cancer#1. Accessed 2020-08-20.
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