November 14 2023
Updates from the NRG Oncology Pancreatic Cancer Working GroupHappy November! As part of pancreas cancer awareness month, we wish to update you all on some of the activities of the NRG Oncology Pancreas Working Group. After decades of research globally, there have certainly been advancements in the treatment of pancreas cancer but overall, the prognosis remains poor. Thus, the goal of the NRG Oncology Pancreas Working Group is straightforward: to bring forward novel trial concepts that could improve patient-centered outcomes in pancreas cancer. Since pancreas cancer exists on a spectrum ranging from resectable, to metastastic, to recurrent, we believe it is critical to tailor trials to specific subgroups, since the role of each treatment modality will vary by stage.
In the locally advanced setting, the NRG Oncology Pancreas Working Group has proposed a randomized Phase II trial evaluating whether dose-escalated radiation therapy can improve long-term overall survival, as compared to current standard of care options (continuation of chemotherapy or low dose chemoradiation).
For borderline resectable pancreas cancer, the PREOPANC2 trial was recently presented at ESMO and the results were surprising. This was a randomized trial comparing neoadjuvant FOLFIRINOX versus neoadjuvant gemcitabine with radiotherapy. Most expected the FOLFIRINOX arm (without radiation) to have better outcomes since FOLFIRINOX is more effective in pancreas cancer than single agent gemcitabine. However, the two arms had similar survival. We await the publication for full trial result details, but our group is wondering the following: 1) Should lower-dose/larger volume radiation such as 36 Gy in 15 fractions (the PREOPANC regimen) be used in the neoadjuvant setting? 2) Would combining FOLFIRINOX with this neoadjuvant radiation improve upon outcomes? Dr. Matt Abrams (BIDMC, Boston) is leading the NRG Oncology Pancreas Working Group effort to design a cooperative group trial for borderline resectable pancreas cancer.
The NRG Oncology Pancreas Working Group is also assisting Dr. Yaacov Lawrence (Sheba Medical Center, Israel) in designing a randomized trial assessing celiac plexus radiosurgery for pain management. Dr. Lawrence led a single arm trial including 18 patients with advanced cancer and celiac pain who were treated with a single fraction of radiotherapy to 25 Gy (PMID 35257800). Three weeks after treatment, 84% reported improvement in pain and total opioid requirement decreased. The next step will be to test this regimen in a randomized fashion.
We look forward to reporting back on the progress of these trial concepts from the NRG Oncology Pancreas Working Group. Stay tuned! And if any suggestions or ideas, please reach out to Nina Sanford (nina.sanford@utsouthwestern.edu).