What chemotherapy (chemo) regimen is given for pancreas chemoradiation?

Chemotherapy Regimens for Pancreatic Chemoradiation

For pancreatic chemoradiation, 5-fluorouracil (5-FU) is the preferred chemotherapy agent, typically administered as continuous infusion concurrent with radiation therapy. 1

Recommended Chemoradiation Regimens

Primary Recommendation

• 5-FU-based chemoradiation is the standard approach when radiation is part of the treatment plan
• Radiation dose: 45-54 Gy (1.8-2.0 Gy per day) 1
• 5-FU administration: Continuous infusion during radiation course

Treatment Sequence

When chemoradiation is chosen as part of the treatment approach, the recommended sequence is:

1. Initial systemic gemcitabine (up to 4 months)
2. Followed by 5-FU-based chemoradiation 1

This sequence is supported by evidence suggesting that a period of chemotherapy followed by consolidated chemoradiation may be preferable to up-front chemoradiation.

Specific Dosing Information

5-FU Dosing for Chemoradiation

• Standard dose: 200-250 mg/m²/day as continuous IV infusion throughout radiation course 2
• This dose was established as the maximum tolerated dose in phase I trials

Gemcitabine (When Used Before Chemoradiation)

• Standard dose: 1000 mg/m² IV weekly 3
• Typically administered for up to 4 months before transitioning to chemoradiation

Clinical Considerations

Patient Selection

• Chemoradiation is appropriate for:
  • Locally advanced unresectable disease without metastases
  • Patients with good performance status
  • Adjuvant setting after resection

Treatment Planning

• CT simulation and 3-dimensional treatment planning is strongly encouraged
• Treatment volumes should include primary tumor location and regional lymph nodes
• Based on preoperative CT scans and surgical clips (when placed) 1

Monitoring During Treatment

• Regular assessment for toxicity (particularly oral mucositis with 5-FU)
• Dose adjustments may be necessary based on patient tolerance

Alternative Approaches

Capecitabine

• May be used as an alternative to infusional 5-FU
• Oral administration provides convenience compared to continuous IV infusion

Gemcitabine as Radiosensitizer

• Has been used concurrently with radiation in some protocols
• Evidence suggests similar outcomes to 5-FU-based chemoradiation
• However, no randomized trials have directly compared gemcitabine to 5-FU as a radiosensitizer in this setting 1

Treatment Efficacy

• Median survival with 5-FU-based chemoradiation ranges from 10-12 months for locally advanced disease 4
• In the adjuvant setting, 5-FU-based chemoradiation following gemcitabine has shown median survival of approximately 20-23 months 1

Important Caveats

• Timing is critical: Adjuvant therapy should ideally be initiated within 4-8 weeks after surgery
• Restaging with CT scan is recommended after systemic chemotherapy before starting chemoradiation
• Patients who received neoadjuvant chemoradiation should not receive adjuvant chemoradiation
• Toxicities to monitor include nausea, vomiting, diarrhea, stomatitis, and hematologic suppression 5