What is the comparison between FOLFIRINOX (fluorouracil, oxaliplatin, irinotecan, and leucovorin) and gemcitabine and Abraxane (nab-paclitaxel) in the treatment of pancreatic cancer?

From the Guidelines

FOLFIRINOX is the preferred first-line treatment option for patients with metastatic pancreatic cancer and good performance status, offering better survival outcomes compared to gemcitabine and Abraxane (nab-paclitaxel), with a median overall survival of approximately 11 months versus 8.5 months, respectively, as shown in the PRODIGE trial 1. The choice between FOLFIRINOX and gemcitabine plus nab-paclitaxel (Abraxane) for the treatment of pancreatic cancer depends on various factors, including the patient's performance status, age, comorbidities, and preferences.

• FOLFIRINOX is a more toxic regimen, typically reserved for patients with good performance status (ECOG 0-1), younger age (typically under 75), and adequate organ function, as recommended by the NCCN guidelines 1.
• Gemcitabine plus nab-paclitaxel is better tolerated and often preferred for older patients or those with more comorbidities, with common side effects including myelosuppression, fatigue, and neuropathy, but with less gastrointestinal toxicity, as noted in the ASCO clinical practice guideline update 1. Some key points to consider when making a treatment decision include:
• The patient's overall health and ability to tolerate aggressive therapy
• The potential benefits and risks of each treatment option
• The patient's preferences and values
• The availability of supportive care services to manage side effects It is essential to individualize treatment choices based on the patient's unique characteristics and circumstances, and to discuss the risk-benefit profile of each regimen with the patient, as emphasized in the ASCO clinical practice guideline update 1. Additionally, supportive care, including antiemetics, growth factors, and dose modifications, is often necessary to manage side effects with either regimen, as highlighted in the NCCN guidelines 1.

From the Research

Comparison of FOLFIRINOX and Gemcitabine plus Nab-Paclitaxel

• FOLFIRINOX (fluorouracil, oxaliplatin, irinotecan, and leucovorin) and gemcitabine plus nab-paclitaxel are two common first-line therapies for metastatic pancreatic ductal adenocarcinoma (mPC) 2, 3, 4, 5, 6.
• A study published in JAMA Surgery found that FOLFIRINOX was associated with higher rates of RECIST partial response and subsequent pancreatectomy than gemcitabine plus nab-paclitaxel, but the overall survival associated with these regimens was similar 2.
• Another study published in Future Oncology found that the median overall survival was 9.4 months versus 7.5 months in the mFOLFIRINOX and modified G/Nab-P groups, respectively, but the difference was not statistically significant 4.
• A study published in the American Journal of Clinical Oncology found that only 25% of patients with mPC were eligible for FOLFIRINOX, while 45% were eligible for gemcitabine plus nab-paclitaxel, due to strict inclusion criteria 5.
• A comparative effectiveness study published in JAMA Network Open found that FOLFIRINOX was associated with improved survival of approximately 2 months compared with gemcitabine plus nab-paclitaxel, and was also associated with fewer posttreatment complications 6.

Efficacy and Safety

• FOLFIRINOX has been shown to have higher response rates and longer progression-free survival compared to gemcitabine plus nab-paclitaxel in some studies 2, 6.
• However, FOLFIRINOX has also been associated with higher rates of adverse events, such as neutropenia and diarrhea, compared to gemcitabine plus nab-paclitaxel 4, 6.
• Gemcitabine plus nab-paclitaxel has been shown to have a more favorable safety profile, with lower rates of adverse events, but may have lower response rates and shorter progression-free survival compared to FOLFIRINOX 4, 6.

Patient Eligibility

• Patient eligibility for FOLFIRINOX and gemcitabine plus nab-paclitaxel is an important consideration, as both regimens have strict inclusion criteria 5.
• Patients with poor performance status, older age, and comorbidities may be less likely to be eligible for FOLFIRINOX, while patients with liver or lymph node metastasis may be less likely to be eligible for gemcitabine plus nab-paclitaxel 5.