Pancreatic Cancer

Regimen Options

Last Updated: 06/03/2024 See Details

	Evolent Pathways	Febrile Neutropenic Risk	Emetogenic Risk	References
LIMITED
Neoadjuvant	5FU (fluorouracil) and Radiation	Low	Low	NCCN Guidelines® for Pancreatic Adenocarcinoma V.1.2024.
	Abraxane (protein bound paclitaxel) and gemcitabine	Low	Low	NCCN Guidelines® for Pancreatic Adenocarcinoma V.1.2024. Von Hoff DD, et al. N Engl J Med. 2013;369(18):1691-703. Pusceddu S et al. Cancers (Basel) . 2019 Apr 5;11(4):484.
	FOLFIRINOX or modified FOLFIRINOX (fluorouracil [5FU], leucovorin, irinotecan and oxaliplatin)	High	Moderate	NCCN Guidelines® for Pancreatic Adenocarcinoma V.1.2024. Conroy T et al. N Engl J Med 2018; 379:2395-2406
Adjuvant	5FU (fluorouracil) and Radiation	Low	Low	NCCN Guidelines® for Pancreatic Adenocarcinoma V.1.2024. Kim HS, et al. Anticancer Drugs. 2010;21(1):107-12. Krishnan S, et al. Cancer. 2007;110(1):47-55.
	capecitabine and Radiation	Low	Low	NCCN Guidelines® for Pancreatic Adenocarcinoma V.3.2017. Kim HS, et al. Anticancer Drugs. 2010;21(1):107-12. Krishnan S, et al. Cancer. 2007;110(1):47-55.
	gemcitabine and capecitabine	Low	Low	NCCN Guidelines® for Pancreatic Adenocarcinoma V.3.2017. Cunningham D, et al. J Clin Oncol. 2009;27(33):5513-8.
	FOLFIRINOX or modified FOLFIRINOX (fluorouracil [5FU], leucovorin, irinotecan and oxaliplatin)	High	Moderate	NCCN Guidelines® for Pancreatic Adenocarcinoma V.3.2017. Conroy T et al. N Engl J Med 2018; 379:2395-2406
ADVANCED/METASTATIC
INITIAL THERAPY	FOLFIRINOX or modified FOLFIRINOX (fluorouracil [5FU], leucovorin, irinotecan and oxaliplatin)	High	Moderate	NCCN Guidelines® for Pancreatic Adenocarcinoma V.3.2017. Conroy T, et al. N Engl J Med. 2011;364(19):1817-25.
	Abraxane (protein bound paclitaxel) and gemcitabine	Low	Low	NCCN Guidelines® for Pancreatic Adenocarcinoma V.3.2017. Von Hoff DD, et al. N Engl J Med. 2013;369(18):1691-703. Pusceddu S et al. Cancers (Basel) . 2019 Apr 5;11(4):484.
	gemcitabine	Low	Low	NCCN Guidelines® for Pancreatic Adenocarcinoma V.3.2017. Burris HA et al. J Clin Oncol . 1997 Jun;15(6):2403-13.
	gemcitabine + cisplatin for BRCA1/2	Intermediate	High	NCCN Guidelines® for Pancreatic Adenocarcinoma V.2.2022. O’Reilly EM et al. J Clin Oncol . 2020 May 1;38(13):1378-1388.
	5FU (fluorouracil)	Low	Low	NCCN Guidelines® for Pancreatic Adenocarcinoma V.1.2024.
SUBSEQUENT THERAPY	FOLFIRINOX or modified FOLFIRINOX (fluorouracil [5FU], leucovorin, irinotecan and oxaliplatin)	High	Moderate	NCCN Guidelines® for Pancreatic Adenocarcinoma V.1.2024. Conroy T, et al. N Engl J Med. 2011;364(19):1817-25.
	Abraxane (protein bound paclitaxel) and gemcitabine	Low	Low	NCCN Guidelines® for Pancreatic Adenocarcinoma V.1.2024. Von Hoff DD, et al. N Engl J Med. 2013;369(18):1691-703. Pusceddu S et al. Cancers (Basel) . 2019 Apr 5;11(4):484.
	gemcitabine	Low	Low	NCCN Guidelines® for Pancreatic Adenocarcinoma V.1.2024. Burris HA et al. J Clin Oncol . 1997 Jun;15(6):2403-13.
	gemcitabine + cisplatin for BRCA1/2	Intermediate	High	NCCN Guidelines® for Pancreatic Adenocarcinoma V.2.2022. O’Reilly EM et al. J Clin Oncol . 2020 May 1;38(13):1378-1388.
	FOLFOX (fluorouracil [5FU], leucovorin, oxaliplatin)	Intermediate	Moderate	NCCN Guidelines® for Pancreatic Adenocarcinoma V.1.2024. Sohal DPS et al. J Clin Oncol. 2018 Aug 20;36(24):2545-2556.
	FOLFIRI (fluorouracil [5FU], leucovorin, irinotecan)	Low	Moderate	NCCN Guidelines® for Pancreatic Adenocarcinoma V.1.2024. Pointet AL. Clin Res Hepatol Gastroenterol . 2020 Jun;44(3):295-301.
	5FU (fluorouracil)	Low	Low	NCCN Guidelines® for Pancreatic Adenocarcinoma V.1.2024.
	Best Supportive Care or Clinical Trial	NCCN Guidelines® for Supportive Care.
NEUROENDOCRINE
Advanced/Metastatic: Initial Therapy	everolimus	Low	Low	NCCN Guidelines® for Neuroendocrine Tumors V.3.2017. Yao JC, et al. New Engl J Med. 2011;364(6):514-23.
	sunitinib	Low	Low	NCCN Guidelines® for Neuroendocrine Tumors V.3.2017. Raymond E, et al. New Engl J Med. 2011;364(6):501-13.
Advanced/Metastatic: Subsequent Therapy	everolimus if sunitinib 1st line	Low	Low	NCCN Guidelines® for Neuroendocrine Tumors V.3.2017. Yao JC, et al. New Engl J Med. 2011;364(6):514-23.
	sunitinib if everolimus 1st line	Low	Low	NCCN Guidelines® for Neuroendocrine Tumors V.3.2017. Raymond E, et al. New Engl J Med. 2011;364(6):501-13.
	Best Supportive Care or Clinical Trial	NCCN Guidelines® for Supportive Care.

LIMITED

Neoadjuvant

Evolent Pathways

5FU (fluorouracil) and Radiation

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

Abraxane (protein bound paclitaxel) and gemcitabine

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

FOLFIRINOX or modified FOLFIRINOX (fluorouracil [5FU], leucovorin, irinotecan and oxaliplatin)

Febrile Neutropenic Risk

high

Emetogenic Risk

moderate

References

Adjuvant

Evolent Pathways

5FU (fluorouracil) and Radiation

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

capecitabine and Radiation

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

gemcitabine and capecitabine

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

FOLFIRINOX or modified FOLFIRINOX (fluorouracil [5FU], leucovorin, irinotecan and oxaliplatin)

Febrile Neutropenic Risk

high

Emetogenic Risk

moderate

References

ADVANCED/METASTATIC

INITIAL THERAPY

Evolent Pathways

FOLFIRINOX or modified FOLFIRINOX (fluorouracil [5FU], leucovorin, irinotecan and oxaliplatin)

Febrile Neutropenic Risk

high

Emetogenic Risk

moderate

References

Evolent Pathways

Abraxane (protein bound paclitaxel) and gemcitabine

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

gemcitabine

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

gemcitabine + cisplatin for BRCA1/2

Febrile Neutropenic Risk

intermediate

Emetogenic Risk

high

References

Evolent Pathways

5FU (fluorouracil)

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

SUBSEQUENT THERAPY

Evolent Pathways

FOLFIRINOX or modified FOLFIRINOX (fluorouracil [5FU], leucovorin, irinotecan and oxaliplatin)

Febrile Neutropenic Risk

high

Emetogenic Risk

moderate

References

Evolent Pathways

Abraxane (protein bound paclitaxel) and gemcitabine

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

gemcitabine

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

gemcitabine + cisplatin for BRCA1/2

Febrile Neutropenic Risk

intermediate

Emetogenic Risk

high

References

Evolent Pathways

FOLFOX (fluorouracil [5FU], leucovorin, oxaliplatin)

Febrile Neutropenic Risk

intermediate

Emetogenic Risk

moderate

References

Evolent Pathways

FOLFIRI (fluorouracil [5FU], leucovorin, irinotecan)

Febrile Neutropenic Risk

low

Emetogenic Risk

moderate

References

Evolent Pathways

5FU (fluorouracil)

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

Best Supportive Care or Clinical Trial

References

NEUROENDOCRINE

Advanced/Metastatic: Initial Therapy

Evolent Pathways

everolimus

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

sunitinib

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Advanced/Metastatic: Subsequent Therapy

Evolent Pathways

everolimus *if sunitinib 1st line*

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

sunitinib *if everolimus 1st line*

Febrile Neutropenic Risk

low

Emetogenic Risk

low

References

Evolent Pathways

Best Supportive Care or Clinical Trial

References

	Regimen	Alternative
LOW VALUE REGIMENS (NON-PATHWAY) WITH SUPERIOR ALTERNATIVES
Initial/Subsequent Therapy	gemcitabine and erlotinib	Alternative: gemcitabine
	NALIRIFOX (liposomal irinotecan plus 5-fluorouracil/leucovorin and oxaliplatin)	Alternative: FOLFIRINOX or modified FOLFIRINOX (fluorouracil [5FU], leucovorin, irinotecan and oxaliplatin)

LOW VALUE REGIMENS (NON-PATHWAY) WITH SUPERIOR ALTERNATIVES

Initial/Subsequent Therapy

Regimen

** gemcitabine and erlotinib **

Regimen

** NALIRIFOX (liposomal irinotecan plus 5-fluorouracil/leucovorin and oxaliplatin) **

Pathways and Low-Value Regimens

Pancreatic Cancer