Aligning Goals in mPDAC: Shared Decision-Making in First-Line Therapy

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Patient involvement in pancreatic cancer treatment decisions is fundamental, though approaches vary based on individual preferences and physician guidance. Treatment selection must consider both immediate tolerability and long-term effects, particularly the significant difference in neuropathy rates between FOLFIRINOX and NALIRIFOX due to varying oxaliplatin doses. The higher cumulative oxaliplatin exposure in FOLFIRINOX increases peripheral neuropathy risk, making NALIRIFOX attractive for patients concerned about long-term neurological adverse effects.

Gastrointestinal toxicity, including diarrhea and nausea, represents another key differentiating factor between regimens, with 5-fluorouracil–based combinations generally causing more intestinal adverse effects than gemcitabine-based therapies. Patient education about expected outcomes is crucial, particularly explaining that stable disease represents a positive outcome in pancreatic cancer, contrasting with other malignancies where progression-free survival expectations differ. Setting realistic expectations helps patients navigate the psychological challenges of prolonged treatment.

The decision-making process balances patient life goals, performance status, and treatment tolerance while acknowledging limited comparative data between regimens. Most patients with good performance status ultimately receive triplet therapy, but the specific regimen choice involves detailed discussions about adverse effect profiles and quality of life priorities. Physicians must remain transparent about data limitations while providing evidence-based recommendations tailored to individual patient circumstances and treatment goals.