John Marshall, MD: We get a lot of razzing as oncologists, as we get down lines of therapy with metastatic pancreatic cancer. These patients are occasionally getting admitted to the hospital, and they’re needing more palliative care. What does 1 do with that failing-PS [performance status] pancreas patient who still wants to try something? Are there things that are out there that may not be eligible for a clinical trial, or is this a patient for whom the nihilism starts to play? It’s a hard question to ask, but I’m tagging you with it.

Edward Kim, MD: This is very challenging.

Shubham Pant, MD: Never sit on the right side of John.

Edward Kim, MD: On 1 hand, I think it’s a difficult question, but it’s just interesting that it’s questioned at all, because it hasn’t been that long that we’ve had the option of having multiple lines of therapy. In some part, we’ve been discussing deconstructing and whether you have 2 lines of therapy or 3 lines of therapy. If you start with GEM [gemcitabine]—nab-paclitaxel, you go to 5-FU [5-fluorouracil] and liposomal irinotecan. You do still have the option to consider 5-FU and oxaliplatin. I think that’s something to consider. We don’t have high-level data, but it’s something to reasonably argue—that it’s a component of active therapies that we could still incorporate. I think the challenge of what you’re asking is—I’m going to turn it around—how many patients actually have a suitable performance status at the third line, or even the second line, to be able to go on to additional therapies? I think that’s true for clinical trials too. You can’t go on a clinical trial with a performance status of 3. It’s true for standard therapies as well. If we can get some benefit with monotherapy, I think those are things to still consider.

John Marshall, MD: Yes, I just always worry about the fairly sharp decline in pancreatic cancer patients too, but I totally agree with everything you just said.

Paul Oberstein, MD: I think they exist, at least in New York. There are patients who are third line who really have no obvious treatment option but are fit enough to get treatment. They want to go on phase I clinical trials. There was a study here at ASCO [the American Society of Clinical Oncology Annual Meeting] from the Memorial Sloan Kettering Cancer Center group about those patients going on trial, and almost none of them have benefit because there are no almost no agents. But when we do trials, the patients come out of the woodwork and we find third-line trials. However, the majority of patients are not boldly going to third line; they’re struggling. I think it’s really not in their benefit to give them toxic chemotherapy when they’re not performance status 0 or 1 and able to handle it.

John Marshall, MD: There was a time when almost every patient with a metastatic GI [gastrointestinal] cancer got all the known therapies because we didn’t have that many. Now, more and more, at least in my practice, there are patients who are not getting all the therapies because of this. I always struggle with trying them to see if it turns somebody around, versus worrying that I’m not going to have enough time, in this patient population.

Allyson Ocean, MD: I want to say that in the BRCA subset of patients, if the performance status is 0 or 1 still, and sometimes we do see that, I try to add in mitomycin or irinotecan combinations again. I think we can rescue a few patients here and there using that approach. Paul, have you done that?

Paul Oberstein, MD: We’ve done it very occasionally. It’s toxic. I think the BRCA-mutated patients, or the surrogate—the ones who did really well with FOLFIRINOX [folinic acid, 5-fluorouracil, irinotecan hydrochloride, oxaliplatin]…

Allyson Ocean, MD: Right.

Paul Oberstein, MD: We don’t know if they’re BRCA-mutated. They’ll often be able to handle more lines of therapy and alternative therapy—go back, even—or mitomycin.

Allyson Ocean, MD: Correct.

John Marshall, MD: I think we all have this subtype in our patient populations. Often, it’s a little old lady who’s living 2 or 3 years with metastatic pancreatic cancer, and there’s clearly this subtype that is much quieter. You don’t find that subtype unless you treat. Often it’s that older, frailer patient who’s going to stick around for a while.

Shubham Pant, MD: You’re right. There is definitely a subtype. Lung-only metastases is a definite subtype in pancreatic patients who tend to do better. I think there’s the BRCA subset. There’s also a BRCAness subset. They may not have the germline mutation, but there’s a first-degree family member who does. I think there are definitely these patients who are out there. You just have to look at the third line. You have to look at parameters. Albumen is a big 1. If they’re getting frequent taps or peritoneal disease—you can look at those patients who would benefit. In the ones we don’t think would benefit, supportive care is necessary because we start them early on supportive care during frontline treatment. We always have our supportive care group follow them because that really improves the quality of life, and that transition can be a little easier. I think they do benefit from that early initiation of supportive-care hospice if they‘re truly headed in that direction.

John Marshall, MD: It’s absolutely the worst part of our job, but maybe the most important part of our job and the 1 that makes it hard. It’s a hard job we have, knowing when or how to coach that patient and supporting them, not only as palliative care docs, because much of what we do is that, but also as their life coach and psychologist as we go through that.

Transcript Edited for Clarity