John Marshall, MD: Allyson mentioned earlier that 3-on, 1-off schedule for GEM [gemcitabine] and NAB [nab-paclitaxel]. What are you doing with that schedule?

Allyson Ocean, MD: Most of the time, I start with 3 on, 1 off. I don’t give 125 mg of nab-paclitaxel, just because…

John Marshall, MD: You cut that back a little bit—3 on, 1 off.

Allyson Ocean, MD: Yes, to 100 mg, usually, maybe 75 mg for some people. It’s kind of like 2 pills of Xeloda. You know what to give by looking at them, but then it morphs into 2 weeks on, 1 week off, and then it morphs into every other week. That’s usually how I do it. If they’re doing well, you see their markers coming down, and you’re running into toxicity, so most of my patients end up being 2 on, 1 off.

John Marshall, MD: Right from the beginning, what do you do?

Shubham Pant, MD: For every other week, retrospective data have shown that it has efficacy. I think that’s much better tolerated by patients. It’s very challenging beyond the first couple of cycles, because we rarely see patients. Like Allyson, everyone has their own secret sauce. Exactly as Allyson was saying, you either have to dose reduce—day 8, the majority of patients get dose reduced in clinical practice, if you’re trying to do it. Even the day 1, day 15—at least based on the retrospective data that we have—that does seem to be fairly effective in these patients and fairly tolerable in these patients.

John Marshall, MD: I apply that sort of thinking. If they’re more symptomatic, I give them every week and see if I can pull them off the ledge early. If they’re not that symptomatic, I start with every other week. What do you guys do?

Edward Kim, MD: I still go with days 1, 8, and 15 if they’re a reasonable candidate. I try to use that to sift out, for me, whether doing 2 weeks on and 1 week off is better. If they do OK with the first 2 and they fall off the cliff on the third week, I just use that. It’s a little bit more dose intense than going to every other week. The Ohio State University Comprehensive Cancer Center did it, and it gave me a lot of comfort and reassurance that it’s OK to make these modifications if they can’t tolerate it, but I generally start with 3 on, 1 off.

John Marshall, MD: Paul, anything to add?

Paul Oberstein, MD: I also start with 3 weeks on, 1 week off.

John Marshall, MD: You start with the full?

Paul Oberstein, MD: I do similar to what Allyson does. I usually would just do nab-paclitaxel—100 mg or so.

John Marshall, MD: It’s easier math.

Paul Oberstein, MD: I would say, in the phase I study, 100 mg and 125 mg looked pretty similar, so that gives me some confidence, even though it’s not as big of a study. It’s a good opportunity to watch them and see what happens weeks 1 to 3, because there are dramatic changes in counts, especially.

John Marshall, MD: Yes. Vincent Picozzi, MD, of Virginia Mason Cancer Center in Seattle, Washington is always fiddling with things. He’s solving my worry about which 1 to start with. He’s doing this alternating thing. Shub, I think we tagged you to look at that abstract. Do you remember what it showed?

Shubham Pant, MD: Yes. I think what Vince presented was a single arm of alternating therapy, and it seemed to be that the patients could tolerate that. With the PRODIGE35 data, I think it was more randomized. If you give FOLFIRINOX [folinic acid, fluorouracil, irinotecan hydrochloride, oxaliplatin] for 4 months followed by 5-FU [5-fluorouracil], versus FOLFIRINOX continuously for 4 months and give a break, and then give the 5-FU, they had equal survival. The interesting thing in that was that patients who got the FOLFIRINOX followed by 5-FU actually had a higher percentage of neuropathy, because they got more FOLFIRINOX at the back end. I think for the maintenance, that’s a fair approach to use in our patients in which you give something. Unless the patient requests it, I really don’t give a complete break a lot. I just think, exactly as Allyson was saying, this disease makes patients feel so badly. It can improve. I think we can improve the quality of life by actually giving chemotherapy to patients and keeping the disease under control, so I tend not to give them a break, unless they’re really struggling or they request it. Obviously, it depends on the patient’s preference.

Transcript Edited for Clarity