Chemotherapy and other supportive modalities in the palliative setting for pancreatic cancer

Metastatic pancreatic cancer is a devastating disease with a dismal prognosis. Gemcitabine chemotherapy has been the mainstay of treatment for many years. Efforts to improve survival outcomes with gemcitabine-based combination chemotherapy regimens have been largely disappointing, with the possible exception of the addition of the targeted agent erlotinib. The multi-agent cytotoxic chemotherapy regimen FOLFIRINOX (sequential administration of oxaliplatin immediately followed by leucovorin over 2 hours, and then irinotecan, followed by a bolus dose of 5-fluorouracil, and finally, a 46-hour infusion of 5-fluorouracil) has significantly improved survival compared with gemcitabine alone; however, this regimen can be highly toxic and may need to be reserved for those with an excellent performance status. This article reviews the existing evidence for the management of patients with metastatic pancreatic cancer with chemotherapy with special attention to careful patient selection. The data for chemotherapy combined with targeted therapy are discussed. Additional supportive modalities in the areas of pharmacologic and nutritional support to maximize quality of life are also outlined.