Johanna C. Bendell, MD; Tanios Bekaii-Saab, MD, FACP; Michael J. Pishvaian, MD, PhD; and Rachna T. Shroff, MD, MS prepared useful practice aids pertaining to pancreatic cancer for this CME/MOC activity titled How I Think, How I Treat—Personal Insights on Current Practices and Evolving Standards of Care in Pancreatic Cancer: Expert Perspectives on Implementing State-of-the-Art Care in the Clinic. For the full presentation, monograph, complete CME/MOC information, and to apply for credit, please visit us at http://bit.ly/2uNJtbI. CME/MOC credit will be available until March 4, 2021.

1. Guidance for Discussing Pancreatic Cancer,
Symptoms, and Disease Management With Patients
PRACTICE AID
MW: molecular weight; NSAID: nonsteroidal anti-inflammatory drug; VTE: venous thromboembolism.
1. https://www.lustgarten.org/get-informed/quick-facts-a-pancreatic-cancer-infographic. Accessed January 6, 2020. 2. https://www.cancer.gov/types/pancreatic/hp/pancreatic-treatment-pdq. Accessed January 6, 2020. 3. https://www.pancan.org/facing-pancreatic-cancer.
Accessed January 6, 2020. 4. https://letswinpc.org/symptoms. Accessed January 6, 2020. 5. https://www.lustgarten.org/get-informed/stages-of-pancreatic-cancer. Accessed January 6, 2020. 6. NCCN Clinical Practice Guidelines in Oncology. Pancreatic Adenocarcinoma. V1.2020.
https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf. Accessed January 6, 2020. 7. https://www.nccn.org/patients/resources/life_with_cancer/managing_symptoms/fatigue.aspx. Accessed January 6, 2020. 8. Akizuki N et al. Jpn J Clin Oncol. 2016;46:71-77.
9. Laquente B et al. Clin Transl Oncol. 2017;19:1293-1302.
Types of Pancreatic Cancer1-3
• Ductal adenocarcinoma (most common)
• Acinar cell carcinoma
• Intraductal papillary mucinous carcinoma
• Pancreatoblastoma
• Neuroendocrine
• Tumors may lie within the pancreas
or extend beyond, but no involvement
of critical arteries or veins
Normal Function of the Pancreas1-3
• Produces digestive enzymes (exocrine cells)
• Helps to regulate blood sugar (endocrine cells)
Disease Symptoms1-4
• Jaundice
• Pain in the back or abdomen
• Fatigue
• Loss of appetite/unintended
weight loss
Abdominal pain
• NSAIDs
• Opioids
• Celiac plexus nerve block
Biliary obstruction & jaundice
• Biliary stent; endoscopic or external
Gastric outlet obstruction
• Enteral stent
• Gastrojejunostomy
VTE
• Low MW heparin
Fatigue
• Nutrition, exercise, sleep
• Psychological support
• Thyroid function
• Testosterone levels in men
Exocrine insufficiency
• Pancreatic enzymes at the
beginning of each meal/snack
• Nausea and vomiting
• Acute pancreatitis attacks
• New onset diabetes
• Diarrhea
SYMPTOMS AND MANAGEMENT7-9
CLINICAL STAGING5,6
Resectable pancreatic cancer can be
surgically removed
Physical
Anorexia/weight loss
• Registered dietitian
• Appetite stimulants
Nausea
• Antiemetics
• Add promotility agent if evidence
of gastroparesis
Dehydration
• IV hydration
Anxiety, depression, and suicide risk
• Psychosocial support
• Referral for counselling
• Antidepressant
Diet & Nutrition Psychosocial
• Confined to area around pancreas;
intertwined with blood vessels; invasion
of surrounding organs
Locally advanced, unresectable; treatment
includes chemotherapy, clinical trials,
and radiation
• Has spread beyond the area of the
pancreas and involves other organs
Metastatic pancreatic cancer; chemotherapy
can be used across multiple lines of
therapy; clinical trials are an important
treatment option
Liver
Stomach
Gallbladder
Lymph nodes
Pancreas Cancer cells
Liver
Stomach
Gallbladder
Lymph
nodes
Pancreas
Liver
Stomach
Gallbladder
Lymph nodes
Pancreas Cancer cells
Liver
Stomach
Gallbladder
Lymph nodes
Pancreas Cancer cells
No detectable
evidence of
spread to areas
outside of the tissue;
removed during
surgery
No evidence
of spread to
other areas
of the body
Involved organs
may include the liver
and lungs; other areas
of the abdomen may
be affected
Access the activity, “How I Think, How I Treat—Personal Insights on Current Practices and Evolving
Standards of Care in Pancreatic Cancer: Expert Perspectives on Implementing State-of-the-Art Care
in the Clinic” at PeerView.com/QAF40

2. Selected Ongoing Clinical Trials
in Pancreatic Cancer1
PRACTICE AID
Access the activity, “How I Think, How I Treat—Personal Insights on Current Practices and Evolving
Standards of Care in Pancreatic Cancer: Expert Perspectives on Implementing State-of-the-Art Care
in the Clinic” at PeerView.com/QAF40
• Clinical trials can be an important therapeutic tool for the
treatment of pancreatic cancer
• Share these resources on clinical trials and pancreatic cancer
education with your patients
• Let’s Win offers information for patients on therapies being
tested in clinical trials: letswinpc.org/clinical-trials
• Pancreatic Cancer Action Network offers several clinical
resources: clinicaltrials.pancan.org
PARP Inhibitors
NCT03553004 NIRA-PANC
Niraparib; metastatic
NCT03601923
Niraparib; previously treated metastatic
NCT03404960 Parpvax
Niraparib + nivolumab or ipilimumab;
previously treated metastatic
NCT03140670
Rucaparib; locally advanced or metastatic
NCT04005690
Olaparib or cobimetinib; previously
untreated resectable disease
NCT02677038
Olaparib; previously treated metastatic
Phase 2
Immune Checkpoint Inhibitors
NCT03697564 GemCaN Trial
Nivolumab + cabiralizumab + gemcitabine;
metastatic
NCT03190265
Nivolumab + ipilimumab + GVAX vaccine
+ CRS-207; previously treated metastatic
NCT03161379
Nivolumab + GVAX vaccine + cyclophosphamide
+ SBRT; borderline resectable disease
NCT03104439
Nivolumab + ipilimumab + RT; metastatic
NCT03563248
Nivolumab + losartan + FOLFIRINOX + SBRT
+ surgery; localized disease
NCT03599362
Nivolumab + cabiralizumab ± nab-paclitaxel
+ gemcitabine or 5-FU + oxaliplatin + LV;
locally advanced unresectable
Phase 2
Phase 1/2

3. Selected Ongoing Clinical Trials
in Pancreatic Cancer1
PRACTICE AID
Access the activity, “How I Think, How I Treat—Personal Insights on Current Practices and Evolving
Standards of Care in Pancreatic Cancer: Expert Perspectives on Implementing State-of-the-Art Care
in the Clinic” at PeerView.com/QAF40
Immune Checkpoint Inhibitors (Cont’d)
NCT03264404
Pembrolizumab + azacitidine;
previously treated metastatic
NCT02451982
Nivolumab + cyclophosphamide + GVAX
vaccine; resectable disease
NCT03193190 Morpheus-Pancreatic Cancer
Atezolizumab combinations;
previously untreated metastatic
NCT03970252
Nivolumab + mFOLFIRINOX + surgery;
resectable disease
NCT02305186 UVA-PC-PD101
Pembrolizumab ± chemoradiotherapy;
resectable disease
NCT04058964
Pembrolizumab + PEGPH20;
previously treated metastatic
NCT03723915
Pembrolizumab + pelareorep;
metastatic
NCT03634332
Pembrolizumab + PEGPH20;
previously treated metastatic
NCT02648282
Pembrolizumab + cyclophosphamide + GVAX
+ SBRT; locally advanced disease
NCT03572400
Durvalumab + gemcitabine + RT;
resectable disease
NCT03727880
Pembrolizumab + defactinib;
resectable disease
NCT04177810
Cemiplimab + plerixafor;
previously treated metastatic
NCT03006302
Pembrolizumab + epacadostat + CRS-207
+ cyclophosphamide + GVAX vaccine;
previously treated metastatic
NCT04156087 MIMIPAC
Durvalumab + tremelimumab + gemcitabine
+ MWA; unresectable locally advanced
NCT02826486 COMBAT/KEYNOTE-202
Pembrolizumab + BL-8040 ± nal-IRI/LV/5-FU;
previously treated metastatic
Phase 2
Phase 1/2

4. Selected Ongoing Clinical Trials
in Pancreatic Cancer1
PRACTICE AID
Access the activity, “How I Think, How I Treat—Personal Insights on Current Practices and Evolving
Standards of Care in Pancreatic Cancer: Expert Perspectives on Implementing State-of-the-Art Care
in the Clinic” at PeerView.com/QAF40
Chemotherapy
NCT03941093
Nab-paclitaxel + gemcitabine + neoadjuvant
pamrevlumab; locally advanced unresectable
NCT03257033 TIGeR-PaC
Intra-arterial gemcitabine following RT;
locally advanced unresectable
NCT01954992
Glufosfamide vs 5-FU;
previously treated metastatic
NCT03816163
Nab-paclitaxel + zolbetuximab +
gemcitabine; previously untreated metastatic
NCT03415802
Nab-paclitaxel + S-1;
previously untreated metastatic
NCT02427841
Nab-paclitaxel + 5-FU + gemcitabine + RT
+ surgery; resectable early disease
NCT03986294 NAPAN
Nal-IRI + S-1 + LV + 5-FU;
previously treated metastatic
NCT03693677 FUNGEMAX
Nal-IRI + 5-FU/LV or nal-IRI + 5-FU/LV +
nab-paclitaxel + gemcitabine;
first-line metastatic
NCT03861702
Nal-IRI + FOLFOX; previously untreated
locally advanced unresectable
Phase 3
NCT03861702
Nal-IRI + trifluridine/tipiracil;
locally advanced
Phase 1/2
Phase 2

5. Selected Ongoing Clinical Trials
in Pancreatic Cancer1
PRACTICE AID
Access the activity, “How I Think, How I Treat—Personal Insights on Current Practices and Evolving
Standards of Care in Pancreatic Cancer: Expert Perspectives on Implementing State-of-the-Art Care
in the Clinic” at PeerView.com/QAF40
Novel Modalities and Other Treatment Strategies
NCT03126435
EndoTAG-1 + gemcitabine; previously treated
locally advanced or metastatic
NCT03377491 PANOVA-3
TTFields + nab-paclitaxel + gemcitabine;
previously untreated locally advanced
NCT03899636 DIRECT
NanoKnife + mFOLFIRINOX;
previously treated metastatic
NCT03621644
SMART; unresectable locally advanced
Phase 3
NCT03086369
Olaratumab + nab-paclitaxel + gemcitabine;
previously untreated metastatic
NCT03649321
Bemcentinib + nab-paclitaxel + gemcitabine
+ cisplatin; metastatic
Phase 1/2
Phase 2
5-FU: 5- fluorouracil; FOLFIRINOX: leucovorin, 5-fluorouracil, irinotecan, and oxaliplatin; FOLFOX: folinic acid, fluorouracil, and oxaliplatin; GVAX: granulocyte-macrophage colony stimulating factor (GM-CSF) vaccine; LV: leucovorin; mFOLFIRINOX: modified FOLFIRINOX (bolus
5-FU omitted); MWA: microwave ablation; nab-paclitaxel: nanoparticle albumin–bound paclitaxel; nal-IRI: nanoliposomal irinotecan; PARP: poly (ADP-ribose) polymerase; PEGPH20: pegvorhyaluronidase alfa; RT: radiation therapy; SBRT: stereotactic body radiation therapy; SMART:
stereotactic MRI-guided on-table adaptive radiation therapy; TTFields: tumor-treating fields.
1. https://clinicaltrials.gov. Accessed January 6, 2020.

6. Algorithm of Systemic Treatment Selection
for Advanced Pancreatic Cancer1
Access the activity, “How I Think, How I Treat—Personal Insights on Current Practices and Evolving
Standards of Care in Pancreatic Cancer: Expert Perspectives on Implementing State-of-the-Art Care
in the Clinic” at PeerView.com/QAF40
PRACTICE AID
a
Patients who progress with metastatic disease are not candidates for radiation therapy unless required for palliative purposes. b
FOLFIRINOX or mFOLFIRINOX should be limited to those with ECOG PS 0-1. Nab-paclitaxel + gemcitabine is reasonable for patients with ECOG 0-2. 5-FU +
LV + nal-IRI is a reasonable second-line option for patients with ECOG PS 0-2. c
Patients who have response or stable disease after 4-6 mo of chemotherapy may undergo maintenance. d
ECOG PS 0-2 for combination regimens; ECOG PS 0-3 for single-agent options.
5-FU: 5- fluorouracil; dMMR: deficient mismatch repair; ECOG: Eastern Cooperative Oncology Group; FOLFIRI: leucovorin, 5-fluorouracil, and irinotecan; FOLFIRINOX: leucovorin, 5-fluorouracil, irinotecan, and oxaliplatin; FOLFOX: folinic acid, fluorouracil, and oxaliplatin; LV: leucovorin;
mFOLFIRINOX: modified FOLFIRINOX (bolus 5-FU omitted); MSI-H: microsatellite instability high; nab-paclitaxel: nanoparticle albumin–bound paclitaxel; nal-IRI: nanoliposomal irinotecan; PS: performance status.
1. NCCN Clinical Practice Guidelines in Oncology. Pancreatic Adenocarcinoma. V1.2020. https://www.nccn.org/professionals/physician_gls/pdf/pancreatic_blocks.pdf. Accessed January 6, 2020.
Metastatic disease
Maintenance settingc,d
Preferred regimens
PS
PoorGood
First linea
Second line
• FOLFIRINOX (category 1) or
mFOLFIRINOXb
(category 2A)
• Nab-paclitaxel + gemcitabineb
(category 1)
For BRCA1/2 or PALB2 mutations:
• FOLFIRINOX (category 1) or
mFOLFIRINOXb
(category 2A)
• Gemcitabine + cisplatin
(category 2A)
Gemcitabine:
• 1,000 mg/m2
over 30 min weekly for
3 wk every 28 d (category 1)
• Fixed-dose-rate gemcitabine
(10 mg/m2
/min) may substitute for
standard infusion of gemcitabine over
30 min (category 2B)
• Capecitabine (category 2B)
• Continuous-infusion 5-FU
(category 2B)
No preferred regimens
Other recommended regimens
No preferred regimens
Other recommended regimens
• Pembrolizumab (MSI-H or dMMR;
category 2A)
• Larotrectinib (NTRK fusion;
category 2A)
• Entrectinib (NTRK fusion;
category 2B)
Useful in certain circumstances
Prior gemcitabine-based tx:
• 5-FU + LV + nal-IRIb (category 1 for
metastatic disease)
• FOLFIRI (category 2A)
• FOLFIRINOX/mFOLFIRINOXb
(category 2A)
• Oxaliplatin + 5-FU + LV (category 2A)
• FOLFOX (category 2A)
• Capecitabine + oxaliplatin
(category 2A)
• Capecitabine (category 2A)
• Continuous infusion 5-FU (category 2A)
Prior fluoropyrimidine-based tx:
• Gemcitabine (category 2A)
• Nab-paclitaxel + gemcitabineb
(category 2A)
• Gemcitabine + cisplatin (BRCA1/2 or
PALB2 mutations; category 2A)
• 5-FU + LV + nal-IRIb
(if no prior
irinotecan; category 2A)
Preferred regimens
Gemcitabine:
• 1,000 mg/m2
over 30 min weekly for
3 wk every 28 d (category 1)
• Fixed-dose-rate gemcitabine
(10 mg/m2
/min) may substitute for
standard infusion of gemcitabine
over 30 min (category 2B)
• Capecitabine (category 2B)
• Continuous-infusion 5-FU (category 2B)
Useful in certain circumstances
• Pembrolizumab (MSI-H or dMMR;
category 2A)
• Larotrectinib (NTRK fusion;
category 2A)
• Entrectinib (NTRK fusion;
category 2B)
Other recommended regimens
• Gemcitabine + erlotinib (category 1)
• Gemcitabine (category 1)
• Gemcitabine + capecitabine
(category 2A)
• Fixed-dose-rate gemcitabine,
docetaxel, capecitabine (category 2A)
• Fluoropyrimidine + oxaliplatin
(category 2B)
Preferred regimens
If previous first-line FOLFIRINOX:
• FOLFIRI (category 2A)
Other recommended regimens
If previous first-line FOLFIRINOX:
• FOLFOX (category 2B)
• Clinical trial (category 2A)
Useful in certain circumstances
If previous first-line FOLFIRINOX:
• Capecitabine (category 2A)
If previous first-line platinum-based chemo:
• Olaparib (BRCA1/2 positive)
If previous first-line nab-paclitaxel + gemcitabine:
• Nab-paclitaxel + gemcitabine modified
dosing schedule (category 2B)
• Single-agent gemcitabine (category 2B)
Recurrent locally advanced/metastatic disease
Line of
Therapy
PS
PoorGood