I think this is very important. The evidence-based approach is there for effective symptom management and quality of life, but it just has not been codified. Therefore, if you speak to a pain specialist, gastrointestinal (GI) doctor, or nutritionist, the pain specialist will tell you how to treat pain in an evidence-based manner. The GI doctor will tell you how to approach the layer of obstruction, and the nutritionist will tell you how to approach pancreatic enzyme insufficiency. For the oncologist who has a busy practice and has a lot to handle, it can be a lot to address all of these concerns, and we need to get our palliative care colleagues involved and helping out. For all of the clinical trials that look at combination chemotherapy, even single-agent gemcitabine study vs 5-fluorouracil (5-FU), they all show definite improvement in quality of life, and it is interesting that that aspect of the treatment really has not been emphasized, except for the gemcitabine study, which was in 1997 (a long 20 years ago). That was basically approved for quality-of-life benefit, but the measure of quality of life at that time wouldn’t stand today. Now we have better validated instruments that we need to use for quality of life, which is vital to improving the outcomes in this group. We have to understand more than response rate and overall survival. We have to look at quality of life and how patients are actually doing, and that will really inform how we treat them. For first-line treatment with either gemcitabine + nab-paclitaxel or with FOLFIRINOX*, at first blush you’re likely to wonder if it is really a good idea for an advanced pancreatic patient who is really sick and terminal. You might wonder if you should really do it, and then you look at the quality-of-life data and you realize, not only do they live longer but their quality of life is improved. So most clinicians would feel reassured about aggressive first-line treatment.

*FOLFIRINOX: FOL=leucovorin calcium (folinic acid); F=5-fluorouracil; IRIN=irinotecan hydrochloride; OX=oxaliplatin

I think that we do tend to separate quality of life and overall survival as 2 separate outcomes. Of course you can measure them differently, but in reality, they dovetail. With good quality of life, patients are going to live longer. By combining quality of life and overall survival as outcomes, we will have better uptake in the community as a very important way of assessing patients and seeing how they’re responding to treatment. There have been several landmark studies in pancreatic cancer that used validated quality-of-life measures and have shown consistently that the application of cytotoxic chemotherapy along with very good supportive care will prevent the degradation of quality of life in patients with this disease. So, I think there are certainly several validated systems for measuring symptom burden and quality of life, and we’ve incorporated them into some landmark studies and found that quality of life can certainly be preserved for patients who are receiving chemotherapy and having their symptoms managed aggressively through supportive measures.