Next, medical oncologist survey participants were asked a series of practice assessment questions. Expert faculty optimal answers are in bold capital letters, and other acceptable answers are in bold. If a question was deemed unquestionably inappropriate as per the expert panel, it is identified as such in italics.
1. An 80-year-old man with borderline resectable pancreatic adenocarcinoma presents to your clinic. Per discussions with the surgeon, the tumor could become resectable if there was some shrinkage using pre- operative therapy. He has diabetes, stable CAD, and mild renal insufficiency, all of which are under good control through his internist. Which of the following therapies would you recommend?
- FULL DOSE FOLFIRINOX
- Gemcitabine and abraxane
- Gemcitabine alone
- Capecitabine alone
- Gemcitabine and capecitabine
Forty-six percent of respondents chose the ideal response of gemcitabine and abraxane. Gemcitabine alone would not be the optimal choice for this patient, given that tumor shrinkage is a goal and there is a fairly low chance of tumor shrinkage with gemcitabine alone. Gemcitabine with capecitabine is more appropriate for the adjuvant postoperative setting. There is very little data on use of full-dose FOLFIRINOX in geriatric patients or those with low performance status, and is unquestionably not appropriate given the other options presented here.
2. A 90-year-old male underwent resection of a stage IIIC colon cancer. He has excellent performance status and no major comorbidities. His creatinine clearance is 30. He lives independently and takes care of his own activities of daily living. He is afraid of falling and breaking his hip because this happened to his wife. Which approach would you take in considering adjuvant therapy?
- Do no adjuvant therapy
- Use folfox for 6 months
- Use capecitabine for 6 months
- USE 5FU LEUCOVORIN ON A WEEKLY SCHEDULE FOR 6 WEEKS, FOLLOWED BY A 2-WEEK BREAK FOR 3 CYCLES
- Use folfiri for 6 months
Per the expert advisory panel, the 5FU leucovorin choice would also be most appropriate. Despite this, only 16% of survey responders chose this option. Capecitabine could be acceptable, with the caveat that dose adjustment would be required and creatinine clearance would need to be monitored in this patient with moderate renal impairment . The decision to do no adjuvant therapy could also be considered appropriate, given that the patient is 90 years old and it may not impact his survival. Given the evidence that the addition of oxaliplatin does not provide survival benefit to patients aged >70 years, the choice of FOLFOX is inappropriate .