LWBK1006-20 LWW-Govindan-Review December 12, 2011 19:4
250 DeVita, Hellman, and Rosenberg’s CANCER: Principles and Practice of Oncology Reviewpatients receiving combined modality therapy compared with survival
of patients who underwent surgery alone (median 21.0 months vs. 10.9
months, respectively; one-tailedp=.03). In ESPAC-1, patients receiv-
ing chemoradiation did worse (median survival of 15.9 months; HR for
death 1.28; 95% CI, .99 to 1.66) than those not receiving chemoradi-
ation (median survival of 17.9 months;p=.05). Conversely, patients
who received chemotherapy had a median survival of 20.6 months (HR
for death 0.71; 95% CI, 0.55 to 0.92) versus 15.5 months for those
patients who did not receive chemotherapy, a statistically significant result
(p=.009).Answer 20.2.7. The answer is B.
The optimal treatment of locally advanced pancreatic cancer remains con-
troversial. Locally advanced disease is generally incurable, and all ther-
apies have significant limitations. Gemcitabine-based chemotherapy for
2 to 4 months followed by 5FU or capecitabine-based chemoradiation
is the most appropriate choice for the majority of patients with locally
advanced, unresectable disease. If patients are responding to chemother-
apy (objective radiographic response or CA 19-9 level decline) after
2 months and tolerating therapy well, it is reasonable to continue for
2 more months. When there is radiographic local progression, a CA 19-9
level plateau or increase, local symptomatic progression, or chemother-
apy is poorly tolerated, chemoradiation should be initiated. In patients
in whom distant progression has become evident during chemotherapy,
a 2-week course of 30 Gy of 5FU or capecitabine-based chemoradia-
tion should be considered only in patients with symptomatic primary
tumors. The patients who have not progressed after systemic therapy
are most likely to benefit from chemoradiation, and typically a 5.5-week
course (50.4 Gy) of radiation therapy is appropriate with concurrent
chemotherapy.Answer 20.2.8. The answer is C.
Thus far, only inhibition of epidermal growth factor receptor with
erlotinib combined with gemcitabine has led to a small, but statistically
significant improvement in survival compared with gemcitabine alone. In
a study performed by the National Cancer Institute of Canada Clinical
Trials Group, patients with advanced pancreatic cancer were randomized
to receive gemcitabine alone at 1000 mg/m^2 weekly for 7 weeks, then
1 week off, followed by gemcitabine days 1, 8, 15, every 28 days, or the
combination of gemcitabine with erlotinib at a dose of 100 to 150 mg
orally daily. Overall survival was improved for patients randomized to
receive gemcitabine and erlotinib compared with patients receiving gem-
citabine alone (191 vs. 177 days, respectively; HR for death 0.82;p=.02).Answer 20.2.9. The answer is B.
Results from an interim analysis of phase III randomized trial reported
significant improvement in overall survival for patients receiving