Neoadjuvant FOLFIRINOX a Better Option Than Surgery Plus Adjuvant Therapy in Pancreatic Cancer

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nFOLFIRINOX more efficacious, more cost-effective for BR/LA PDAC vs surgery with GEM/CAPE or with gemcitabine.
nFOLFIRINOX more efficacious, more cost-effective for BR/LA PDAC vs surgery with GEM/CAPE or with gemcitabine.

Neoadjuvant FOLFIRINOX (nFOLFIRINOX) is both more efficacious and more cost-effective than upfront surgery in patients with borderline resectable or locally advanced pancreatic ductal adenocarcinoma (BR/LA PDAC), study results published in The Oncologist have shown.

This study assessed nFOLFIRINOX (folinic acid, fluorouracil, irinotecan, oxaliplatin) vs resection surgery with adjuvant gemcitabine plus capecitabine (GEM/CAPE) or with single-agent gemcitabine.

Researchers used a mathematical simulation model with transition probabilities composed from estimates based on published and institutional clinical data to compare overall survival (OS), disease-free survival (DFS), quality-adjusted life-years (QALYs), cost (US dollars), and cost-effectiveness (as an incremental cost-effectiveness ratio) between nFOLFIRINOX and surgery followed by GEM/CAPE or gemcitabine in patients with BR/LA PDAC.

The results of this decision-analysis indicated median OS was best with nFOLFIRINOX at 34.5 months vs 28.0 months for surgery with GEM/CAPE vs 22.0 months for surgery with gemcitabine. Median DFS was also better with nFOLFIRINOX: 15.0 months vs 14.0 months  vs 13.0 months, respectively.

According to this model, treatment with nFOLFIRINOX resulted in an additional 0.35 life-years and 0.30 QALYs with a cost of $46,200 per QALY gained vs surgery with GEM/CAPE. In sensitivity analysis of the model, complete resection and cancer recurrence rates had the largest impact on model results, although the model remained otherwise robust.

Probabilistic sensitivity analysis indicated nFOLFIRINOX was cost-effective 92.4% of the time at a willingness-to-pay threshold of $100,000 per QALY.

Although additional clinical data on the long-term efficacy of nFOLFIRINOX are needed to confirm these results, they suggest nFOLFIRINOX is prefereable to surgery followed by adjuvant therapy in both clinical efficacy and cost-effectiveness.

Reference

Choi JG, Nipp RD, Tramontano A, et al. Neoadjuvant FOLFIRINOX for patients with borderline resectable or locally advanced pancreatic cancer: results of a decision analysis [published online December 17, 2018]. Oncologist. doi: 10.1634/theoncologist.2018-0114

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