Does “OPTINAB” strategy (“stop-and-go”) work in treatment of advanced pancreatic cancer (APC) with nab-paclitaxel–gemcitabine?

MPACT demonstrated a survival benefit of nab-paclitaxel plus gemcitabine versus gemcitabine in advanced pancreatic cancer (APC). However, sensory peripheral neuropathy is a dose-limiting toxicity and neuromodulators have shown limited, if any activity in ameliorating neuropathy. In colorectal cancer, the OPTIMOX (“stop-and-go”) approach offered a strategy to reduce neuropathy. No data exist to support this strategy for nab-paclitaxel in APC.

Retrospective study of APC patients who developed grade 3 neuropathy during nab-paclitaxel plus gemcitabine was done. Nab-paclitaxel was held and then reinstituted upon radiological or tumor marker progression. Duration of disease control (DCC) was measured. We named this strategy “OPTINAB”.

Seven patients out of 27 (25%) developed grade 3 neuropathy after an average of 4.2 months; nab-paclitaxel was suspended while gemcitabine was continued. Maintenance gemcitabine continued for a mean of 2.8 months. Upon progression (radiologic or CA19-9) nab-paclitaxel was re-instituted with gemcitabine. One patient could not tolerate nab-paclitaxel due to worsening of neuropathy while other six continued the combo with mean progression-free survival 2 (PFS2) of 2.2 months. The six patients continued nab-paclitaxel for a mean of PFS2 of 2.2 months (range 1–4 months). Nab-paclitaxel resulted in improvement of an average DDC with an average of (7.0 + 2.2 =) 8.2 months (range 8–13 months). Average overall survival for this group was 11.7 months (range 9.5–17 months). Reintroduction of nab-paclitaxel resulted in an average DDC of 9.4 months. Average overall survival (OS) for this group was 11.7 months.

“OPTINAB” approach improved PFS2 in these patients and was feasible as majority of the patient tolerated nab-paclitaxel. Although it is a small study, it supports the need for a randomized, prospective study to test the concept of “OPTINAB”.