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Pancreatic cancer is one of the most fatal malignancies. Palliative care represents an important aspect of management in patients with pancreatic malignancy. Identifying and treating disease related symptoms are very important. As a physician taking care of these patients it is essential to know these symptoms and treatment modalities. Common problems include biliary obstruction, anticoagulation, and pain management. This review discusses the data presented at the 2011 American Society of Clinical Oncology (ASCO) Annual Meeting symptom management and supportive care strategies including Abstracts #e14665, #e14622, and #LBA9014. Success is needed in managing these symptoms to palliate patients with advanced pancreatic cancer. It is important for oncologists to recognize the importance of supportive measures that can minimize the symptoms of advanced disease and side effects of cancer treatment.

Strong evidence exists for the use of adjuvant chemotherapy following surgical resection in pancreatic cancer, whereas the role of adjuvant chemoradiotherapy remains controversial. The optimal time to initiate adjuvant therapy has yet to be elucidated, but is usually started 2-10 weeks following resection. First line adjuvant chemotherapy is gemcitabine, as this drug has demonstrated the better efficacy in studies. Other chemotherapeutic agents and gemcitabine in combination with biologic agents are under investigation. Furthermore, predicting response to gemcitabine based chemotherapy and other adjuvant therapies will be invaluable in guiding the practitioner to choose the most appropriate adjuvant treatment. Once adjuvant therapy has been started, accurately quantifying response to therapy is also important. The adjuvant regimen may be appropriately modified if response is inadequate. This review is an update from the 2011 American Society of Clinical Oncology (ASCO) Annual Meeting regarding recent developments in the adjuvant treatment of pancreatic cancer with regards to choice of adjuvant regimen, timing of adjuvant therapy, predicting response to therapy and measuring response to adjuvant therapy. We will present the findings from Abstracts #4039, #4042, #e14519, #4118, and #4024. In conclusion, multiple adjuvant therapeutic regimens are associated with incremental improvements in the management of pancreatic cancer. The timing of initiation of adjuvant therapy appears to be important in outcomes. Research is ongoing into markers that can predict response to adjuvant therapy.

There are urgent needs to develop novel and more effective regimens to improve outcomes of pancreatic cancer given its dismal prognosis and limited treatment options. Several phase I clinical trials involving novel agents were recently presented at the 2011 American Society of Clinical Oncology (ASCO) Annual Meeting. It appears that hedgehog inhibition with IPI-926 was well-tolerated and might be effective in treating pancreatic cancer when combined with gemcitabine. The survival benefits will be tested in the following randomized phase II trial. The new combination of gemcitabine and blockade of checkpoint kinases with AZD7762 showed an acceptable safety profile. Furthermore, inhibition of PI3K by BAY80-6946 was well tolerated with PET-CT suggesting reduction in FDG uptake in some pancreatic cancer. The benefits of above novel agents/regimens need to be further tested in phase II trials.

Screening and early detection of pancreatic cancer has the potential to substantially impact outcomes in this deadly disease. Over the last ten years several cohort studies have been conducted and report on the yield of screening in high risk populations. With better understanding of the cellular compartments and the genetic and epigenetic changes that occur, biomarkers have also emerged as promising means of early detection. In this paper we summarize the results of the latest screening cohort and highlight a novel proteomic approach that may be used in future biomarker studies.

Despite the extensive research, mounting knowledge in the cancer field and enormous investments, pancreatic cancer remains a rather incurable disease with aggressive natural course and high mortality rate. The very slow progress is a result of the complex pathogenesis of this disease, which prevents us from targeting the culprit and making a step forward. Therefore, the field is still unexplored and this is a real challenge and opportunity for new ideas and novel approaches. In this paper, we will present the most interesting studies in the first line pancreatic cancer setting, presented at the American Society of Clinical Oncology (ASCO) 2011 Annual Meeting. While there are few studies testing the role of combining the cytotoxic S-1 and gemcitabine, the majority of the studies are examining the safety and impact of adding to the classic gemcitabine treatment novel molecular agents which target key pathways or overexpressed proteins.

Ampullary cancer is an uncommon tumor and tends to have a better prognosis than pancreatic cancer. However, one half of patients will die from recurrent disease suggesting the need for effective adjuvant therapy. Currently, there is lack of randomized trials to guide the use of adjuvant therapy in ampullary cancer. At the 2011 American Society of Clinical Oncology (ASCO) Annual Meeting, the largest trial (Abstract #4006) evaluating adjuvant treatment of ampullary cancer was presented.

Pancreatic cancer is the fourth leading cause of cancer death in the United States. Risk factors for pancreatic cancer are smoking, family history, chronic pancreatitis, and diabetes. There is controversy with regards to the causal relationship between diabetes and pancreatic cancer because many patients with pancreatic cancer have new onset diabetes. Abstracts presented at the 2011 American Society of Clinical Oncology (ASCO) Annual Meeting highlighted and supported the positive association between pancreatic cancer and diabetes. Abstract #4102 reports a two-fold risk of pancreatic cancer in diabetic patients. Abstract #4063 also presented at the 2011 ASCO Meeting shows that metformin prolongs survival and decreases risk of death in patients with pancreatic malignancy and diabetes.

Pancreatic neuroendocrine tumors represent a small percentage of all pancreatic tumors (1.3%) but their incidence is rising. Prior to 2011, the only approved agent for unresectable disease was streptozicin (often used in combination with doxorubicin) but the efficacy of this drug is in question and there had not been any new drugs approved for this disease in more than 20 years. Recently there has been new excitement for the treatment of advanced neuroendocrine tumors including those of the pancreas (pNET) with FDA approval of 2 new agents in 2011. One of these agents was everolimus, an mTOR inhibitor, which was approved on the basis of a landmark phase III study (RADIANT-3). At the 2011 American Society of Clinical Oncology (ASCO) Annual Meeting, several abstracts were presented reviewing novel agents in the treatment of advanced NET. Three abstracts looked at characteristics of patients treated on the RADIANT-3 study and looked at the role of prior chemotherapy use (Abstract #4103), somatostatin analog use (Abstract #4010), and updated safety data (Abstract #4009) from this trial. Additionally, an abstract was presented (Abstract 4008) looking at updated data from the other targeted agent approved for advanced pNET, sunitinib, a multi-tyrosine kinase inhibitor, which demonstrated improvement in progression-free survival compared to placebo. Novel agents were also presented, including a phase II trial looking at the combination of sorafenib and bevacizumab (Abstract #4113), and a phase I trial looking at a novel somatostatin analog, pasireotide, in combination with everolimus (Abstract #4120) The authors review and summarize these abstracts in this article.

Appropriate identification and validation of biomarkers as well as pharmacogenetics are important in formulating patient-oriented, individualized chemotherapy or biological therapy in cancer patients. These markers can be especially valuable in pancreatic cancer, where high mortality and complex disease biology are frequently encountered. Recently, several advances have been made to further our knowledge in this specific area of pancreatic cancer. In the 2011 American Society of Clinical Oncology (ASCO) Annual Meeting, researchers have presented several interesting results in biomarkers development: the identifications of 9 single nucleotide polymorphisms (SNPs) that is associated with positive efficacy of gemcitabine (Abstract #4022); the introduction of circulating tumor cells as a prognostic markers in pancreatic adenocarcinoma (Abstract #e14657); the re-affirmation of plasma cytidine deaminase (CDA) as a positive predictive markers for gemcitabine efficacy, as well as the postulations that CDA*3 as a potential genotype marker to predict gemcitabine responses (Abstract #e14645); and finally the retrospective tumor tissues analysis in the Arbeitsgemeinschaft Internistische Onkologie (AIO) trial in an attempt for epidermal growth factor receptor (EGFR) pathway biomarker identifications (Abstract #4047).

Pancreatic cancer is the 4th leading cancer cause mortality in both men and women. Pancreatic cancer is usually diagnosed in the advanced setting, and only 10-15% of patients present with operable disease. About 25% are locally advanced and unresectable and the rest are metastatic. Studies presented at the 2010 American Society of Clinical Oncology (ASCO) Annual Meeting highlighted both current treatment options and promising novel therapeutic agents and approaches.

Pancreatic cancer is one of the most devastating solid tumor malignancies. Majority of patients have metastatic disease upon diagnosis. Five-year survival is less than 5% for all stages of pancreatic cancer combined. Gemcitabine has been the standard palliative therapy for advanced pancreatic cancer over the past decade. Many studies attempted to develop combination regimens, but they failed to improve overall survival in the metastatic settings. The combination of gemcitabine and erlotinib was the first combination regimen to show improvements in survival benefit compared with gemcitabine alone and became the first-line combination therapy in advanced pancreatic cancer. The search for better treatment strategies to prolong survival in this deadly disease is very much needed and is a worldwide effort. There were many studies presented at the 2010 American Society of Clinical Oncology (ASCO) Annual Meeting focused on first-line therapy in metastatic pancreatic cancer. This article highlights a few phase III and II studies that have demonstrated encouraging results.

Pancreatic cancer represents the 4th leading cause of cancer deaths in the United States. Surgical resection remains the only potential curative approach. Current standard adjuvant therapy is gemcitabine monotherapy for 6 months. This year several trials investigated other combinations with or without molecular target agents, with or without concurrent radiation attempting to optimize adjuvant therapy. Several abstracts presented at the 2010 American Society of Clinical Oncology (ASCO) Annual Meeting are highlighted here and will be further discussed in this review article. Abstracts #4012, #4059, and TPS226 added immunotherapy to adjuvant treatment. Abstract #4034 demonstrated lack of efficacy by adding either cetuximab or bevacizumab to known adjuvant therapies. Abstract e14625 combined S-1 to gemcitabine and abstract #4113 demonstrated a positive correlation between symptoms and CA 19-9 levels with the length of survival.

Pancreatic neuroendocrine tumors display a range of clinical presentations and outcomes. Surgical resection remains the only potentially curative approach for primary tumors, and is also associated with a survival benefit for hepatic metastases as well. Data presented at the American Society of Clinical Oncology (ASCO) Annual Meeting this year suggest that targeted agents may also play a role in advanced disease. Sunitinib, which targets VEGF-1, 2 and 3 and PDGF seems to be a well tolerated treatment for advanced tumors. The mTOR inhibitor everolimus when combined with the VEGF inhibitor bevacizumab, resulted in measurable responses. The combination of bevacizumab and cytotoxic chemotherapy also shows potential.

Among various abstracts presented at the Annual Meeting of the American Society of Clinical Oncology (ASCO) held in Chicago, June 2010, four interesting abstracts focusing on pancreatic cancer merit further discussion in this post-ASCO commentary as they potentially provide insight to clinicians and hope to patients. These abstracts point to the future of pancreatic cancer management through identification of molecular targets and prognostic factors to overcome the limits of efficacious chemotherapy delivery.

Pancreatic cancer is a disease with dismal prognosis and treatment options are limited. Development of novel active compounds is mandatory. A number of pancreatic cancer clinical trials that included a novel agent among their arms were presented at the recent 2010 American Society of Clinical Oncology (ASCO) Annual Meeting. It appears that IGF-1R inhibition might be effective and this should be tested in further trials. Microtubule stabilization with ixabepilone in combination with EGFR does not lead to promising improvement in prognosis whereas nab-paclitaxel in combination with anti-angiogenetic agents is a combination not previously tested that showed an acceptable safety profile. This combination might be worth testing in a phase II clinical trial. Last but not least, CTLA-4 blockade has an acceptable toxicity profile but its efficacy needs to be proven over placebo in phase II and III trials. Finally, understanding of the tumor biology and biomarker analysis from the clinical trials is warranted.

Most patients with adenocarcinoma of the pancreas present with locally advanced or metastatic disease. Although single agent gemcitabine is widely accepted as first-line therapy, there is no current standard of care for gemcitabine-refractory patients. Common second-line chemotherapy regimens included oxaliplatin and 5-FU/leucovorin (OFF), gemcitabine and oxaliplatin (GEMOX), oxaliplatin and capecitabine (XELOX), and irinotecan-oxaliplatin. At the 2010 American Society of Clinical Oncology (ASCO) Annual Meeting, several new second-line chemotherapy regimens were presented, including gemcitabine and oxaliplatin with imatinib, single agent nab-paclitaxel, and the combination of high-dose capecitabine with oxaliplatin and sorafenib. These abstracts provide exciting new directions for the treatment of gemcitabine-refractory advanced pancreatic cancer.

Diabetes mellitus and its related factors such as hyperinsulinemia have been linked to various cancer risks and outcomes. Previous research has offered inconsistent results in terms of relationship between diabetes and pancreatic cancers. Establishing clear association between these two entities may guide us in improving clinical outcomes of pancreatic cancer patients. Two abstracts that examined the association between diabetes mellitus and pancreatic cancer are updated in this paper. Herein, the authors report updated information from the 2010 American Society of Clinical Oncology (ASCO) Annual Meeting in association between pancreatic cancer and diabetes mellitus. The present paper illustrates insufficient knowledge base to draw a conclusion in this topic. However, validation and understanding of the association could have significant clinical implications with respect to cancer prevention, early detection, and treatment. As such, further investigations are warranted to explore the link diabetes and pancreatic cancers.