Metastatic pancreatic cancer treatment is increasingly personalized, considering tumor biology, patient health, and treatment goals. Assessing comorbidities, nutrition, and performance status helps guide therapy intensity, while molecular testing—including BRCA and RAS mutations—identifies actionable targets.
The FDA-approved NALIRIFOX regimen (liposomal irinotecan, oxaliplatin, 5-FU, leucovorin) demonstrated improved outcomes over gemcitabine plus nab-paclitaxel in the NAPOLI 3 trial. Compared with FOLFIRINOX, NALIRIFOX has similar efficacy but a lower oxaliplatin dose, which may reduce neuropathy and improve tolerability, though cost limits widespread use.
For frail or older patients, the GIANT trial tested reduced-dose regimens. Patients receiving more than two doses achieved survival comparable to standard therapy, highlighting the value of dose adjustment, good nutrition, and quality-of-life management.
Ongoing clinical trials are critical to develop novel therapies, including RAS inhibitors and anti-cachexia drugs, and expanding trial access in community settings may broaden patient benefit.