My treatment that successfully treated stage IV PACC was using the original version of Folfirinox (20% higher) than (m)Folfirinox well beyond 12 cycles. An interesting history of how 12 was picked for number of cycles. It was an ASCO working committee of Pancretic oncologists that when asked the question of how many cycles was it felt to achieve N.E.D. and the patients could tolerate the side effects. And that’s how 12 was selected.

The problem with that is that N.E.D. is determined by using a conventional imaging technique (CT, MRI or PET). All have a lower limit to sensitivity of detection. So the can and likely is minimal residual disease (MRD) remaining (micrometastatic disease) when stopping for 12. My physical condition was otherwise very good and I advocated for doing as much Folfirinox as my body could tolerate. My oncologist was concerned with chemo induced peripheral neuropathy and it becoming permanent, so he did dosing of the first six cycles at full dose and then the next six cycles were just 5-Fluorouricil and Leucovorin at full dose. After those ‘“resting” cycles which were also effective against the tumors, it was back to full-dose Folfirinox. The alternating group of six cycles continued over 24 months resulting in a total of 46 chemo cycles with 24 being full dose Folfirinox and 22 of 5-FU/Leucovorin.

While I did develop neuropathy, it was not as severe as the average patient. It eventually resolved fully after several years. The aggressive treatment was determined to result in cure. I went on a PARPi after cycles 46 to prevent development of a new primary tumor as well as two other types.