1. Use the following CASE to answer questions 1 through 3:
HP is a 72-year-old African American male with a history of chronic pancreatitis due to alcohol intake. He is also a smoker. After he complained of severe back pain and upper abdominal pain, he underwent a computed tomography (CT) scan, which found a 2-cm mass in the head of the pancreas. Endoscopic ultrasonography (EUS) and magnetic resonance imaging (MRI) have been completed and HP’s tumor has been determined to be resectable. An endoscopic retrograde cholangiopancreatography ( ERCP) procedure confirmed the histology as pancreatic ductal adenocarcinoma.
Which of the following is NOT a risk factor for pancreatic cancer?
A. Chronic pancreatitis
B. Smoking and alcohol intake
C. Older age
D. Red meat intake
E. Unsure
2. Prior to surgery, should HP undergo neoadjuvant therapy?
A. No, neoadjuvant therapy has no proven benefit and the patient is not at high risk
B. Yes, neoadjuvant therapy has clearly shown that surgical resection is better with chemoradiation prior to surgery
C. No, while neoadjuvant therapy is effective in some cases, the adenocarcinoma histology is rare and studies have not been done in patients with this type of disease
D. Yes, neoadjuvant therapy with chemotherapy plus chemoradiation followed by surgery and adjuvant therapy is the current standard of care
E. Unsure
3. HP undergoes successful surgical resection with an R0 status. Post-surgery, he is being prepped for adjuvant therapy. His Eastern Cooperative Oncology Group (ECOG) performance status is 0 and his organ function is all within normal limits. He is feeling better than he ever has. Which of the following therapies would be considered the best option for this patient for adjuvant therapy?
A. Modified FOLFIRINOX (fluorouracil [5-FU], leucovorin, oxaliplatin, and irinotecan)
B. Gemcitabine monotherapy
C. Gemcitabine plus capecitabine
D. Modified FOLFIRINOX followed by chemoradiotherapy with radiation and 5-FU
E. Unsure
4. Use the following CASE to answer questions 4 through 6: RW is a 71-year-old Caucasian male with newly diagnosed pancreatic ductal adenocarcinoma. Work-up has found metastases to the liver, peritoneum, and lungs. His tumor is BRCA1/2 positive, mismatch-repair deficient/microsatellite instability-high (dMMR/MSI-H) negative, and neurotrophic receptor tyrosine kinase (NTRK) negative. His Eastern Cooperative Oncology Group (ECOG) performance status is 1.
Based on the information provided, what is the recommended front-line therapy for RW?
A. Gemcitabine plus capecitabine
B. FOLFIRINOX (fluorouracil [5-FU], leucovorin, oxaliplatin, and irinotecan)
C. Pembrolizumab
D. Best supportive care
E. Unsure
5. After 16 weeks of therapy, RW has achieved a partial response. According to the POLO trial, which agent should RW receive as maintenance therapy?
A. Gemcitabine plus capecitabine
B. 5-FU/leucovorin
C. Larotrectinib
D. Olaparib
E. Unsure
6. After 6 months on maintenance therapy, RW relapses. His performance status remains an ECOG level 1. What is the best option for RW as second-line therapy?
A. Nanoliposomal irinotecan
B. 5-FU/leucovorin
C. Nab-paclitaxel plus gemcitabine
D. Best supportive care
E. Unsure
7. Use the following CASE to answer questions 7 through 10: HG is a 70-year-old Caucasian female with newly diagnosed ductal pancreatic adenocarcinoma that has metastasized to the lungs. From a tissue biopsy, this tumor is determined to be mismatch-repair deficient/microsatellite instability-high (dMMR/MSI-H) positive, BRCA1/2 negative, and neurotrophic receptor tyrosine kinase (NTRK) negative. Her Eastern Cooperative Oncology Group (ECOG) performance status is 2.
According to the information presented, what is most appropriate as first-line therapy for HG?
A. FOLFIRINOX (fluorouracil [5-FU], leucovorin, oxaliplatin, and irinotecan)
B. Gemcitabine plus erlotinib
C. Gemcitabine
D. Pembrolizumab
E. Unsure
8. The oncology fellow was interested to know why erlotinib was not added, since many pancreatic tumors are endothelial growth factor receptor (EGFR) positive. What is the best response to this question?
A. Erlotinib showed no benefit when given alone or in combination with fluoropyrimidine-based therapy compared with chemotherapy alone
B. Erlotinib has only shown benefit when tested with EGFR strong-positive tumors; only tumors with immunohistochemistry scores of 2+ or greater showed responses
C. Erlotinib has been determined not to be effective because K-RAS activation blocks the EGFR receptor and prevents erlotinib from binding appropriately to the receptor site
D. Erlotinib, when combined with gemcitabine, showed statistically significant, but not clinically meaningful, increases in overall survival and progression-free survival compared to gemcitabine alone
E. Unsure
9. Six months later, HG relapses. Her ECOG status has maintained at 2. What would be a reasonable second-line therapy?
A. Gemcitabine plus capecitabine
B. Gemcitabine plus erlotinib
C. FOLFIRINOX
D. Pembrolizumab
E. Unsure
10. Second-line therapy provided relief from most of HG's symptoms, and she achieved a partial response. However, 3 months later, HG relapses again. Her ECOG status is now 3. What is the best option for HG at this time?
A. Gemcitabine plus erlotinib
B. Larotrectinib
C. Best supportive care
D. Capecitabine
E. Unsure
Evaluation Questions
11. How confident are in your treatment choice for HP in the previous questions:
A. Not at all confident
B. Somewhat confident
C. Confident
D. Highly confident
12. How confident are in your treatment choice for RW in the previous questions:
A. Not at all confident
B. Somewhat confident
C. Confident
D. Highly confident
13. How confident are in your treatment choice for HG in the previous questions:
A. Not at all confident
B. Somewhat confident
C. Confident
D. Highly confident
