Treatment Name: FOLFIRINOX (Fluorouracil + Leucovorin + Irinotecan + Oxaliplatin)
FOLFIRINOX (Fluorouracil + Leucovorin + Irinotecan + Oxaliplatin) is a Chemotherapy Regimen for Pancreatic Cancer
How does FOLFIRINOX work?
Each of the medications in FOLFIRINOX are designed to kill cancer cells or slow their growth and ability to multiply.
FOL - folinic acid (leucovorin)
F - fluorouracil (5-FU)
IRIN - irinotecan (Camptosar)
OX – oxaliplatin (Eloxatin)
Goals of therapy:
FOLFIRINOX is most commonly given to decrease symptoms and extend life when the disease is advanced pancreatic cancer or, metastatic, which means: spread beyond the pancreas and lymph nodes. FOLFIRINOX chemotherapy is not commonly given with the goal of cure. In rare instances, FOLFIRINOX can be given to shrink tumors early in treatment with the goal of then removing the cancer by surgery leading to better overall survival or a cure.
Olaparib (Lynparza®) may be given to some patients after at least 16 weeks of therapy with FOLFIRINOX. Metastatic pancreatic cancer patients with BRCA mutations who’s disease has not progressed while on FOLFIRINOX may be candidates for olaparib maintenance therapy. The goal of olaparib is not cure, but to slow the progression of pancreatic cancer.
- Oxaliplatin intravenous (I.V.) infusion is given over 2 hours on Day 1
- Folinic acid (Leucovorin) I.V. infusion is given over 2 hours on Day 1
- Irinotecan I.V. infusion is given over 90 minutes on Day 1
- Fluorouracil (5-FU) I.V. push, is usually given over 3 to 5 minutes on Day 1
- Fluorouracil (5-FU) continuous I.V. infusion is given via home-infusion pump over 46 hours beginning Day 1
Estimated total infusion time for FOLFIRINOX treatment:
- Total infusion time usually takes up to 50 hours, but typically only up to 5 hours are spent in the outpatient infusion center and the rest is spent at home receiving chemotherapy via home-infusion pump
- Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and I.V. fluids, such as hydration, may add more time
FOLFIRINOX cancer treatment is usually given in an outpatient infusion center, allowing the person to go home afterwards.
Each two-day FOLFIRINOX treatment is repeated every 14 days (two weeks). This is known as one Cycle. Each cycle may be repeated up to 12 times. Duration of therapy may last up to six months, depending upon response, tolerability, and number of cycles prescribed.
Click for the common FOLFIRINOX starting doses.
In a multi-drug regimen, each medication has unique side effects. When these medicines are given together, drug-related side effects reported in clinical studies give the best estimate of what to expect. In clinical studies, the most common drug side effects with FOLFIRINOX are shown here. The percentages represent only the most severe incidences of side effects reported in clinical trials:
- Low white blood cells [neutropenia], (46%)
- Fatigue, (24%)
- Vomiting, (15%)
- Diarrhea, (13%)
- Increased bleeding risk [Low platelets], (9%)
- Numbness in fingers or toes [numbness or tingling], (9%)
- Anemia [Low red blood cells], (8%)
- Decreased Liver function, (7%)
- Blood clots, (7%)
- Neutropenic fever, (5%)
How often is monitoring needed?
Labs (blood tests) may be checked before each treatment. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), plus any others your doctor may order. The CA19-9 (a tumor marker) is usually checked using a blood test at the beginning of treatment, then about every eight weeks thereafter to determine response rate, which means: are the chemotherapy drugs working?
How often is imaging needed?
Imaging may be checked before treatment and may be checked periodically during treatment and after completion of treatment. Imaging may include: X-rays, magnetic resonance imaging (MRI), computerized tomography (CT) scans, or positron emission tomography (PET) scans.
How might blood test results/imaging affect treatment?
Depending upon the results, your doctor may advise to continue FOLFIRINOX as planned, or delay or switch therapy.
- The cancer patient will have an infusion pump strapped to their body for 2 days to allow fluorouracil (5-FU) to continuously infuse into a vein. The I.V. line is connected at the end of the Day 1 chemotherapy session by a nurse and the patient is able to go home, if not home already. When the two-day continuous infusion is finished, the patient will have to go back to the infusion center or hospital to have it disconnected unless a home health nurse comes to the patient’s home to do this
- Diarrhea caused by irinotecan is treated with atropine injections in the medical setting, both before and after the irinotecan infusion. Diarrhea at home is commonly treated with loperamide purchased over-the-counter at a pharmacy. You may receive special instructions on how to use loperamide for diarrhea caused specifically by irinotecan. Tell your doctor immidiately of you have severe diarrhea at home or go to an emergency department immediately
- Oxaliplatin can make you very sensitive to cold things such as cold drinks or cold weather for a few days after receiving oxaliplatin. It is best to wear warm clothes in cold weather and to not drink cold liquids, especially those with ice, or hold cold objects in your hands for up to 2 days after each oxaliplatin infusion
- A pharmacist should ALWAYS review your medication list to ensure that drug interactions are prevented or managed appropriately
- Clinical trials may exist for pancreatic cancer. Ask your doctor if any studies are currently enrolling in your area. If not, go to clinicaltrials.gov to search for other centers offering treatments for pancreatic cancer
Patient Assistance & Co-payment Coverage
Patients under the age of 65 years, or those with private insurance plans:
If you have insurance and are looking for patient assistance or copay assistance for FOLFIRINOX (Fluorouracil + Leucovorin + Irinotecan + Oxaliplatin), we have provided links that may help.
Visit our Patient Assistance page and click the links to various patient assistance programs for help paying for FOLFIRINOX (Fluorouracil + Leucovorin + Irinotecan + Oxaliplatin). Depending upon your income, they may be able to help cover the cost of:
- Folinic acid
For Branded medications (may be available for generic medications too), check with the manufacturer to determine if a co-pay card is offered and if it could reduce your monthly copay.
- If you are uninsured, check with the manufacturer to determine if you are eligible to receive medication at no cost.
Medicare and Medicaid patients (Patients 65 years or older):
The clinic providing treatment will likely pre-authorize medications and immune therapies such as FOLFIRINOX (Fluorouracil + Leucovorin + Irinotecan + Oxaliplatin) and are the best source to help you understand drug cost.
- Ask to speak with a patient assistance technician or financial counselor at the clinic or hospital administering this therapy.
What is Emotional Wellness?
Emotional wellness is having a positive outlook balanced with a realistic understanding of current life events. This requires both an awareness and acceptance of your emotions. It is with this knowledge that you can develop a plan to take the necessary actions to positively impact your life.
Emotional wellness uses an ongoing process to continually reflect on the stressors of life in a constructive manner to move forward and create happiness.
Because emotional wellness is deeply connected with physical, social, and spiritual wellness, pursuing it often becomes particularly difficult in times of major illness. Despite this difficulty, working toward emotional wellness has been connected to improved treatment outcomes and a higher likelihood of achieving goals of therapy.
Learn more about pursuing emotional wellness while receiving treatment with FOLFIRINOX (Fluorouracil + Leucovorin + Irinotecan + Oxaliplatin)
What is Pancreatic Cancer?
A disease of the cells of the pancreas organ. There are different types of pancreatic cancer, the most common being pancreatic adenocarcinoma that accounts for about 85% of cases. This type affects the digestive enzymes produced by the pancreas. Risk factors include: smoking tobacco, obesity, diabetes, and some rare genetic conditions. It can spread to neighboring organs such as: liver, duodenum, stomach, colon, spleen, and kidneys.
Pancreatic cancer is treated with surgery, chemotherapy, radiation therapy, a combination of all these, or sometimes supportive care alone. Surgery can be curative, but it can also be used to reduce tumor size and improve quality of life. The stage can vary at diagnosis and throughout treatment. The Tumor, Node, Metastasis (TNM) staging system is used to stage pancreas cancer. Staging systems describe the extent of cancer throughout the body and help doctors determine which treatments to offer. The effectiveness of the treatment may depend upon the stage at diagnosis.
NOTE: Treatment Options listed below are not all-inclusive. Other treatments may be available. ChemoExperts provides drug information and does not recommend any one treatment over another. Only your Doctor can choose which therapy is appropriate for you.
What does "Cure" mean?
The word “cure” means there are no cancer cells left in the body and cancer will never come back. Depending on the cancer type and stage, this may be the true goal of therapy. However, it is very difficult to prove all cancer cells are gone. Even though images, like X-rays and MRI’s, and blood tests may not show any signs of cancer, there can be a small amount of cancer cells still left in the body. Because of this, doctors use the word “remission” is used more often. This means there are no signs or symptoms of cancer. Patients in remission are followed closely for any signs of cancer returning. Sometimes, more chemotherapy may be given while in remission to prevent the cancer from coming back.
Doctors usually do not consider a patient “cured” until the chance of cancer returning is extremely low. If cancer does return, it usually happens within 5 years of having a remission. Because of this, doctors do not consider a patient cured unless the cancer has not come back within 5 years of remission. The five-year cutoff does not apply to all cancers.
Common Starting Doses
- Oxaliplatin 85 mg/m2 intravenous (I.V.) infusion is given over 2 hours on Day 1
- Folinic acid (Leucovorin) 400 mg/m2 I.V. infusion is given over 2 hours on Day 1
- Irinotecan 180 mg/m2 I.V. infusion is given over 90 minutes on Day 1
- Fluorouracil 400 mg/m2 I.V. push, is usually given over 3 to 5 minutes on Day 1
- Fluorouracil 2400 mg/m2 continuous I.V. infusion is given via home-infusion pump over 46 hours beginning Day 1 and ending on Day 2
If you are interested in reading the clinical trials results, please click on reference below:
Conroy T, Desseigne F, Ychou M, et al. FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med. 2011;364:1817-1825.
What is a CBC?
A Complete Blood Count (CBC) is a frequently ordered blood test that tells clinicians the status of your: 1) White blood cell count, 2) Hemoglobin, and 3) Platelet count at the time the test was taken.
1) White blood cell count (WBC): is used to determine infection risk, or response to chemotherapy. Certain chemotherapy agents may harm our good infection-fighting cells. Sometimes chemotherapy may need to be delayed to allow these cells to recover.
2) Hemoglobin: is used to determine if someone is anemic. Anytime the hemoglobin is below 12 g/dL, the person is said to be anemic. Red blood cell transfusions, and sometimes iron can be given to restore the hemoglobin level, but anemia treatment should always aim at treating the underlying cause or condition.
3) Platelet count: is used to determine if the risk of bleeding is increased or if a platelet transfusion is required to prevent bleeding. Certain medications that increase bleeding risk, such as: aspirin, certain chemotherapy agents, and blood thinners, may need to be stopped temporarily until the platelet count is within a safe range.
What is a CMP?
A Comprehensive Metabolic Panel (CMP) is a frequently ordered blood test that tells clinicians the status of your: 1) Electrolytes & Acid/Base status, 2) Kidney function, 3) Liver function, 4) Blood sugar, and 5) Calcium at the time the test was taken. It is commonly used to monitor liver and kidney function when beginning new medications such as chemotherapy. A total of 14 tests are run simultaneously and are shown below.
Electrolytes & Acid/Base status:
1) Sodium, 2) Potassium, 3) Carbon dioxide, 4) Chloride
5) BUN (blood urea nitrogen), 6) Serum creatinine (Scr)
7) AST, 8) ALT, 9) Total bilirubin, 10) Alk Phos, 11) Albumin, 12) Total protein
13) Serum glucose
14) Serum calcium