Perioperative Intervention to Reduce Metastatic Processes in Pancreatic Cancer Patients Undergoing Curative Surgery

Perioperative Use of a Beta-adrenergic Blocker and a COX-2 Inhibitor in Patients Undergoing Surgery With Primary Pancreatic Cancer: Intervention Aiming to Reduce Pro-metastatic Processes

In Israel, of the ~1000 patients diagnosed annually with pancreatic cancer (PC), approximately 250 (25 percent) will be eligible for curative surgery, of which 80 percent will succumb to post-surgical metastatic disease. A reduction in post-surgical metastatic disease will save dozens of patients in Israel annually, and tens-of thousands-around the world. The short perioperative period (days to weeks around surgery) is characterized by stress-inflammatory responses, including catecholamines (CAs, e.g., adrenaline) and prostaglandins (PGs, e.g., prostaglandin-E2) release, and induce deleterious pro-metastatic effects. Animal studies implicated excess perioperative release of CAs and PGs in facilitating cancer progression by affecting the malignant tissue, its local environment, and anti-metastatic immune functions. Congruently, our animal studies indicate that combined use of the beta-adrenergic blocker, propranolol, and the prostaglandins inhibitor, etodolac - but neither drug separately - efficiently prevented post-operative metastatic development. We recently conducted two clinical trials in three medical centers in Israel, recruiting breast (n=38) and colorectal (n=34) cancer patients, assessing the safety and short-term efficacy of perioperative propranolol and etodolac treatment. Drugs were well tolerated, without severe adverse events. Importantly, molecular/biological analyses of the excised primary tumor indicated that drug treatment caused promising anti-metastatic transformations, as well as improvements in immune and inflammatory indices. These included (i) decreased tumor cell capacity to migrate, (ii) reduced pro-metastatic capacity of the malignant tissue, and (iii) improvement in immune infiltrating into the tumor (Paper published in Clinical Cancer Research, 2017). Herein, we propose to conduct a double-blind placebo-controlled two-arm Phase II clinical trial in 210 pancreatic cancer patients undergoing curative surgery in Israel. A perioperative 35-day drug treatment will be initiated 5 days before surgery. Primary outcomes will include (i) 1-year disease-free-survival (DFS), and 5-year overall survival (OS); and (ii) biological markers in blood samples, and in the excised tumor tissue. Secondary outcomes will include safety indices and psychological measures of depression, anxiety, distress, and fatigue.

Inclusion Criteria:

• Newly diagnosed Stage I or II adenocarcinoma of the head, neck, or uncinated- process of the pancreas.
• Surgically resectable disease (R0 or R1) by spiral CT chest and abdomen scan, No distant metastases
• Eastern Cooperative Oncology Group (ECOG) Performance Status of 0 to 1
• Signed informed consent form
• Willing and able to comply with study procedures
• Men and women from age 20 up to age 80

Exclusion Criteria:

• Patients with metastatic disease, known prior to surgery

• Patients with history or concomitant malignant disease of any type (except for the current pancreatic cancer

• Patients who were treated with chemotherapy in the last 10 years for any reason

• Patients in whom surgical resection is planned without curative intent

• Patients exhibiting levels Carbohydrate antigen (CA) 19-9 above 500

• Patients with renal failure, measured by creatinine level >1.5

• Patients with significant heart failure (NYHA functional class 3 or higher),

• Patients with significant liver failure (known cirrhosis)

• Patients suffering from active asthma

• Patients with known allergy to any medication from the non-steroidal anti- inflammatory or beta-blockers drug group

• Patients treated chronically with any type of a beta-adrenergic blocker or a cyclooxygenase (COX) inhibitor

• Patients with bradycardia or second or third degree atrioventricular block (AV) block

• Patients with a history of cerebrovascular accident (CVA) or established diagnosed transient ischemic attack (TIA)

• Patients with prinzmetal's angina

• Patients with right sided heart failure owing to pulmonary hypertension

• Patients with significant diagnosed cardiomegaly

• Patients with (current) pheochromocytoma

• Patients with chronic Digoxin treatment

• Patients with active peptic disease

• Patients with peripheral vascular disease

• Pregnant woman

• Special population with impaired judgment

• Patients currently actively participating in any other clinical trial

• contraindication for Whipple procedure

• Patients suffering from sick sinus syndrome

• Patients with borderline resectable tumors, as defined by one of the following:

  • an infiltration >180° of the portal vein
  • abutment of the tumor to the superior mesenteric artery
  • infiltration of the superior mesenteric artery or the celiac trunk