PAXG vs mFOLFIRINOX: Pancreatic Cancer Treatment
PAXG Chemotherapy Shows Promise in Pancreatic cancer Treatment
Updated June 02,2025
A new study suggests that PAXG chemotherapy may offer a significant advantage over the standard mFOLFIRINOX regimen for patients wiht resectable stage I-III pancreatic ductal adenocarcinoma (PDAC). The phase 3 CASSANDRA PACT-21 trial, presented at the American Society of Clinical Oncology (ASCO) 2025 Annual Meeting, revealed that PAXG significantly prolonged event-free survival in these patients.
The study’s findings, however, are prompting cautious optimism among experts.While PAXG demonstrated improved event-free survival and other key secondary outcomes, longer-term overall survival data are still needed to definitively establish it as the new standard of care for neoadjuvant treatment of pancreatic cancer.
The CASSANDRA PACT-21 trial involved 261 patients, aged 75 and younger, with previously untreated stage I-III resectable or borderline resectable PDAC. Participants were randomly assigned to receive either PAXG (capecitabine, cisplatin, nab-paclitaxel, and gemcitabine) or mFOLFIRINOX (oxaliplatin, irinotecan, leucovorin, and 5-fluorouracil) every 14 days for four months, followed by a second randomization to either additional chemotherapy or surgery.
After a median follow-up of 24.5 months in the PAXG group and 26 months in the mFOLFIRINOX group, the median event-free survival was 16 months with PAXG compared to 10 months with mFOLFIRINOX. The three-year event-free survival rate was 31% with PAXG versus 13% with mFOLFIRINOX.
PAXG appears to be the “most suitable option” for neoadjuvant treatment of these patients.
In addition to improved event-free survival, PAXG also demonstrated significant improvements in the disease control rate, CA19-9 response, pathological complete response rate, N0 resection rate, and reduced detection of intra- or postoperative metastases.
While the overall survival data are not yet mature, they currently favor PAXG over mFOLFIRINOX, with a median overall survival of 37 months versus 26 months and a three-year overall survival rate of 51% versus 40%.
Regarding adverse events,the study found no statistically significant difference between the two regimens,except for a higher rate of grade 3-4 neutropenia in the PAXG group (42% vs 29%).
While preoperative PAXG is a “very promising approach with the potential to change standard of care, more follow-up is needed, particularly overall survival data, to decide whether it should change our standard of care.”
What’s next
Experts await further data from the CASSANDRA trial, as well as results from other ongoing trials, to further refine treatment strategies for pancreatic cancer and determine the optimal therapy for these patients.