Overview

This study will investigate whether or not it is feasible to closely monitor and manage glucose levels in people with pancreatic cancer. It will also investigate what impact glucose management may have on pancreatic cancer.

This is a pilot study that will use continuous glucose monitors (CGM) to monitor glucose levels in approximately 50 participants with pancreatic cancer. Participants will receive standard chemotherapy with a combination of up to four drugs to treat their pancreatic cancer: oxaliplatin, irinotecan, 5-fluorouracil, and leucovorin (FOLFIRINOX). To treat high glucose levels, participants will be randomly assigned to one of two groups: Group 1 will receive anti-hyperglycemic treatment as guided by an endocrinologist with the aim of maintaining glucose levels between 4 and 10 mmol/L; Group 2 will receive anti-hyperglycemic treatment if their glucose levels are above 15 mmol/L, which is standard care. Participants in both Groups 1 and 2 will receive standard anti-hyperglycemic treatments: metformin, insulin, glucagon-like peptide-1 (GLP-1) receptor agonists, sodium glucose co-transporter (SGLT2) inhibitors, and dipeptidyl peptidase 4 (DPP-4) inhibitors.

After 4 cycles of FOLFIRINOX, the CGM will be removed but any anti-hyperglycemic treatments will continue as needed. If participants discontinue treatment with FOLFIRINOX, they will continue to be followed for survival and subsequent anti-cancer therapy and will continue follow-up for glucose-related concerns at the discretion of their endocrinologist and/or medical oncologist.

Eligibility

Inclusion Criteria:

• Histological/cytological diagnosis of pancreatic ductal adenocarcinoma (PDAC).
• Planned to undergo first-line systemic therapy with FOLFIRINOX.
• Age greater than or equal to 18 years.
• Eastern Cooperative Oncology Group (ECOG) performance status 0-1.
• Adequate bone marrow and organ function as defined by the following laboratory values:
  1. Absolute neutrophil count (ANC) greater than or equal to 1.5 x 10^9/L.
  2. Platelet count greater than or equal to 75 x 10^9/L.
  3. Hemoglobin greater than or equal to 9.0 g/dL.
  4. Estimated glomerular filtration rate (GFR) by Cockroft-Gault equation OR 24 hour urine collection greater than or equal to 40 ml/min.
  5. Creatinine clearance greater than or equal to 40 mL/min using Cockcroft-Gault formula.
  6. Potassium within normal limits, or corrected with supplements.
  7. International normalized ratio (INR) less than or equal to 1.5.
  8. Total serum bilirubin less than or equal to 2 x upper limit of normal (ULN) (any elevated bilirubin should be asymptomatic at enrollment) except for participants with documented Gilbert's syndrome who may only be included if the total bilirubin less than or equal to 3 x ULN or direct bilirubin less than or equal to 1.5 x ULN).
  9. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) less than or equal to 2.5 x ULN (or less than or equal to 5 x ULN if liver metastases are present).
• Able to understand and voluntarily sign the informed consent form.
• Able to comply with the study visit schedule and other protocol requirements.
• Able to swallow oral medications and has no contraindications to subcutaneous insulin injections.
• Measurable or evaluable disease by Response Evaluation Criteria in Solid Tumours (RECIST) 1.1 at baseline.
• Life expectancy of more than 90 days as judged by the study doctor.

Exclusion Criteria:

• Absence of distant or lymph node metastases. Participants with borderline resectable or locally advanced PDAC are not eligible.
• Received prior systemic therapy (chemotherapy or any other anti-cancer agent) for treatment of metastatic PDAC. Participants who received adjuvant chemotherapy after surgical resection of early stage disease are eligible.
• Currently receiving anti-cancer therapy (chemotherapy or any other anti-cancer agent).
• Not fit for combination chemotherapy as judged by the study doctor.
• Presence of brain metastases.
• Known diagnosis of type I diabetes where strict glucose control and close Endocrinology follow-up is already indicated.
• Known diagnosis of type II diabetes and already followed by Endocrinologist.
• Female participants with a positive pregnancy test.
• Participants who are not safe to include in the study as judged by the study doctor for any medical or non-medical reason.
• Unable to comply with study assessments and follow-up.