DR SCHWARTZ: Yes. So this is not so much a sequencing question for me but more a practical management issue that comes up. For patients off study, do you feel comfortable relying on CA 19-9 values over imaging? Because otherwise, you end up doing very frequent imaging. And for those patients that can make CA 19-9 and have elevated values, what’s your approach?

DR TEMPERO: I usually tell patients, “Now, listen. I’ve got 3 ways to figure out if you’re getting better. Do you feel better? Does your scan look okay? And is your CA 19-9 falling?” But I say those 3 ways because I don’t trust any one of them except for the patient feeling better. That one I can trust. CA 19-9 is not a very precise test. The assays differ from place to place. In a general sense they give you a pretty good barometer of what’s going on, but it’s not perfect. And so I don’t use only that number.

DR LOVE: So before Tony answers that question, I was kind of flashing again. There’s so many other tumors, obviously, this comes up. It’s a cost issue. It’s a convenience issue. Do you think if you just use way 1 in terms of seeing how the patient’s doing, if there was a trial between way 1 and way 1, 2 and 3, do you think it really makes a difference, or how does it affect the patient in the long run?

DR TEMPERO: It does. There are many times when patients get started on treatment, they’re really sick from their disease, usually. Then you’re going to make them kind of sick from the treatment. So you’ve got a month of being really rocky, and you’re nervous and you don’t know if you’re doing the right thing.

If you see that CA 19-9 coming down, then you feel a lot better about asking the patient to go through another month worth of treatment. So that’s 1 example.

There’s another thing that occurs, which is rare but happens. It’s pseudoprogression. We are used to seeing pseudoprogression in other diseases, but pseudoprogression can actually happen in pancreatic cancer, much like in breast cancer. If you have someone with bone mets and you treat the bone mets, their bone mets look worse while they’re getting better. But having another test like the CA 19-9 help you dissect out and discriminate between real progression and pseudoprogression.