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Summarizing discussion and future perspectives1136mutation olaparib can be considered after FOLFIRINOX based on PFS benefit in the POLO trial although no significant OS benefit was observed (21). The OS of patients retreated with FOLFIRINOX without maintenance therapy in our cohort does not seem detrimental compared to the survival rates in the maintenance studies, although these data cannot be directly compared. Drawing conclusions from our cohort study is challenging because of the diverse patient population found in a realworld cohort comprising all individuals who received systemic therapy for PDAC in the Netherlands. The database was based on information registered in the medical charts without strict inclusion criteria, uniform registration of given treatments and response monitoring such as used in clinical trials. We did not compare our patients with those who initiated a different second-line treatment because our primary focus was on patients who underwent retreatment with FOLFIRINOX, rather than those with FOLFIRINOX-resistant disease. The small subgroup of patients that was retreated with FOLFIRINOX experienced stable disease or response during first line FOLFIRINOX as best response and a favorable OS (with a large range in OS and treatment cycles). To further identify patients who could particularly benefit from this approach, we looked at characteristics of patients that either stopped or died 30 days after restarting FOLFIRINOX. In these patients (approximately 20% of the patients in which FOLFIRINOX was reintroduced), the therapy-free interval after firstline FOLFIRINOX was shorter (5.4 vs. 7.1 months) compared to patients who were treated > 30 days with FOLFIRINOX reintroduction.Despite all the limitations of a retrospective cohort study, the results described in chapter 3 can be used as background information to provide answers of real world outcomes to patients who are eligible and consider retreatment with FOLFIRINOX. Also the knowledge that a drug holiday of many months is used in selected patients with reasonable outcomes can be useful. The ideal second-line systemic therapy for patients who remain in good clinical condition after FOLFIRINOX failure (FOLFIRINOX resistant PDAC) remains uncertain. Retrospective data reported an OS of 11.5 months with gemcitabine-based therapy following FOLFIRINOX resistance (22). Liposomal irinotecan and 5-FU/leucovorin are approved for use in metastatic PDAC patients previously treated with gemcitabinebased therapy, based on improved median OS compared to 5-FU/LV alone in the NAPOLI-1 trial (OS 6.2 vs 4.2 months; HR 0.75) (23). A Dutch cohort study reported a median OS of 11.2 months with various second-line systemic therapies (20). Best supportive care is considered for patients in moderate condition.