# FOLFIRINOX / mFOLFIRINOX

Source: https://onco.cc/drugs/folfirinox/  
OnCo record `folfirinox` (Treatment). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

FOLFIRINOX is a four-drug chemotherapy combination that, in 2011, became the first treatment to meaningfully extend life in metastatic pancreatic cancer; it is now the standard before and after surgery.

## Summary

Oxaliplatin, irinotecan, leucovorin, and 5-fluorouracil. PRODIGE 4/ACCORD 11 (2011): OS 11.1 vs 6.8 months versus gemcitabine in fit metastatic patients. Modified FOLFIRINOX (PRODIGE 24, 2018) became the adjuvant standard after resection with median OS ~54 months, and is the most used neoadjuvant regimen for borderline-resectable disease. Toxicity (neutropenia, diarrhoea, neuropathy) restricts it to ECOG 0-1 patients. NALIRIFOX (liposomal irinotecan) is a 2024 variant for metastatic disease.

## Fields

- Kind: Treatment
- Status: standard-of-care
- Last checked: 2026-09-06
- Modality: Cytotoxic regimen
- Mechanism: DNA crosslinking (oxaliplatin), topoisomerase-I inhibition (irinotecan), antimetabolite (5-FU with leucovorin modulation).
- Approvals: Global 2011: Metastatic PDAC (PRODIGE 4 / ACCORD 11; component drugs generic)

## Notes

- Pancreatic cancer, UK status: NICE NG85 1.9.4 offers FOLFIRINOX to people with metastatic disease and ECOG performance status 0 to 1 (recorded as an off-label use in February 2018), and modified FOLFIRINOX is given as adjuvant treatment on PRODIGE 24 although NG85 (2018) predates that trial and names gemcitabine plus capecitabine. Regulator status: a combination of individually licensed generic medicines with no single marketing authorisation. Four months of FOLFIRINOX followed by fluorouracil and leucovorin maintenance is an accepted alternative to six months (PANOPTIMOX-PRODIGE 35).

## Sources

- Wikipedia: https://en.wikipedia.org/wiki/FOLFIRINOX
- Wikipedia: https://en.wikipedia.org/wiki/FOLFIRINOX
- NICE NG85 recommendation 1.9.4: https://www.nice.org.uk/guidance/ng85/chapter/Recommendations
- Conroy et al., PRODIGE 4/ACCORD 11 (NEJM 2011): https://doi.org/10.1056/NEJMoa1011923
- Conroy et al., PRODIGE 24 five-year outcomes (JAMA Oncology 2022): https://doi.org/10.1001/jamaoncol.2022.3829

## Connected records

- cancers: [Adenosquamous carcinoma of the pancreas](https://onco.cc/cancers/pancreatic-adenosquamous-carcinoma/), [Ampullary cancer (ampulla of Vater)](https://onco.cc/cancers/ampullary/), [Borderline resectable pancreatic ductal adenocarcinoma](https://onco.cc/cancers/borderline-resectable-pdac/), [BRCA or PALB2-mutant pancreatic ductal adenocarcinoma](https://onco.cc/cancers/brca-palb2-pdac/), [Colloid (mucinous non-cystic) carcinoma of the pancreas](https://onco.cc/cancers/pancreatic-colloid-carcinoma/), [Intraductal papillary mucinous neoplasm and other pancreatic cystic precursors](https://onco.cc/cancers/ipmn-cystic-precursors/), [Invasive carcinoma arising in an intraductal papillary mucinous neoplasm (IPMN-associated carcinoma)](https://onco.cc/cancers/ipmn-associated-carcinoma/), [KRAS G12C-mutant pancreatic ductal adenocarcinoma](https://onco.cc/cancers/kras-g12c-pdac/), [KRAS wild-type pancreatic ductal adenocarcinoma](https://onco.cc/cancers/kras-wild-type-pdac/), [Locally advanced unresectable pancreatic ductal adenocarcinoma](https://onco.cc/cancers/locally-advanced-pdac/), [Metastatic pancreatic ductal adenocarcinoma](https://onco.cc/cancers/metastatic-pdac/), [Mismatch repair deficient (MSI-high) pancreatic ductal adenocarcinoma](https://onco.cc/cancers/msi-high-pdac/), [Mucinous cystic neoplasm of the pancreas with associated invasive carcinoma (MCN-associated carcinoma)](https://onco.cc/cancers/mcn-associated-carcinoma/), [Pancreatic acinar cell carcinoma](https://onco.cc/cancers/pancreatic-acinar-cell-carcinoma/), [Pancreatic ductal adenocarcinoma](https://onco.cc/cancers/pancreatic/), [Resectable pancreatic ductal adenocarcinoma](https://onco.cc/cancers/resectable-pdac/), [Undifferentiated carcinoma of the pancreas with osteoclast-like giant cells](https://onco.cc/cancers/pancreatic-undifferentiated-carcinoma-ogc/)
- technologies: [Cytotoxic chemotherapy](https://onco.cc/technologies/cytotoxic-chemotherapy/), [Platinum agents](https://onco.cc/technologies/platinum/), [Topoisomerase-I inhibitors (and ADC payloads)](https://onco.cc/technologies/topoisomerase-inhibitors/)
- trials: [24BRO681 : Alternating Gnp and mFOLFIRINOX for BR-PDAC](https://onco.cc/trials/nct07043270/), [A Clinical Trial Testing the Safety of Pumitamig (an Investigational Drug) and How Well it Works When Combined With Chemotherapy for People Who Have N](https://onco.cc/trials/nct07255404/), [A Phase II Study Evaluating BMS-986504 in MTAP-deleted Pancreatic Cancer](https://onco.cc/trials/nct07283705/), [Adjuvant mFOLFIRINOX for High-risk Stage III Colon Cancer](https://onco.cc/trials/nct05179889/), [Alliance A021501](https://onco.cc/trials/alliance-a021501/), [Alliance A021806](https://onco.cc/trials/alliance-a021806/), [Autogene cevumeran phase 1 in resected pancreatic cancer (Memorial Sloan Kettering)](https://onco.cc/trials/autogene-cevumeran-phase-1/), [AVENGER 500](https://onco.cc/trials/avenger-500/), [Basal-like PDAC Treated With Gemcitabine, Erlotinib, and Nab-paclitaxel](https://onco.cc/trials/nct06483555/), [Bortezomib Combined with PD-1 MAb and MFOLFIRINOX for Metastatic Pancreatic Cancer](https://onco.cc/trials/nct06572813/), [CONKO-007](https://onco.cc/trials/conko-007/), [CROSSFIRE](https://onco.cc/trials/crossfire/), [ESPAC-5](https://onco.cc/trials/espac-5/), [LAPIS](https://onco.cc/trials/lapis-trial/), [mFOLFIRINOX as Adjuvent Chemotherapy in Treating Chinese Pancreatic Cancer Patients](https://onco.cc/trials/nct04084496/), [Modulation of the Gut Microbiome With Pembrolizumab Following Chemotherapy in Resectable Pancreatic Cancer](https://onco.cc/trials/nct05462496/), [NAPOLI 3](https://onco.cc/trials/napoli-3/), [Neoadjuvant FOLFIRINOX and Preoperative Chemoradiotherapy for Locally Advanced Rectal Cancer Patients](https://onco.cc/trials/nct06812728/), [Neoadjuvant Folfirinox Combined With Pembrolizumab Followed by Surgery for Patients With Resectable Pancreatic Cancer](https://onco.cc/trials/nct05132504/), [Neoadjuvant Triple Therapy for (Borderline) Resectable Pancreatic Cancer (PREOPANC-5)](https://onco.cc/trials/nct06384560/), [NeoFOL-R Trial (Perioperative Versus Adjuvnat FOLFIRINOX in Resectable Pancreatic Cancer)](https://onco.cc/trials/nct05529940/), [NEOLAP](https://onco.cc/trials/neolap/), [Nimotuzumab Combined With mFOLFIRINOX/GX as Postoperative Adjuvant Therapy in Pancreatic Cancer](https://onco.cc/trials/nct06389760/), [NORPACT-1](https://onco.cc/trials/norpact-1/), [PANOPTIMOX-PRODIGE 35](https://onco.cc/trials/panoptimox-prodige-35/), [Personalizing Chemotherapy Selection After Surgery for Patients With Stage III Colorectal Cancer Using a Blood Test](https://onco.cc/trials/nct07340567/), [Precision Promise](https://onco.cc/trials/precision-promise/), [PREOPANC-2](https://onco.cc/trials/preopanc-2/), [PREOPANC-3](https://onco.cc/trials/preopanc-3/), [PRODIGE 24 / CCTG PA6](https://onco.cc/trials/prodige-24/), [PRODIGE 4 / ACCORD 11](https://onco.cc/trials/prodige-4-accord-11/), [Study to Evaluate the Safety, Tolerability & Efficacy of TNG462 in Combination in PDAC & NSCLC Patients](https://onco.cc/trials/nct06922591/), [Surufatinib in Combination With Iparomlimab and Tuvonralimab Injection and AG Chemotherapy for Neoadjuvant Therapy of HRPC or BRPC](https://onco.cc/trials/nct07833241/), [Surufatinib Plus mFOLFIRINOX and PD-1 Inhibitor as the Neoadjuvant Therapy for High-risk or Borderline Resectable Pancreatic Cancer](https://onco.cc/trials/nct07469956/), [SWOG S1505](https://onco.cc/trials/swog-s1505/)
- ideas: [Chemotherapy before surgery for every resectable pancreatic cancer, settled by the two perioperative trials rather than assumed](https://onco.cc/ideas/idea-pdac-neoadjuvant-chemotherapy-for-all-resectable-disease/), [Embed cachexia treatment in chemotherapy trials: weight, muscle and treatment delivery as co-primary endpoints](https://onco.cc/ideas/idea-pdac-cachexia-trials-embedded-in-chemotherapy-trials/), [RAS inhibitor combinations and sequence: pan-RAS plus G12D-selective, plus chemotherapy, and what to give after progression](https://onco.cc/ideas/idea-pdac-ras-inhibitor-combinations-and-sequencing/), [RAS(ON) inhibitors to convert unresectable pancreatic cancer to resectable](https://onco.cc/ideas/idea-ras-inhibitor-neoadjuvant-pdac/)
- terms: [Classical versus basal-like (squamous) subtypes of pancreatic cancer, and GATA6](https://onco.cc/terms/classical-vs-basal-like/), [Living with FOLFIRINOX, NALIRIFOX and gemcitabine with nab-paclitaxel](https://onco.cc/terms/chemotherapy-side-effects-pancreatic/), [Neoadjuvant therapy versus surgery first for resectable and borderline resectable pancreatic cancer](https://onco.cc/terms/neoadjuvant-versus-upfront-surgery-pancreatic/), [Pancreatic cancer drugs in England: NICE appraisals and the Cancer Drugs Fund (September 2026)](https://onco.cc/terms/pancreatic-cancer-uk-drug-access/)
- people: [Paula Ghaneh](https://onco.cc/people/paula-ghaneh/)
- drugs: [FOLFOX (5-FU, leucovorin, oxaliplatin)](https://onco.cc/drugs/folfox/)
- key papers: [Alliance A021501: preoperative modified FOLFIRINOX with or without hypofractionated radiotherapy for borderline resectable pancreatic cancer](https://onco.cc/key-papers/paper-alliance-a021501-mfolfirinox-radiotherapy-borderline-resectable-jama-oncol-2022/), [ESPAC5: immediate surgery versus short-course neoadjuvant chemotherapy or chemoradiotherapy for borderline resectable pancreatic cancer](https://onco.cc/key-papers/paper-espac-5-neoadjuvant-borderline-resectable-pancreatic-lancet-gastro-hep-2023/), [Five-Year Outcomes of FOLFIRINOX vs Gemcitabine as Adjuvant Therapy for Pancreatic Cancer: A Randomized Clinical Trial](https://onco.cc/key-papers/paper-prodige-24-five-year-outcomes-jama-oncol-2022/), [FOLFOXIRI plus bevacizumab versus FOLFIRI plus bevacizumab as first-line treatment of patients with metastatic colorectal cancer: updated overall survival and molecular subgroup analyses of TRIBE](https://onco.cc/key-papers/paper-cremolini-tribe-folfoxiri-bevacizumab-lancet-oncol-2015/), [GATA6 expression distinguishes classical and basal-like subtypes in advanced pancreatic cancer](https://onco.cc/key-papers/paper-okane-gata6-basal-like-compass-ccr-2020/), [Genomic methods identify homologous recombination deficiency in pancreas adenocarcinoma and optimize treatment selection](https://onco.cc/key-papers/paper-park-hrd-pancreatic-platinum-ccr-2020/), [Genomics-driven precision medicine for advanced pancreatic cancer: early results from the COMPASS trial](https://onco.cc/key-papers/paper-aung-compass-early-results-ccr-2018/), [Neoadjuvant chemotherapy with FOLFIRINOX and preoperative chemoradiotherapy for patients with locally advanced rectal cancer (UNICANCER-PRODIGE 23)](https://onco.cc/key-papers/paper-conroy-prodige-23-neoadjuvant-folfirinox-rectal-lancet-oncol-2021/), [Neoadjuvant FOLFIRINOX versus neoadjuvant gemcitabine-based chemoradiotherapy in resectable and borderline resectable pancreatic cancer (PREOPANC-2): a multicentre, open-label, phase 3 randomised trial](https://onco.cc/key-papers/paper-preopanc-2-neoadjuvant-folfirinox-vs-chemoradiotherapy-lancet-oncol-2025/), [NORPACT-1: neoadjuvant FOLFIRINOX versus upfront surgery for resectable pancreatic head cancer](https://onco.cc/key-papers/paper-norpact-1-neoadjuvant-folfirinox-labori-lancet-gastroenterol-hepatol-2024/), [Overall survival and clinical characteristics of pancreatic cancer in BRCA mutation carriers](https://onco.cc/key-papers/paper-golan-brca-pancreatic-platinum-survival-bjc-2014/), [Potentially Curable Pancreatic Adenocarcinoma: ASCO Clinical Practice Guideline Update](https://onco.cc/key-papers/paper-asco-potentially-curable-pancreatic-guideline-update-jco-2019/), [PRODIGE 24/CCTG PA6: adjuvant modified FOLFIRINOX versus gemcitabine after resection of pancreatic cancer](https://onco.cc/key-papers/paper-prodige-24-adjuvant-mfolfirinox-pancreatic-nejm-2018/), [Purity Independent Subtyping of Tumors (PurIST), a clinically robust, single-sample classifier for tumor subtyping in pancreatic cancer](https://onco.cc/key-papers/paper-rashid-purist-pancreatic-subtype-classifier-ccr-2020/), [RNA neoantigen vaccines prime long-lived CD8+ T cells in pancreatic cancer](https://onco.cc/key-papers/paper-sethna-rna-neoantigen-vaccine-long-lived-t-cells-nature-2025/)
- roadmaps: [Pancreatic cancer roadmap: from Whipple's operation to gemcitabine, FOLFIRINOX, adjuvant chemotherapy, PARP inhibition, KRAS inhibition, vaccines and the surveillance question](https://onco.cc/roadmaps/pancreatic-roadmap/)
- pathways: [Pancreatic cancer (KEGG map)](https://onco.cc/pathways/pancreatic-cancer-signalling/)

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