Stimulation With Bethanechol in Combination With Gemcitabine and Nab-paclitaxel in Pancreatic Adenocarcinoma

The purpose of this study is to determine whether the drug, bethanechol, could potentially be used in combination with chemotherapy regimen gemcitabine and nab-paclitaxel and surgery to decrease the chance of the cancer coming back after it is removed. Animal models have shown that treatment with bethanechol can inhibit cancer growth and spread. The chemotherapy regimen nab-paclitaxel for use in combination with gemcitabine to treat patients with metastatic pancreatic cancer is FDA approved. Although bethanechol is FDA approved, in this study its use is experimental. The aim of the study is to show that the medication is easy to tolerate and that it shows signs of slowing cancer cell growth. The investigators hypothesize that treatment with bethanechol will alter nerve conduction within tumors by stimulating the parasympathetic nervous system and reduce tumor proliferation, decrease CD44+ expression in cancer cells, decrease tumor growth rate resulting in an improved R0 resection rate.

• Bethanechol (Drug), also known as Bethanechol chloride tablet: Study Drug: Bethanechol (generic), supplied as 50mg oral tablets. Subjects will take 2 tablets (100mg) twice daily. Medication should be taken 1 hour before meals in AM and PM. Medication will be purchased commercially and dispensed at the research pharmacy.
• Gemcitabine (Drug): Non-experimental. Chemotherapy will be administered on a day 1, 8 and 15 schedule with gemcitabine at a dose of 1000 mg/m2
• nab-paclitaxel (Drug): Non-experimental. Chemotherapy will be administered on a day 1, 8 and 15 schedule with nab-paclitaxel dose at 125 mg/m2

Primary outcomes

• R0 resection rate [36 months]: This rate will be analyzed in patients treated with bethanechol in combination with gemcitabine and nab-paclitaxel compared to historical R0 resection rates.

Secondary outcomes

• Ki-67 expression in tumor cells [36 months]: This is to measure cell proliferation by Ki-67 expression in tumor cells, to quantify the change in tumor growth and alterations in inflammatory cytokines and immune profiles.

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* Pancreatic Ductal Adenocarcinoma
* Plan for neoadjuvant chemotherapy
* Available diagnostic tissue adequate for biomarker analysis
* Ability to tolerate PO meds and comply with study procedures

Exclusion Criteria:

* Metastatic disease
* Evidence of GI obstruction
* Baseline bradycardia (HR<55) or hypotension (systolic blood pressure<90)
* Use of acetylcholinesterase inhibitors
* Medical conditions including: hyperthyroidism, active/symptomatic coronary artery disease, seizure disorder, peptic ulcer disease.

• Susan E Bates, MD, Principal investigator, Columbia University