A Randomized Phase II Trial Comparing Molecularly Tailored Therapy to Physician's Discretion Standard of Care as Second-Line Therapy for Patients With Metastatic Pancreatic Cancer

• Histologically confirmed metastatic adenocarcinoma of the pancreas (at enrollment)

• Actively on (or about to initiate) first line therapy for metastatic pancreatic cancer (at enrollment)

‣ Patients may have had neo-adjuvant and/or chemotherapy that must have been completed \>3 months prior to starting first line therapy

⁃ Patients may be actively on maintenance therapy, such as maintenance capecitabine up to starting first line therapy for metastatic disease

• Radiographically measurable disease (prior to initiation of second-line therapy)

• Tumor deposits that are clearly accessible for serial tumor biopsies - A patient's biopsied lesion must be at least 1cm in diameter (in at least one dimension) (prior to initiation of second-line therapy)

• Age ≥ 18 years (at enrollment)

• Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1 (Table 6, Appendix D) (at enrollment)

• Adequate hepatic, bone marrow, and renal function at the time of enrollment AND at initiation of second line therapy:

‣ Bone Marrow: Absolute neutrophil count (ANC) ≥ 1,500/mm3; Platelets ≥ 75,000/mm3; Hemoglobin ≥ 9.0 g/dL

⁃ Patients may have a transfusion of red blood cells to meet the hemoglobin requirement

⁃ Renal function: Serum creatinine ≤ 1.5 X upper normal limit of institution's normal range OR creatinine clearance ≥ 50 mL/min/1.73 m2 for subjects with creatinine levels above institutional normal

⁃ Hepatic function: Aspartate transaminase (AST) and Alanine transaminase (ALT) ≤ 3 X the upper normal limit of institution's normal range; bilirubin ≤ 1.5 X the upper limit of normal. For patients with known hepatic metastases, AST and ALT ≤ 5 X the upper normal limit of institution's normal range

⁃ Prothrombin Time and Partial Thromboplastin Time (PTT) must be ≤ 2 X the upper limit of the institution's normal range and International Normalized Ratio (INR) \< 2. Subjects on anticoagulation (such as coumadin) will be permitted to enroll as long as the INR is in the acceptable therapeutic range as determined by the investigator

• Patients must have fully recovered from all effects of surgery (prior to initiation of second-line therapy). Patients must have had at least two weeks after minor surgery and four weeks after major surgery before starting therapy. Minor procedures requiring Twilight sedation such as endoscopies or mediport placement may only require a 24-hour waiting period, but this must be discussed with an investigator.

• Women of childbearing potential must have a negative serum pregnancy test within 14 days prior to initiation of treatment and/or postmenopausal women must be amenorrheic for at least 12 months to be considered of non-childbearing potential (at enrollment).

⁃ Subject is capable of understanding and complying with parameters as outlined in the protocol and able to sign and date the informed consent, approved by the Institutional Review Board (IRB), prior to the initiation of any screening or study-specific procedures (at enrollment).