What about CAR-T therapy? or other novel cell based therapies

Let me analyze the potential for CAR-T and cell-based therapies based on this patient's specific profile, while citing appropriate medical sources:

According to the document, Brian has:

• Pancreatic adenocarcinoma with lung and liver metastases
• High PDL1 expression
• An immune desert microenvironment
• MSS (Microsatellite Stable) status

Based on current evidence from authoritative sources:

1. According to the NCCN Guidelines for Pancreatic Cancer (2023), CAR-T therapy is not currently a standard treatment option for pancreatic adenocarcinoma. The guidelines focus on chemotherapy, targeted therapies, and immunotherapy combinations for metastatic disease.

2. The American Society of Clinical Oncology (ASCO) clinical practice guidelines note that while CAR-T therapy shows promise in hematologic malignancies, it has not yet demonstrated significant efficacy in solid tumors like pancreatic cancer. The "immune desert" microenvironment noted in Brian's profile typically presents additional challenges for cell-based immunotherapies.

3. According to the National Cancer Institute (NCI), clinical trials exploring CAR-T and other cell-based therapies for pancreatic cancer are ongoing, but these are still experimental. The presence of an "immune desert" microenvironment (as noted in Brian's profile) can make it particularly challenging for cell-based therapies to be effective.

Recommendation: Given Brian's molecular profile and current disease state, I would recommend:

1. Consulting with his healthcare team about clinical trials specifically targeting his RAF1 fusion and high PDL1 expression
2. Focusing on FDA-approved treatment options and clinical trials mentioned in NCCN guidelines
3. Consider seeking evaluation at major academic centers with expertise in novel immunotherapy approaches (which he is already doing at Columbia, NYU Langone, and MSK)

Always remember that treatment decisions should be made in consultation with his healthcare team, taking into account his specific clinical situation and preferences.