Locally Advanced Pancreatic Cancer

Published online May 31, 2016, DOI: 10.1200/JCO.2016.67.5561

Edward P. Balaban, Pamela B. Mangu, Alok A. Khorana, Manish A. Shah, Somnath Mukherjee, Christopher H. Crane, Milind M. Javle, Jennifer R. Eads, Peter Allen, Andrew H. Ko, Anitra Engebretson, Joseph M. Herman, John H. Strickler, Al B. Benson III, Susan Urba, and Nelson S. Yee

Purpose

To provide evidence-based recommendations to oncologists and others for treatment of patients with locally advanced, unresectable pancreatic cancer.

Methods

ASCO convened an Expert Panel of medical oncology, radiation oncology, surgical oncology, gastroenterology, palliative care, and advocacy experts and conducted a systematic review of the literature from January 2002 to June 2015. Outcomes included overall survival, disease-free survival, progression-free survival, and adverse events.

Results

Twenty-six randomized controlled trials met the systematic review criteria.

Recommendations

A multiphase computed tomography scan of the chest, abdomen, and pelvis should be performed. Baseline performance status and comorbidity profile should be evaluated. The goals of care, patient preferences, psychological status, support systems, and symptoms should guide decisions for treatments.
A palliative care referral should occur at first visit. Initial systemic chemotherapy (6 months) with a combination regimen is recommended for most patients (for some patients radiation therapy may be offered up front) with Eastern Cooperative Oncology Group performance status 0 or 1 and a favorable
comorbidity profile. There is no clear evidence to support one regimen over another. The gemcitabine-based combinations and treatments recommended in the metastatic setting (eg, FOLFIRINOX and gemcitabine plus nanoparticle albumin-bound paclitaxel) have not been evaluated in randomized controlled trials involving locally advanced, unresectable pancreatic cancer. If there is local disease progression after induction chemotherapy, without metastasis, then radiation therapy or stereotactic body radiotherapy may be offered also with a performance status of Eastern Cooperative Oncology Group ≤ 2 and an adequate comorbidity profile. If there is stable disease after 6 months of induction chemotherapy but unacceptable toxicities, radiation therapymay be offered as an alternative. Patients with disease progression should be offered treatment per the ASCO Metastatic Pancreatic Cancer Treatment Guideline. Follow-up visits every 3 to 4 months are recommended.

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