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Pancreatic cancer

What's new

The European Society of Medical Oncology (ESMO) has released an express update for the management of metastatic pancreatic cancer. Recommended first-line regimens for appropriate candidates include FOLFIRINOX and NALIRIFOX, with gemcitabine plus nab-paclitaxel as an alternative option. After FOLFIRINOX treatment, suggested regimens include gemcitabine plus paclitaxel, gemcitabine plus nab-paclitaxel, and gemcitabine monotherapy. After NALIRIFOX treatment, a gemcitabine-based regimen is suggested. .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of pancreatic cancer are prepared by our editorial team based on guidelines from the European Society of Medical Oncology (ESMO 2025,2023,2015), the American Academy of Family Physicians (AAFP 2024), the American Society for Gastrointestinal Endoscopy (ASGE 2024,2022,2021,2016), the Surgical Infection Society (SIS 2024), the European Society of Anaesthesiology and Intensive Care ...
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Screening and diagnosis

Indications for screening, general population: as per AAFP 2024 guidelines, do not obtain screening for pancreatic cancer in average-risk individuals. Do not obtain CA 19-9 in asymptomatic patients because of a very low positive predictive value.
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  • Indications for screening (genetically susceptible individuals)

  • Indications for screening (family relatives)

Classification and risk stratification

Staging: as per ESMO 2023 guidelines, use the UICC TNM 8th edition classification system for staging pancreatic cancer.
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Diagnostic investigations

History and physical examination
As per ASCO 2020 guidelines:
Obtain a careful evaluation of baseline performance status, symptom burden, and comorbidity profile in patients with pancreatic cancer.
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Obtain a full assessment of symptom burden, psychological status, and social support as early as possible, preferably at the first visit, in patients with pancreatic cancer, in order to indicate a need for a formal palliative care consultation and services in most cases.
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  • Diagnostic imaging

  • Tumor markers

  • Genetic testing

  • Imaging for staging

Diagnostic procedures

ERCP, cystic lesions: as per ASGE 2016 guidelines, consider obtaining ERCP for the diagnosis and characterization of suspected main duct intraductal papillary mucinous neoplasms.
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  • ERCP (solid lesions)

  • EUS-guided FNA (cystic lesions)

  • EUS-guided FNA (solid lesions)

  • Pancreatic biopsy

Medical management

General principles: as per AAFP 2024 guidelines, refer patients with pancreatic cancer for multidisciplinary consultation, including imaging, interventional endoscopy, oncology, surgery, genetic counseling, and palliative care.
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  • Management of resectable disease (neoadjuvant chemoradiotherapy)

  • Management of resectable disease (surgical resection)

  • Management of resectable disease (management of perioperative bleeding)

  • Management of resectable disease (adjuvant chemoradiotherapy)

  • Management of borderline resectable disease

  • Management of unresectable disease (neoadjuvant chemoradiotherapy)

  • Management of unresectable disease (definitive chemoradiotherapy)

  • Management of unresectable disease (palliative radiotherapy)

  • Management of advanced/metastatic disease (first-line therapy)

  • Management of advanced/metastatic disease (second-line therapy)

  • Management of advanced/metastatic disease (third-line therapy)

  • Management of advanced/metastatic disease (targeted therapy)

  • Management of advanced/metastatic disease (treatment duration)

  • Management of advanced/metastatic disease (thromboprophylaxis)

  • Management of advanced/metastatic disease (palliative radiotherapy)

  • Management of pain

  • Clinical trials

Nonpharmacologic interventions

Lifestyle modifications: as per ESMO 2023 guidelines, advise smoking cessation, limiting alcohol intake, and maintaining a healthy weight to reduce the risk of pancreatic cancer.
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  • Nutritional support

Therapeutic procedures

Technical considerations for radiotherapy, treatment planning: as per ASTRO 2019 guidelines, use modulated treatment techniques, such as intensity-modulated radiation therapy and volumetric modulated arc therapy, for planning and delivery of both conventionally fractionated and hypofractionated radiotherapy in patients with localized pancreatic cancer.
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  • Technical considerations for radiotherapy (premedication)

  • Technical considerations for radiotherapy (respiratory motion management)

  • Technical considerations for radiotherapy (image guidance)

  • Management of biliary obstruction (endoscopic stenting)

  • Management of biliary obstruction (EUS-guided procedures)

Perioperative care

Perioperative antibiotic prophylaxis
As per SIS 2024 guidelines:
Administer targeted perioperative antibiotic prophylaxis based on a positive preoperative bile culture in patients undergoing surgical procedures for hepatopancreatobiliary malignant disease.
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Consider continuing antibiotic prophylaxis for at least 24 hours in patients undergoing pancreatoduodenectomy with positive bile cultures following preoperative biliary drainage to prevent organ-space surgical site infection.
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Patient education

General counseling
As per ASCO 2020 guidelines:
Discuss the goals of care (including a discussion of an advance directive), patient preferences, and support systems with all patients with pancreatic cancer and their caregivers.
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Inform all patients with pancreatic cancer about clinical trials, including therapeutic trials in all lines of treatment, as well as palliative care, biorepository/biomarker, and observational studies.
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  • Genetic counseling

Follow-up and surveillance

Assessment of treatment response: as per ASCO 2020 guidelines, obtain imaging, preferably contrast-enhanced CT, at 2-3 months from the initiation of treatment to assess the first response in patients on active cancer-directed therapy outside of a clinical trial. Obtain clinical assessment thereafter, conducted frequently during visits for cancer-directed therapy, to replace imaging.
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  • Follow-up