The American Society of Clinical Oncology (ASCO) has released a clinical practice guideline for the treatment of patients with localized pancreatic cancer, published in the Journal of Clinical Oncology.
A panel of medical oncology, radiation oncology, surgical oncology, palliative care, and advocacy experts reviewed literature from January 2002 to June 2015. In total, 9 randomized controlled trials met the systemic review criteria and were used to develop the guideline.
The guideline includes the following recommendations when dealing with patients with potentially curable pancreatic cancer:
- Patients should undergo a multiphase CT scan of the abdomen and pelvis using a pancreatic protocol or an MRI to assess the anatomic relationships of the primary tumor and the presence of intra-abdominal metastases. A serum level of CA 19-9 and baseline standard laboratory studies should be obtained.
- The baseline performance status, symptom burden, and comorbidity profile should be assessed in each patient.
- The goals of care, patient preferences, and supports systems should be discussed with the patient and their caregivers.
- The standard of care should be multidisciplinary collaboration to determine treatment, care plans, and disease management.
- Patients should be offered information about clinical trials, including those in all lines of treatment, as well as palliative care, biorepository/biomarker, and observational studies.
- Preoperative therapy is recommended if a patient meets any of the following criteria:
- Radiographic findings that are suspicious but not diagnostic for extrapancreatic disease
- A performance status or comorbidity that is not currently appropriate for a major abdominal operation (if the status/comorbidity is potentially reversible)
- Radiographic interference between the primary tumor and mesenteric vasculature on cross-sectional imagining that does not meet the criteria for primary resection
- A CA 19-9 level suggestive of disseminated disease, in the absence of jaundice
- If a patient meets all of the above criteria for preoperative therapy, it should be offered as an alternative treatment strategy.
- If a patient undergoes preoperative therapy, he or she should have a complete restaging evaluation before final surgical planning.
- Patients with resected pancreatic cancer who did not undergo preoperative therapy should be offered 6 months of adjuvant chemotherapy with either gemcitabine or fluorouracil plus folinic acid. Adjuvant treatment should begin within 8 weeks of surgical resection.
- Patients who did not receive preoperative therapy and present after resection with microscopically positive margins and/or node-positive disease after completion of 4 to 6 months of systemic adjuvant chemotherapy may be offered adjuvant chemoradiation.
- For patients who received preoperative therapy, a total of 6 months of adjuvant therapy is recommended.
- Patients should be assessed for symptom burden, psychological status, and social supports as early as possible. Assessments may indicate a need for palliative care consults and services.
- Patients who have undergone pancreatectomy should receive ongoing supportive care for symptom burden.
- Patients who have completed treatment and have no evidence of disease should be monitored for recovery of treatment-related toxicities and recurrence at 3- to 6-month intervals.
- Khorana AA, Mangu PB, Berlin J, et al. Potentially curable pancreatic cancer: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. Published online before print May 31, 2016. doi:10.1200/JCO.2016.67.5553.