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Pancreatic cancer

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 2023; 2015), the Society for Immunotherapy of Cancer (SITC 2023), the American Society for Gastrointestinal Endoscopy (ASGE 2022; 2021; 2016), the American Society of Clinical Oncology (ASCO 2020; 2019; 2016), the American Gastroenterological Association (AGA 2020), the American Society for Radiation Oncology (ASTRO 2019), the American College of Radiology (ACR 2019), and the U.S. Preventive Services Task Force (USPSTF 2019).
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Guidelines

1.Screening and diagnosis

Indications for screening, general population, AGA: do not screen average-risk individuals for pancreatic cancer.
D
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  • Indications for screening (genetically susceptible individuals)

  • Indications for screening (family relatives)

2.Classification and risk stratification

Staging: use the UICC TNM eighth edition classification system for staging pancreatic cancer.
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3.Diagnostic investigations

History and physical examination
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

4.Diagnostic procedures

Endoscopic retrograde cholangiopancreatography, solid lesions: do not perform preoperative ERCP in patients with obstructive jaundice due to resectable adenocarcinoma of the pancreas in the absence of cholangitis, unless a substantial delay in operative resection of a symptomatic patient is anticipated.
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  • ERCP (cystic lesions)

  • EUS-guided FNA (cystic lesions)

  • EUS-guided FNA (solid lesions)

  • Pancreatic biopsy

5.Medical management

General principles: as per ESMO 2023 guidelines, arrange a multidisciplinary tumor board discussion in expert centers to define the treatment strategy for patients with pancreatic cancer.
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  • Management of resectable disease (neoadjuvant chemoradiotherapy)

  • Management of resectable disease (surgical resection)

  • 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)

  • Pain management

  • Palliative endoscopic stenting

  • Clinical trials

6.Nonpharmacologic interventions

Lifestyle modifications: advise smoking cessation, limiting alcohol intake, and maintaining a healthy weight to reduce the risk of pancreatic cancer.
B

7.Therapeutic procedures

Technical considerations for radiotherapy, treatment planning: 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)

8.Patient education

General counseling
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.
B
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.
B

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  • Genetic counseling

9.Follow-up and surveillance

Assessment of treatment response: 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