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    Patent Pending

    Potentially Curable Pancreatic Adenocarcinoma (beta)

    Based on guidelines from the American Society of Clinical Oncology.

    Strength
    Strong recommendation
    Moderate recommendation
    Weak recommendation
    Evidence
    High quality evidence
    Intermediate quality evidence
    Low quality evidence
    Insufficient evidence

    Initial Assessment

    Initial Assessment
    1. A multiphase computed tomography (CT) scan of the abdomen and pelvis using a pancreatic protocol or magnetic resonance imaging (MRI) should be performed for all patients with pancreatic cancer to assess the anatomic relationships of the primary tumor and to assess for the presence of intra-abdominal metastases. Endoscopic ultrasonography and/or diagnostic laparoscopy may be used as supplemental studies, and to facilitate acquisition of a biopsy specimen. A chest x-ray may be performed to stage the thorax. Other staging studies should be performed only as dictated by symptom burden. A serum level of CA 19-9 and baseline standard laboratory studies should be assayed.
    2. The baseline performance status, symptom burden, and comorbidity profile of a person diagnosed with potentially curable pancreatic cancer should be carefully evaluated.
    3. The goals of care (including a discussion of advance directives), patient preferences, and support systems should be discussed with every person diagnosed with potentially curable pancreatic cancer and his or her caregivers.
    4. Multidisciplinary collaboration to formulate treatment and care plans and disease management for patients with potentially curable pancreatic cancer should be the standard of care.
    5. Every person with pancreatic cancer should be offered information about clinical trials, including therapeutic trials in all lines of treatment, as well as palliative care, biorepository/biomarker, and observational studies.

    Treatment

    Primary Tumor Resection
    1. Primary surgical resection of the primary tumor and regional lymph nodes is recommended for patients with potentially curable pancreatic cancer who meet all of the following criteria: no clinical evidence for metastatic disease, a performance status and comorbidity profile appropriate for a major abdominal operation, no radiographic interface between primary tumor and mesenteric vasculature on high-definition cross-sectional imaging, and a CA 19-9 level (in absence of jaundice) suggestive of potentially curable disease.
    Preoperative Therapy
    1. Preoperative therapy is recommended for patients with pancreatic cancer who meet any of the following criteria: radiographic findings suspicious but not diagnostic for extrapancreatic disease, a performance status or comorbidity profile not currently appropriate (but potentially reversible) for a major abdominal operation, a radiographic interface between primary tumor and mesenteric vasculature on cross-sectional imaging that does not meet appropriate criteria for primary resection, or a CA 19-9 level (in absence of jaundice) suggestive of disseminated disease.
    2. Preoperative therapy should be offered as an alternative treatment strategy for any patient who meets all of the following criteria: no clinical evidence for metastatic disease, a performance status and comorbidity profile appropriate for a major abdominal operation, no radiographic interface between primary tumor and mesenteric vasculature on high-definition cross-sectional imaging, and a CA 19-9 level (in absence of jaundice) suggestive of potentially curable disease.
    3. If preoperative therapy is administered, a complete restaging evaluation is recommended after completion of treatment and before final surgical planning.
    Adjuvant Therapy
    1. All patients with resected pancreatic adenocarcinoma who did not receive preoperative therapy should be offered 6 months of adjuvant chemotherapy in the absence of medical or surgical contraindications. The modified combination regimen of 5-fluorouracil (FU), oxaliplatin, and irinotecan (mFOLFIRINOX) as used in the latter part of the Partenariat de Recherche en Oncologie Digestive (PRODIGE) 24/Canadian Cancer Trials Group Pancreatic Adenocarcinoma 6 (CCTG PA.6) trial (oxaliplatin 85 mg/m2, leucovorin 400 mg/m2, irinotecan 150 mg/m2 D1, and 5-FU 2.4 g/m2 over 46 hours every 14 days for 12 cycles) is preferred in the absence of concerns for toxicity or tolerance; alternatively, doublet therapy with gemcitabine and capecitabine or monotherapy with gemcitabine alone or fluorouracil plus folinic acid alone can be offered.
    2. Adjuvant chemoradiation may be offered to patients who did not receive preoperative therapy and present post-resection with microscopically positive margins (R1) and/or node-positive disease after completion of 4 to 6 months of systemic adjuvant chemotherapy. There is clinical equipoise regarding the benefit of adjuvant radiation therapy in this setting pending results of an ongoing international RCT.
    3. For patients with pancreatic cancer who received preoperative therapy, there are no RCT data to guide the administration of postoperative therapy. The Panel recommends that a total of 6 months of adjuvant therapy (including preoperative regimen) be offered based on extrapolation from adjuvant therapy trials.
    Palliative Care
    1. People with potentially curable pancreatic cancer should have a full assessment of symptom burden, psychological status, and social supports as early as possible, preferably at the first visit. In some cases, this may indicate a need for a formal palliative care consult and services.
    2. People who have undergone pancreatectomy for potentially curable pancreatic cancer should receive ongoing supportive care for symptom burden that may result from the surgery and (preoperative and/or adjuvant) chemotherapy.

    Follow-up and Surveillance

    Follow-up and Surveillance
    1. In the absence of RCT evidence, the Panel recommends that people who have completed treatment for potentially curable pancreatic cancer and have no evidence of disease be monitored for recovery of treatment-related toxicities and recurrence. Visits may be offered at 3- to 6- month intervals; the role of serial cross-sectional imaging, the extent to which surveillance intervals should be prolonged over time, and the duration of recommended surveillance are all undefined.
    What do the icons mean?  
    Research PaperKhorana AA, Mckernin SE, Berlin J, et al. Potentially Curable Pancreatic Adenocarcinoma: ASCO Clinical Practice Guideline Update. J Clin Oncol. 2019;:JCO1900946.