Metastatic Pancreatic Cancer
Both germline and tumor (somatic) testing are recommended. This includes testing for microsatellite instability/mismatch repair deficiency, BRCA mutations (excluding variants of unknown significance), and NTRK gene fusions. Results of testing can lead to therapies, such as poly (ADP-ribose) polymerase inhibitors, programmed death-1 checkpoint inhibitor therapy, TRK fusion inhibitors, and clinical trials of targeted therapies. Genomic testing is recommended as part of an initial assessment to ensure that the results of testing are available at the time of treatment decision where applicable after first-line therapy (see Treatment Options After First-Line Therapy)
The decision to test for actionable genomic alterations should involve a discussion between the patient and physician regarding the frequency of actionable findings, treatment implications of testing results, and genetic counseling related to germline testing. ASCO has previously developed a provisional clinical opinion on Evaluating Susceptibility to Pancreatic Cancer that contains recommendations for germline genetic testing.
Treatment Options After First-Line Therapy
For the group of platinum-sensitive patients included in Recommendation 3.3, the decision to continue treatment with chemotherapy or proceed to maintenance therapy with olaparib should be based on a discussion between the patient and the oncologist, including consideration of whether a maximum response and plateau in response to chemotherapy have been achieved, the level of cumulative toxicities associated with chemotherapy treatment, patient preference, convenience, toxicity, goals of care, cost, and clinical evidence, including a lack of overall survival benefit demonstrated in the POLO randomized controlled trial.
A phase III trial comparing mFOLFOX6 (infusional fluorouracil, leucovorin, and oxaliplatin) with fluorouracil plus leucovorin demonstrated a higher rate of grade 3 or 4 adverse events and significantly reduced overall survival within the mFOLFOX6 arm of the trial12; however, previous phase III data have demonstrated a benefit with the OFF (oxaliplatin, folinic acid, and fluorouracil) regimen compared with fluorouracil plus leucovorin.5,13 Considering the inconsistency of these results, although fluorouracil plus nanoliposomal irinotecan is preferred, the Expert Panel continues to support the use of fluorouracil plus oxaliplatin as an option when availability of fluorouracil plus nanoliposomal irinotecan is limited or when residual toxicity from first-line therapy or comorbidities preclude the use of fluorouracil plus nanoliposomal irinotecan.
Treatment of Pain and Symptoms
Follow-Up and Surveillance
Metastatic Pancreatic Cancer
August 5, 2020
Last Updated Month/Year
June 9, 2022
Supplemental Implementation Tools
External Publication Status
Country of Publication
Target Patient Population
Patients with metastatic pancreatic cancer
Target Provider Population
Medical oncologists, radiation oncologists, surgeons, gastroenterologists
Male, Female, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, Hospice, Outpatient, Radiology services
Nurse, nurse practitioner, physician, physician assistant
Assessment and screening, Treatment, Management
pancreatic cancer, pancreatic adenocardinoma, metastatic cancer
DOI: 10.1200/JCO.20.01364 Journal of Clinical Oncology 38, no. 27 (September 20, 2020) 3217-3230.