The American Society for Radiation Oncology (ASTRO) just released a new radiation therapy for pancreatic cancer guideline, replacing its previous 2019 version. The guideline, Radiation Therapy for Pancreatic Cancer, includes recommendations on appropriate dose-fractionation regimens and target volumes, preferred treatment planning and delivery techniques, and more.

Today, we’re discussing some of the key changes in the 2026 version of the guideline. View the full-text version of the 2026 ASTRO Radiation Therapy for Pancreatic Cancer guideline to view each recommendation, along with each recommendation’s strength of recommendation, quality of evidence, and consensus gradings. 

Previously, the 2019 guideline divided 29 recommendations into seven groups based on key questions. The 2026 version condenses 28 recommendations down to four groups based on key questions. The four designated key questions in the 2026 ASTRO Radiation Therapy for Pancreatic Cancer guideline are: 

  • What are the appropriate indications for RT, and how should RT be sequenced or combined with systemic therapy and resection for patients with nonmetastatic pancreatic cancer?
  • What are the appropriate dose-fractionation regimens and target volumes for patients with nonmetastatic pancreatic cancer receiving RT?
  • What are the preferred treatment planning and delivery techniques for patients with nonmetastatic pancreatic cancer receiving RT?
  • What are the appropriate indications for RT in the setting of recurrence, reirradiation, metastatic disease, and/or palliation for patients with pancreatic cancer?

Additionally, since 2019, there have been multiple RCTs that clarified the role of radiation therapy for resectable, BRPC, and LAPC. Therefore, the 2026 update features evidence supporting emerging indications for radiation therapy, including dose-escalated radiation therapy and elective targeting of areas at risk for microscopic disease extension, facilitated by improvements in motion management, adaptive radiation therapy technologies, and image guidance. 

Emerging indications for radiation therapy include reirradiation, oligometastatic and oligoprogressive disease, and locoregional recurrence. Celiac plexus radiosurgery and other palliative radiation therapy approaches showcase the expanded role of radiation therapy in quality of life improvements and symptom management.

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