Key Points

• This guideline update incorporates new evidence related to second-line treatment options, including the PANCREOX study comparing treatment with modified FOLFOX6 to fluorouracil and leucovorin (FU/LV),¹ and a study of pembrolizumab in patients whose tumors have a deficiency in mismatch repair.²
• Pancreatic ductal adenocarcinoma is a disease associated with poor prognosis, and its impact on cancer-related mortality in the United States and worldwide is increasing. 
• Pancreatic adenocarcinoma is a systemic disease from the outset, with early micrometastatic spread.
• This disease is an unfortunate exception to the general trend of improvement in cancer-related mortality. Indeed, one estimate suggests that pancreatic cancer will become the second leading cause of cancer-related death in the United States within the next decade. 
• There were an estimated 55,440 new diagnoses and 44,330 deaths from pancreatic cancer in the United States in 2017, and there were an estimated 338,000 deaths worldwide in 2012. 
• The 5-year overall survival (OS) rate remains <6%, with a median survival time of 3–6 months for metastatic disease. 
  • Approximately 20% of patients present with potentially curable pancreatic cancers—resectable or borderline resectable tumors for which surgical resection is an appropriate consideration. 
  • However, even after multimodality therapy that includes surgical resection, 
    5 year OS rates remain at 2%.

Diagnosis

Recommendation 1.1 (Updated)

• A multiphase computerized tomography (CT) scan of the chest, abdomen, and pelvis should be performed to assess extent of disease. Other staging studies should be performed only as dictated by symptoms. (Strong Recommendation; EB-B-I). 

Recommendation 1.2 

• The baseline performance status (PS), symptom burden, and comorbidity profile of a patient with metastatic pancreatic cancer should be evaluated carefully (Strong Recommendation; EB-B-I). 

Recommendation 1.3 

• The goals of care (to include a discussion of an advance directive), patient preferences, as well as support systems should be discussed with every patient with metastatic pancreatic cancer and his or her caregivers (Strong Recommendation; EB-B-I). 

Recommendation 1.4 

• Multidisciplinary collaboration to formulate treatment and care plans and disease management for patients with metastatic pancreatic cancer should be the standard of care (Strong Recommendation; EB-B-I). 

Recommendation 1.5 

• Every patient with pancreatic cancer should be offered information about clinical trials, which include therapeutic trials in all lines of treatment as well as palliative care, biorepository/biomarker, and observational studies (Strong Recommendation; IC-B-I).