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Living with cancer·Standard of care

Resectable pancreatic ductal adenocarcinoma: the decisions you may face

Cancer page →Second-opinion finder →

6 treatment settings, 4 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.

3 options

Pancreas-protocol CT, chest CT and CA 19-9; endoscopic ultrasound with biopsy when tissue is needed before treatment; biliary stenting only for cholangitis, deep jaundice or delayed surgery.

Guideline
NCCN Guidelines: Pancreatic Adenocarcinoma
The options, in plain words
CT (computed tomography)Standard of care

A CT scan is a fast 3D X-ray that shows the size and shape of tumours and whether they have spread.

  • Fast, ubiquitous
  • Sub-millimetre resolution
  • Standard for RECIST response
Endoscopic ultrasound and EBUS systemsStandard of care

Endoscopes with an ultrasound probe on the tip, passed down the gullet or windpipe, that see through the wall of the gut or airway to stage tumours and guide a needle into lymph nodes and the pancreas without an operation.

  • Most accurate staging of wall depth and regional nodes
  • Tissue from pancreas and mediastinum without surgery
  • Therapeutic channel for drainage, ablation and neurolysis
Biliary stenting and drainageStandard of care

A small tube placed by endoscope or through the skin reopens a blocked bile duct, relieving jaundice so chemotherapy can be given.

  • Rapid symptom relief
  • Enables chemotherapy dosing
Also referenced:CA 19-9Resectable, borderline resectable and unresectable
The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record
CT (computed tomography)
  • Anatomic only; cannot distinguish scar from live tumour
  • Radiation dose
  • Poor for brain, marrow, and small peritoneal disease
Endoscopic ultrasound and EBUS systems
  • Operator dependent
  • Range limited to a few centimetres from the lumen
  • Needs on-site cytopathology
Biliary stenting and drainage
  • Cholangitis and stent occlusion
  • Pre-operative drainage is debated for resectable disease
Questions to ask about this decision
  1. Between CT (computed tomography), Endoscopic ultrasound and EBUS systems and Biliary stenting and drainage, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  4. Does your recommendation follow the current guideline (NCCN Guidelines: Pancreatic Adenocarcinoma), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  5. For my situation (staging), which of the standard options do you recommend and why?
    Why: Guideline options include: Pancreas-protocol CT, chest CT and CA 19-9; endoscopic ultrasound with biopsy when tissue is needed before treatment; biliary stenting only for cholangitis, deep jaundice or delayed surgery.

Add these to your appointment list, or take the full question set for this cancer.

One path named

Pancreatoduodenectomy for head tumours, distal pancreatectomy with splenectomy for body and tail tumours, with regional lymphadenectomy; open, laparoscopic or robotic in high-volume centres.

Guideline
NCCN Guidelines: Pancreatic Adenocarcinoma
The path, in plain words
Robotic & minimally invasive surgeryStandard of care

Surgeons operate through small incisions using robotic arms with tremor-free precision and 3D vision.

  • Precision, shorter stay
  • Enables complex minimally invasive resections
Also referenced:Whipple procedure (pancreaticoduodenectomy)Lymphadenectomy (lymph node dissection)Resection margins (R0 / R1 / R2)
The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record
Robotic & minimally invasive surgery
  • Cost
  • Loss of haptic feedback
  • Not superior for every indication
Questions to ask about this decision
  1. Is Robotic & minimally invasive surgery the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?
    Why: A single standard does not mean a single choice; timing and trials are decisions too.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  4. Does your recommendation follow the current guideline (NCCN Guidelines: Pancreatic Adenocarcinoma), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  5. For my situation (surgery), which of the standard options do you recommend and why?
    Why: Guideline options include: Pancreatoduodenectomy for head tumours, distal pancreatectomy with splenectomy for body and tail tumours, with regional lymphadenectomy; open, laparoscopic or robotic in high-volume centres.

Add these to your appointment list, or take the full question set for this cancer.

Early / localised

Adjuvant chemotherapy

3 optionsCompare side by side →

Six months of modified FOLFIRINOX for fit patients (PRODIGE 24); gemcitabine plus capecitabine (ESPAC-4) or gemcitabine alone (CONKO-001) for those who cannot tolerate it, started within twelve weeks of surgery.

Guideline
NCCN Guidelines: Pancreatic Adenocarcinoma
The options, in plain words
FOLFIRINOX / mFOLFIRINOXStandard of careCytotoxic regimen

FOLFIRINOX is a four-drug chemotherapy combination that, in 2011, became the first treatment to meaningfully extend life in metastatic pancreatic cancer; it is now the standard before and after surgery.

GemcitabineApprovedNucleoside analogue (deoxycytidine)

A versatile chemotherapy used in pancreatic, bladder, lung, ovarian, breast and biliary cancers, in nasopharyngeal cancer, and as a bladder instillation.

CapecitabineApprovedOral fluoropyrimidine prodrug (antimetabolite)

Capecitabine (Xeloda) is a tablet form of the chemotherapy fluorouracil. It is a backbone of treatment for bowel cancer and a standard option in advanced breast cancer.

Also referenced:Neoadjuvant / adjuvant / perioperative
The evidence behind it
The main trade-offs on record

No side-effect rates or interaction flags are recorded for these options yet. The side-effect lookup and interaction checker cover the products that have them.

Questions to ask about this decision
  1. Between FOLFIRINOX / mFOLFIRINOX, Gemcitabine and Capecitabine, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. How closely do I match the people in PRODIGE 24 / CCTG PA6, and does that change what the results mean for me?
    Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
  4. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  5. Does your recommendation follow the current guideline (NCCN Guidelines: Pancreatic Adenocarcinoma), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  6. For my situation (adjuvant chemotherapy), which of the standard options do you recommend and why?
    Why: Guideline options include: Six months of modified FOLFIRINOX for fit patients (PRODIGE 24); gemcitabine plus capecitabine (ESPAC-4) or gemcitabine alone (CONKO-001) for those who cannot tolerate it, started within twelve weeks of surgery.
  7. Am I a candidate for FOLFIRINOX / mFOLFIRINOX, Gemcitabine, Capecitabine, and what side effects should I expect?
    Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
  8. How do the results of PRODIGE 24 / CCTG PA6 apply to someone like me?
    Why: Trial populations differ from individual patients; ask how closely you match.

Add these to your appointment list, or take the full question set for this cancer.

Early / localised

Neoadjuvant chemotherapy

2 optionsCompare side by side →

Considered for tumours with high-risk features (large size, very high CA 19-9, suspicious nodes) and increasingly offered in trials for all resectable disease; PREOPANC and NORPACT-1 are the evidence for and against.

Guideline
NCCN Guidelines: Pancreatic Adenocarcinoma
The options, in plain words
FOLFIRINOX / mFOLFIRINOXStandard of careCytotoxic regimen

FOLFIRINOX is a four-drug chemotherapy combination that, in 2011, became the first treatment to meaningfully extend life in metastatic pancreatic cancer; it is now the standard before and after surgery.

Gemcitabine + nab-paclitaxelStandard of careCytotoxic regimen

Gemcitabine plus nab-paclitaxel is the gentler of the two standard chemotherapy backbones for pancreatic cancer, and the base on which most new drugs are being tested.

Also referenced:Neoadjuvant / adjuvant / perioperative
The evidence behind it
  • PREOPANC-1 / PREOPANC-2Phase 3NTR37092022246 peopleevidence 83
    Tests FOLFIRINOX / mFOLFIRINOX
    Resectable and borderline-resectable PDAC: neoadjuvant chemoradiation (PREOPANC-1) or neoadjuvant FOLFIRINOX (PREOPANC-2) vs upfront surgery
    Show survival figures (1)

    Averages across everyone diagnosed, often years ago. Your stage, subtype, age, fitness and the treatment you receive matter more than the average, and the numbers are improving quickly.

    • PREOPANC-1 5-year OS 20.5% vs 6.5%; PREOPANC-2 no OS benefit.
    Overall survival (long-term) (%): Neoadjuvant chemoradiotherapy, 5-year OS 20.5 (n=119) vs Upfront surgery, 5-year OS 6.5 (n=127) · HR 0.73 · source
The main trade-offs on record

No side-effect rates or interaction flags are recorded for these options yet. The side-effect lookup and interaction checker cover the products that have them.

Questions to ask about this decision
  1. Between FOLFIRINOX / mFOLFIRINOX and Gemcitabine + nab-paclitaxel, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. How closely do I match the people in PREOPANC-1 / PREOPANC-2, and does that change what the results mean for me?
    Why: Trial populations are selected; age, fitness, prior treatment and biomarkers all affect how far results carry.
  4. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  5. Does your recommendation follow the current guideline (NCCN Guidelines: Pancreatic Adenocarcinoma), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  6. For my situation (neoadjuvant chemotherapy), which of the standard options do you recommend and why?
    Why: Guideline options include: Considered for tumours with high-risk features (large size, very high CA 19-9, suspicious nodes) and increasingly offered in trials for all resectable disease; PREOPANC and NORPACT-1 are the evidence for and against.
  7. Am I a candidate for FOLFIRINOX / mFOLFIRINOX, Gemcitabine + nab-paclitaxel, and what side effects should I expect?
    Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
  8. How do the results of PREOPANC-1 / PREOPANC-2 apply to someone like me?
    Why: Trial populations differ from individual patients; ask how closely you match.

Add these to your appointment list, or take the full question set for this cancer.

Other settings

Germline testing

2 options

Offered to every patient at diagnosis; carriers of BRCA, PALB2 or ATM variants receive platinum-based chemotherapy and their relatives are offered testing and surveillance.

Guideline
NCCN Guidelines: Pancreatic Adenocarcinoma
The options, in plain words
Germline (hereditary) testingStandard of care

A test of the DNA you were born with, to find inherited risk genes such as BRCA or Lynch syndrome.

  • Actionable for patient and relatives
  • Cheap
High-risk pancreatic surveillance (CAPS / PRECEDE)Established

Yearly MRI or endoscopic ultrasound for people with inherited risk, which catches pancreatic cancers while they are still operable.

  • Stage shift to resectable disease in carriers
  • Defines the population for blood-test validation
Also referenced:Germline BRCA mutation (gBRCA)
The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record
Germline (hereditary) testing
  • VUS burden
  • Uptake and counselling capacity
High-risk pancreatic surveillance (CAPS / PRECEDE)
  • Only ~10% of pancreatic cancers arise in identifiable high-risk groups
  • Cyst overtreatment risk
  • Cost and adherence
Questions to ask about this decision
  1. Between Germline (hereditary) testing and High-risk pancreatic surveillance (CAPS / PRECEDE), which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  4. Does your recommendation follow the current guideline (NCCN Guidelines: Pancreatic Adenocarcinoma), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  5. For my situation (germline testing), which of the standard options do you recommend and why?
    Why: Guideline options include: Offered to every patient at diagnosis; carriers of BRCA, PALB2 or ATM variants receive platinum-based chemotherapy and their relatives are offered testing and surveillance.

Add these to your appointment list, or take the full question set for this cancer.

One path named

CA 19-9 and CT every three to six months for two years then less often; recurrence is treated as metastatic or locally advanced disease.

Guideline
NCCN Guidelines: Pancreatic Adenocarcinoma
The path, in plain words
CT (computed tomography)Standard of care

A CT scan is a fast 3D X-ray that shows the size and shape of tumours and whether they have spread.

  • Fast, ubiquitous
  • Sub-millimetre resolution
  • Standard for RECIST response
Also referenced:CA 19-9
The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record
CT (computed tomography)
  • Anatomic only; cannot distinguish scar from live tumour
  • Radiation dose
  • Poor for brain, marrow, and small peritoneal disease
Questions to ask about this decision
  1. Is CT (computed tomography) the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?
    Why: A single standard does not mean a single choice; timing and trials are decisions too.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  4. Does your recommendation follow the current guideline (NCCN Guidelines: Pancreatic Adenocarcinoma), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  5. For my situation (follow-up), which of the standard options do you recommend and why?
    Why: Guideline options include: CA 19-9 and CT every three to six months for two years then less often; recurrence is treated as metastatic or locally advanced disease.

Add these to your appointment list, or take the full question set for this cancer.

How to read this page. Options and results come from OnCo records with their sources; the settings are the standard-of-care rows on the cancer page, and the lines of therapy are on the sequencing grid. Where a setting names one path, the choice is usually about timing, trials and where to be treated: see expert centres. OnCo is orientation, not medical advice.