The first 60 days: Borderline resectable pancreatic ductal adenocarcinoma
Borderline resectable pancreatic cancer touches the big blood vessels behind the pancreas, so an operation straight away would probably leave cancer behind. Chemotherapy first, usually FOLFIRINOX for several months and sometimes radiotherapy, shrinks the edge of the tumour, and patients whose disease has not spread go on to surgery with a better chance of a clean removal. Below, week by week, is what OnCo's record of Borderline resectable pancreatic ductal adenocarcinoma says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- RadiologistNamed in the standard of care for: Neoadjuvant chemotherapy.
- SurgeonNamed in the standard of care for: Neoadjuvant chemotherapy, Surgery, Progression during neoadjuvant therapy.
- Medical oncologistNamed in the standard of care for: Neoadjuvant chemotherapy, Radiotherapy after chemotherapy, After surgery, Progression during neoadjuvant therapy.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Radiotherapy after chemotherapy.
- Palliative and supportive care teamNamed in the standard of care for: Progression during neoadjuvant therapy.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Modified FOLFIRINOX for two to four months in fit patients, gemcitabine plus nab-paclitaxel otherwise; restage with CT and CA 19-9 before deciding on surgery (PREOPANC, ESPAC-5).
Pancreatoduodenectomy or distal pancreatectomy with venous resection and reconstruction where needed, arterial resection only in specialist centres; proceed on stable or improved disease with falling CA 19-9.
Complete six months of chemotherapy in total, usually with the regimen the tumour responded to.
Manage as locally advanced or metastatic disease; switch chemotherapy backbone, RAS inhibitor trials, biliary stenting for jaundice.
Optional; conventional chemoradiation or stereotactic radiotherapy to secure an arterial margin in selected patients, with ALLIANCE A021501 as the caution against routine use.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example Pancreas-protocol CT with degrees of vessel contact, CA 19-9 trend during neoadjuvant chemotherapy, Restaging CT after chemotherapy, Germline BRCA1, BRCA2, PALB2 and ATM status, Pathological response grade and margin status after resection), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include Borderline resectable PDAC with venous involvement only, Borderline resectable PDAC with limited arterial abutment, Biologically borderline PDAC.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Neoadjuvant chemotherapy
- For my situation (neoadjuvant chemotherapy), which of the standard options do you recommend and why?Guideline options include: Modified FOLFIRINOX for two to four months in fit patients, gemcitabine plus nab-paclitaxel otherwise; restage with CT and CA 19-9 before deciding on surgery (PREOPANC, ESPAC-5).
- Am I a candidate for FOLFIRINOX / mFOLFIRINOX, Gemcitabine + nab-paclitaxel, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of PREOPANC-1 / PREOPANC-2 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Radiotherapy after chemotherapy
- For my situation (radiotherapy after chemotherapy), which of the standard options do you recommend and why?Guideline options include: Optional; conventional chemoradiation or stereotactic radiotherapy to secure an arterial margin in selected patients, with ALLIANCE A021501 as the caution against routine use.
- Am I a candidate for Capecitabine, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Surgery
- For my situation (surgery), which of the standard options do you recommend and why?Guideline options include: Pancreatoduodenectomy or distal pancreatectomy with venous resection and reconstruction where needed, arterial resection only in specialist centres; proceed on stable or improved disease with falling CA 19-9.
After surgery
- For my situation (after surgery), which of the standard options do you recommend and why?Guideline options include: Complete six months of chemotherapy in total, usually with the regimen the tumour responded to.
- Am I a candidate for FOLFIRINOX / mFOLFIRINOX, Gemcitabine + nab-paclitaxel, Gemcitabine or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Progression during neoadjuvant therapy
- For my situation (progression during neoadjuvant therapy), which of the standard options do you recommend and why?Guideline options include: Manage as locally advanced or metastatic disease; switch chemotherapy backbone, RAS inhibitor trials, biliary stenting for jaundice.
- Am I a candidate for NALIRIFOX (liposomal irinotecan + oxaliplatin + 5-FU/LV), Daraxonrasib, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Any stage
- Are there clinical trials I could join, for example of Study of Daraxonrasib (RMC-6236) in Patients With Resected Pancreatic Ductal Adenocarcinoma (PDAC), Initial Feasibility Study to Treat Borderline Resectable Pancreatic Cancer With a Planar LDR Source, Daraxonrasib, Autogene cevumeran?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “Definitions of borderline disease differ between centres, so trial populations are not comparable”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “CT underestimates response after chemotherapy, and there is no validated marker to tell fibrosis from viable tumour before surgery”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
- Study of Daraxonrasib (RMC-6236) in Patients With Resected Pancreatic Ductal Adenocarcinoma (PDAC)Phase 3 · recruiting · NCT07252232RASolute 304: A Phase 3 Multicenter, Open-label, Randomized, 2-Arm Study of Adjuvant Daraxonrasib Versus Standard of Care Observation Following Completion of Neoadjuvant and/or Adjuvant Chemotherapy in Patients With Resected Pancreatic Ductal Adenocarcinoma (PDAC)
- Initial Feasibility Study to Treat Borderline Resectable Pancreatic Cancer With a Planar LDR SourcePhase 1/2 · recruiting · NCT02843945Initial Feasibility Study to Evaluate the Safety and Efficacy of the Permanently Implantable LDR CivaSheet® in Combination With External Beam Radiation in the Treatment of Pancreatic Cancer
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Borderline resectable pancreatic ductal adenocarcinoma: the full pageBorderline resectable pancreatic cancer touches the big blood vessels behind the pancreas, so an operation straight away would probably leave cancer behind. Chemotherapy first, usually FOLFIRINOX for several months and sometimes radiotherapy, shrinks the edge of the tumour, and patients whose disease has not spread go on to surgery with a better chance of a clean removal.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- Stereotactic body radiotherapy (SBRT / SABR): A course of one to five large, pinpoint-accurate radiation doses that destroy a tumour outside the brain almost like surgery, for patients who cannot or prefer not to have an operation.
- Locally advanced and locoregional disease: Cancer that has grown beyond its organ into nearby tissue or lymph nodes but has not spread to distant sites.
- Resection margins (R0 / R1 / R2): Whether the edge of the removed tissue is free of cancer.
- Resectable, borderline resectable and unresectable: The surgeon's verdict on whether the tumour can be completely removed.
- CA 19-9: A sugar molecule shed into the blood by most pancreatic cancers; useful to follow treatment, not to screen.
- Whipple procedure (pancreaticoduodenectomy): The big operation for cancers of the head of the pancreas: the surgeon removes the pancreatic head, the duodenum, the gallbladder and part of the bile duct, then reconnects everything.
- Circulating tumour DNA (ctDNA): Circulating tumour DNA (ctDNA) consists of fragments of DNA shed by tumour cells into the blood, detectable with sensitive sequencing.
- Neoadjuvant / adjuvant / perioperative: Neoadjuvant therapy is treatment given before surgery, adjuvant therapy is treatment given after it, and perioperative therapy is both.
- Chemoradiation (chemoradiotherapy, CRT): Radiotherapy given at the same time as chemotherapy, which sensitises the cancer to radiation.
Every term links to the glossary.