The first 60 days: Locally advanced unresectable pancreatic ductal adenocarcinoma
Locally advanced pancreatic cancer has grown around the arteries or veins behind the pancreas so that it cannot be removed, but it has not spread to other organs. Chemotherapy is the main treatment, joined in 2026 by a device that delivers electric fields to the tumour; radiotherapy controls pain and local growth, and a minority of tumours shrink enough to be operated on after all. Below, week by week, is what OnCo's record of Locally advanced unresectable 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.
- PathologistNamed in the standard of care for: Induction chemotherapy.
- SurgeonNamed in the standard of care for: Induction chemotherapy, Conversion surgery, Ablation.
- Medical oncologistNamed in the standard of care for: Induction chemotherapy, Tumour treating fields, Consolidation local therapy, Ablation and 1 more.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Consolidation local therapy.
- Palliative and supportive care teamNamed in the standard of care for: Induction chemotherapy.
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.
Exploration and resection, sometimes with arterial reconstruction, for the minority with stable or responding disease and a normalised CA 19-9 after induction.
Modified FOLFIRINOX or gemcitabine plus nab-paclitaxel for four to six months, with biliary stenting, pancreatic enzyme replacement and pain control alongside.
Alternating electric fields delivered through skin arrays added to gemcitabine plus nab-paclitaxel (PANOVA-3), approved in 2026.
Chemoradiation with capecitabine, stereotactic body radiotherapy or MR-guided ablative radiotherapy after induction chemotherapy for disease that has not spread; LAP07 shows better local control without longer survival.
Irreversible electroporation in selected centres after induction chemotherapy; no randomised evidence.
Treat as metastatic disease: switch backbone, daraxonrasib after first-line chemotherapy, clinical trials.
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 arterial encasement, CA 19-9 at baseline and during induction, Restaging CT and PET-CT after induction, Germline BRCA1, BRCA2 and PALB2 status, KRAS and other somatic alterations by tissue or plasma sequencing), 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 Locally advanced PDAC with arterial encasement, Locally advanced PDAC with unreconstructable venous occlusion, Locally advanced PDAC converted to resection after induction chemotherapy.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Induction chemotherapy
- For my situation (induction chemotherapy), which of the standard options do you recommend and why?Guideline options include: Modified FOLFIRINOX or gemcitabine plus nab-paclitaxel for four to six months, with biliary stenting, pancreatic enzyme replacement and pain control alongside.
- 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.
Tumour treating fields
- For my situation (tumour treating fields), which of the standard options do you recommend and why?Guideline options include: Alternating electric fields delivered through skin arrays added to gemcitabine plus nab-paclitaxel (PANOVA-3), approved in 2026.
- Am I a candidate for Optune / Optune Pax (TTFields), 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 PANOVA-3 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Consolidation local therapy
- For my situation (consolidation local therapy), which of the standard options do you recommend and why?Guideline options include: Chemoradiation with capecitabine, stereotactic body radiotherapy or MR-guided ablative radiotherapy after induction chemotherapy for disease that has not spread; LAP07 shows better local control without longer survival.
- 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.
Conversion surgery
- For my situation (conversion surgery), which of the standard options do you recommend and why?Guideline options include: Exploration and resection, sometimes with arterial reconstruction, for the minority with stable or responding disease and a normalised CA 19-9 after induction.
Ablation
- For my situation (ablation), which of the standard options do you recommend and why?Guideline options include: Irreversible electroporation in selected centres after induction chemotherapy; no randomised evidence.
Progression
- For my situation (progression), which of the standard options do you recommend and why?Guideline options include: Treat as metastatic disease: switch backbone, daraxonrasib after first-line chemotherapy, clinical trials.
- 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.
- How do the results of RASolute 302 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Any stage
- Are there clinical trials I could join, for example of Clinical Study of Tumor Treating Fields Combined with Gemcitabine and Albumin-bound Paclitaxel in the First-line Treatment of Locally Advanced Pancreatic Cancer, FOLFIRINOX Versus OncoSil™ in Addition to FOLFIRINOX in Patients With Locally Advanced Pancreatic Adenocarcinoma, Acoustic Cluster Therapy (ACT) With Chemotherapy for the Treatment of Locally Advanced Pancreatic Cancer, A Phase 1 Study to Evaluate Safety and Efficacy of XER-001 (Amifostine for Nasoduodenal Delivery) in Combination With Sterotactic Body Radiotherapy for Treatment in Patients With Locally Advanced Pancreatic Cancer.?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 “No local therapy after chemotherapy has lengthened survival in a randomised trial apart from tumour treating fields”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Conversion surgery is uncommon and its benefit over continued non-surgical treatment is unproven”. 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.
- Clinical Study of Tumor Treating Fields Combined with Gemcitabine and Albumin-bound Paclitaxel in the First-line Treatment of Locally Advanced Pancreatic CancerPhase 3 · recruiting · NCT05653453Clinical Study of Tumor Treating Fields Combined with Gemcitabine and Albumin-bound Paclitaxel in the First-line Treatment of Locally Advanced Pancreatic Cancer
- Acoustic Cluster Therapy (ACT) With Chemotherapy for the Treatment of Locally Advanced Pancreatic CancerPhase 2 · recruiting · NCT06850623A Phase 2 Study to Investigate the Efficacy and Safety of Acoustic Cluster Therapy With Modified FOLFIRINOX in Patients With Locally Advanced Pancreatic Cancer
- Combination Immunotherapy Plus Standard-of-Care Chemotherapy Versus Standard-of-Care Chemotherapy for the Treatment of Locally Advanced or Metastatic Pancreatic CancerPhase 2 · active · NCT04390399Open-label, Randomized, Comparative Phase 2 Study of Combination Immunotherapy Plus Standard-of-care Chemotherapy Versus Standard-of-care Chemotherapy for the Treatment of Locally Advanced or Metastatic Pancreatic Cancer
- FOLFIRINOX Versus OncoSil™ in Addition to FOLFIRINOX in Patients With Locally Advanced Pancreatic AdenocarcinomaPhase 2 · active · NCT05466799An Open-label, Multi-centre, Randomized Study of TaRgeted Intratumoural Placement of P-32 (OncoSil™) in Addition to FOLFIRINOX Chemotherapy vs FOLFIRINOX Alone in Patients With Unresectable Locally Advanced Pancreatic Adenocarcinoma.
- A Phase 1 Study to Evaluate Safety and Efficacy of XER-001 (Amifostine for Nasoduodenal Delivery) in Combination With Sterotactic Body Radiotherapy for Treatment in Patients With Locally Advanced Pancreatic Cancer.Phase 1/2 · recruiting · NCT07157033A Phase 1/2a, Open Label, Dose-Escalation Study to Evaluate the Safety and Efficacy of XER-001 (Amifostibe for Nasoduodenal Delivery) in Combination With Sterotactic Body Radiotherapy for Treatment of Locally-Advanced Pancreatic Adenocarcinoma
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Locally advanced unresectable pancreatic ductal adenocarcinoma: the full pageLocally advanced pancreatic cancer has grown around the arteries or veins behind the pancreas so that it cannot be removed, but it has not spread to other organs. Chemotherapy is the main treatment, joined in 2026 by a device that delivers electric fields to the tumour; radiotherapy controls pain and local growth, and a minority of tumours shrink enough to be operated on after all.
- 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.
- Desmoplasia (tumour stroma): The dense scar-like tissue that makes up most of a pancreatic tumour, walling off cancer cells from drugs and immune cells.
- 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.
- Stenting (biliary, oesophageal, airway): Placing a small mesh or plastic tube to hold open a duct or passage that a tumour is squeezing shut, relieving jaundice, swallowing difficulty or breathlessness.
- Cancer cachexia: Severe loss of weight and muscle in advanced cancer that eating more cannot reverse on its own.
- Resectable, borderline resectable and unresectable: The surgeon's verdict on whether the tumour can be completely removed.
- Obstructive jaundice and biliary obstruction: Yellowing of the skin and eyes because a tumour blocks the bile duct, most often pancreatic or bile duct cancer.
- 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.
Every term links to the glossary.