The first 60 days: Pancreatic ductal adenocarcinoma
Almost every pancreatic tumour carries a KRAS mutation, and for the first time drugs against it work: daraxonrasib nearly doubled survival in previously treated disease in 2026. Pancreatic cancer has been the hardest common cancer to treat once advanced; that is what is starting to change. Below, week by week, is what OnCo's record of 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.
- Pancreas-protocol CT, endoscopic ultrasound biopsy, CA19-9; germline testing for BRCA and other genes; biliary stent if jaundiced.
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: High-risk surveillance.
- RadiologistNamed in the standard of care for: High-risk surveillance.
- SurgeonNamed in the standard of care for: Resectable / borderline, Locally advanced unresectable.
- Medical oncologistNamed in the standard of care for: Resectable / borderline, Locally advanced unresectable, Metastatic, first line, Metastatic, second line.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Resectable / borderline, Locally advanced unresectable.
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.
Neoadjuvant mFOLFIRINOX (borderline; increasingly resectable), surgery, then adjuvant mFOLFIRINOX to complete ~6 months (PRODIGE 24); gemcitabine/capecitabine if unfit. Chemoradiation selectively (PREOPANC).
FOLFIRINOX or gem/nab-paclitaxel; TTFields with gem/nab-paclitaxel (Optune Pax, 2026); SBRT or MR-guided ablative radiotherapy; IRE in selected centres; reassess for conversion surgery.
mFOLFIRINOX or NALIRIFOX (fit) or gemcitabine/nab-paclitaxel; olaparib maintenance if gBRCA after ≥16 weeks platinum; zenocutuzumab if NRG1 fusion; pembrolizumab if MSI-H; trials of RAS inhibitors + chemotherapy.
Daraxonrasib once approved (RASolute 302: OS 13.2 vs 6.7 months) is expected to become the standard; otherwise switch backbone (gem/nab-pac after FOLFIRINOX, or liposomal irinotecan/5-FU after gemcitabine).
Annual MRI/MRCP or EUS for germline carriers and familial kindreds (CAPS/PRECEDE); germline testing for every diagnosed patient and first-degree relatives.
- Resectable, borderline or locally advanced?
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 KRAS, Germline BRCA/PALB2, MSI, NRG1 fusions, CLDN18.2), 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 Classical, Basal-like / squamous, KRAS-wild-type.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
High-risk surveillance
- For my situation (high-risk surveillance), which of the standard options do you recommend and why?Guideline options include: Annual MRI/MRCP or EUS for germline carriers and familial kindreds (CAPS/PRECEDE); germline testing for every diagnosed patient and first-degree relatives.
Resectable / borderline
- For my situation (resectable / borderline), which of the standard options do you recommend and why?Guideline options include: Neoadjuvant mFOLFIRINOX (borderline; increasingly resectable), surgery, then adjuvant mFOLFIRINOX to complete ~6 months (PRODIGE 24); gemcitabine/capecitabine if unfit. Chemoradiation selectively (PREOPANC).
- Am I a candidate for FOLFIRINOX / mFOLFIRINOX, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of PRODIGE 24 / CCTG PA6 and PREOPANC-1 / PREOPANC-2 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Locally advanced unresectable
- For my situation (locally advanced unresectable), which of the standard options do you recommend and why?Guideline options include: FOLFIRINOX or gem/nab-paclitaxel; TTFields with gem/nab-paclitaxel (Optune Pax, 2026); SBRT or MR-guided ablative radiotherapy; IRE in selected centres; reassess for conversion surgery.
- 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.
Metastatic, first line
- For my situation (metastatic, first line), which of the standard options do you recommend and why?Guideline options include: mFOLFIRINOX or NALIRIFOX (fit) or gemcitabine/nab-paclitaxel; olaparib maintenance if gBRCA after ≥16 weeks platinum; zenocutuzumab if NRG1 fusion; pembrolizumab if MSI-H; trials of RAS inhibitors + chemotherapy.
- Am I a candidate for NALIRIFOX (liposomal irinotecan + oxaliplatin + 5-FU/LV), Zoldonrasib, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of NAPOLI 3 and POLO apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Metastatic, second line
- For my situation (metastatic, second line), which of the standard options do you recommend and why?Guideline options include: Daraxonrasib once approved (RASolute 302: OS 13.2 vs 6.7 months) is expected to become the standard; otherwise switch backbone (gem/nab-pac after FOLFIRINOX, or liposomal irinotecan/5-FU after gemcitabine).
- Am I a candidate for 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 Daraxonrasib, Autogene cevumeran, Sonesitatug vedotin, FAP-2286 (177Lu / 68Ga)?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 “Late diagnosis; no screening”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Dense stroma blocks drug delivery”. 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.
- A Multicenter Study of IBI343 Monotherapy Versus Placebo in Subjects With Previously Treated, Claudin (CLDN) 18.2-positive, Pancreatic Cancer(G-HOPE-002)Phase 3 · recruiting · NCT07066098A Multicenter, Randomized, Double-Blind, Phase III Study of IBI343 Monotherapy Plus Best Supportive Care Versus Placebo Plus Best Supportive Care in Participants With Claudin (CLDN) 18.2-Positive, Locally Advanced Unresectable or Metastatic Pancreatic Cancer Who Received>=2 Prior Lines of Therapy
- A Phase III Study of Ivonescimab + Chemo With/Without AK117 in Metastatic Pancreatic CancerPhase 3 · recruiting · NCT06953999A Randomized, Controlled, Multi-center Phase III Clinical Study of Ivonescimab Plus Chemotherapy With or Without AK117 Versus Placebo Combined With Chemotherapy as First-line Treatment for Metastatic Pancreatic Cancer
- A Pivotal Study of Safety and Effectiveness of NanoKnife IRE for Stage 3 Pancreatic CancerPhase 3 · active · NCT03899636A Randomized, Multicenter, Controlled, Unblinded Study to Assess the Safety and Efficacy of the NanoKnife® System for the Ablation of Unresectable Stage 3 Pancreatic Adenocarcinoma
- A Study to Compare QLS31905 and Chemotherapy With Placebo and Chemotherapy in Participants With Pancreatic CancerPhase 3 · recruiting · NCT07079228A Phase 3, Multi-Center, Double-blind, Randomized Study of QLS31905 Plus Chemotherapy Versus Placebo Plus Chemotherapy as First-Line Treatment in Participants With Claudin (CLDN)18.2-Positive Advanced Pancreatic Cancer
- A Study to Evaluate Chemotherapy With or Without INCB161734 in Previously Untreated, KRAS G12D-Mutated Metastatic Pancreatic Ductal AdenocarcinomaPhase 3 · recruiting · NCT07522073A Randomized, Double-Blind, Phase 3 Study of Chemotherapy With or Without INCB161734 in Previously Untreated, KRAS G12D-Mutated Metastatic Pancreatic Ductal Adenocarcinoma (DAWN-303)
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Pancreatic ductal adenocarcinoma: the full pageAlmost every pancreatic tumour carries a KRAS mutation, and for the first time drugs against it work: daraxonrasib nearly doubled survival in previously treated disease in 2026. Pancreatic cancer has been the hardest common cancer to treat once advanced; that is what is starting to change.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment journey: ResectableA major operation, two to three months to recover, then six months of combination chemotherapy, which roughly doubled the time patients stay cancer-free in the trial that set the standard.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- Hazard ratio (HR): A hazard ratio is a number comparing the rate of bad events in two groups.
- 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.
- Hot vs cold tumours: 'Hot' tumours are full of immune cells and respond to immunotherapy; 'cold' tumours have kept the immune system out.
- Mechanical theory: stiffness, pressure and force as causes: Cancer cells feel their surroundings.
- Cancer cachexia: Severe loss of weight and muscle in advanced cancer that eating more cannot reverse on its own.
- FOLFOX, FOLFIRI, FOLFIRINOX and CAPOX: The standard chemotherapy recipes for bowel and pancreatic cancer, named from their ingredients: FOL (folinic acid) + F (5-fluorouracil) + OX (oxaliplatin), IRI (irinotecan), or both (FOLFIRINOX).
- KRAS mutation subtypes (G12C, G12D, G12V): KRAS, the most commonly mutated cancer gene, comes in flavours named by the exact amino acid change.
- Downstaging and conversion therapy: Using drugs, radiotherapy or embolisation to shrink a cancer from a stage where curative treatment is impossible to one where it is: for example, shrinking liver metastases until they can be cut out, or liver cancer until it fits transplant criteria.
- 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.
- Fiducial markers: Tiny gold seeds or electromagnetic beacons placed in or near a tumour so the treatment machine can see exactly where it is each day.
Every term links to the glossary.