The first 60 days: Resectable pancreatic ductal adenocarcinoma
Resectable pancreatic cancer is the minority of pancreatic cancer that the surgeon can remove with clear margins because it has not wrapped around the main arteries or spread. Treatment is an operation, usually a Whipple procedure, followed by six months of combination chemotherapy, which is what turns surgery alone into a real chance of cure. Below, week by week, is what OnCo's record of 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.
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.
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: Staging, Germline testing.
- RadiologistNamed in the standard of care for: Staging, Follow-up.
- SurgeonNamed in the standard of care for: Staging, Surgery, Adjuvant chemotherapy, Neoadjuvant chemotherapy.
- Medical oncologistNamed in the standard of care for: Adjuvant chemotherapy, Neoadjuvant chemotherapy, Germline testing.
- Palliative and supportive care teamNamed in the standard of care for: Staging.
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.
Pancreatoduodenectomy for head tumours, distal pancreatectomy with splenectomy for body and tail tumours, with regional lymphadenectomy; open, laparoscopic or robotic in high-volume centres.
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.
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.
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.
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.
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 for vessel contact and metastases, CA 19-9 before and after surgery, Resection margin statusand lymph node ratio, Germline testing for BRCA1, BRCA2, PALB2, ATM and Lynch genes in every patient, Tumour KRAS, TP53, CDKN2A and SMAD4 status), 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 Resectable PDAC of the pancreatic head, Resectable PDAC of the body or tail, Resectable PDAC with a raised CA 19-9 or large tumour.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Staging
- For my situation (staging), which of the standard options do you recommend and 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.
Surgery
- For my situation (surgery), which of the standard options do you recommend and 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.
Adjuvant chemotherapy
- For my situation (adjuvant chemotherapy), which of the standard options do you recommend and 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.
- Am I a candidate for FOLFIRINOX / mFOLFIRINOX, Gemcitabine, Capecitabine, 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 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Neoadjuvant chemotherapy
- For my situation (neoadjuvant chemotherapy), which of the standard options do you recommend and 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.
- 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.
Germline testing
- For my situation (germline testing), which of the standard options do you recommend and 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.
Follow-up
- For my situation (follow-up), which of the standard options do you recommend and 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.
Any stage
- Are there clinical trials I could join, for example of A Study of the Efficacy and Safety of Adjuvant Autogene Cevumeran Plus Atezolizumab and mFOLFIRINOX Versus mFOLFIRINOX Alone in Participants With Resected PDAC, Study of Daraxonrasib (RMC-6236) in Patients With Resected Pancreatic Ductal Adenocarcinoma (PDAC), Autogene cevumeran, Daraxonrasib?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 “Half of patients never complete adjuvant chemotherapy; whether giving it first helps clearly resectable tumours is unproven”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Recurrence after a complete resection and full chemotherapy remains common, and no marker reliably identifies who is cured”. 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.
- Safety and Efficacy of Immuncell-LC With Gemcitabine in Resectable Pancreatic CancerPhase 3 · recruiting · NCT04969731An Open-label, Randomized, Multi-center, Parallel, Phase III Clinical Trial to Evaluate the Efficacy and Safety of Adjuvant Immuncell-LC Therapy Combined With Gemcitabine Versus Adjuvant Gemcitabine Single Therapy After Resection in Patients With Pancreatic Ductal Adenocarcinoma
- 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)
- A Study of the Efficacy and Safety of Adjuvant Autogene Cevumeran Plus Atezolizumab and mFOLFIRINOX Versus mFOLFIRINOX Alone in Participants With Resected PDACPhase 2 · active · NCT05968326A Phase II, Open-Label, Multicenter, Randomized Study of the Efficacy and Safety of Adjuvant Autogene Cevumeran Plus Atezolizumab and mFOLFIRINOX Versus mFOLFIRINOX Alone in Patients With Resected Pancreatic Ductal Adenocarcinoma
- CEB-01 in Locally Resectable Pancreatic CancerPhase 2 · recruiting · NCT06538857Exploratory Clinical Trial to Assess Safety, Tolerability Efficacy and Pharmacokinetics of CEB-01 PLGA Membrane in Participants With 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.
- Resectable pancreatic ductal adenocarcinoma: the full pageResectable pancreatic cancer is the minority of pancreatic cancer that the surgeon can remove with clear margins because it has not wrapped around the main arteries or spread. Treatment is an operation, usually a Whipple procedure, followed by six months of combination chemotherapy, which is what turns surgery alone into a real chance of cure.
- 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.
- 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.
- 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.
- Germline BRCA mutation (gBRCA): An inherited fault in the BRCA1 or BRCA2 gene, present in every cell from birth, that greatly raises the risk of breast, ovarian, prostate and pancreatic cancer and makes those cancers sensitive to PARP inhibitors and platinum.
- 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.
- Minimal / molecular residual disease (MRD): Cancer still present after treatment but too small to see on scans, detected by blood or marrow tests.
- Lymphadenectomy (lymph node dissection): Surgically removing the lymph nodes that drain a tumour, both to stage the cancer and to clear any spread.
Every term links to the glossary.