Appointment sheet
Borderline resectable pancreatic ductal adenocarcinoma
Prepared with OnCo (onco.cc/prep/borderline-resectable-pdac/). Orientation, not medical advice; your team knows your case.
My details
Name
Date of appointment
Hospital and clinician
Who is coming with me
What I know, what is unclear, changes to discuss
Saved in this browserWhat I know so far
What is unclear to me
Changes since last time
My questions
19 on the sheetNewly diagnosed
- 1.What is my exact diagnosis, stage, and grade, and which tests established them?
- 2.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?
- 3.Which subtype is my cancer, and does that change the recommended treatment?
- 4.Is germline (inherited) genetic testing recommended for me or my family?
Neoadjuvant chemotherapy
- 5.For my situation (neoadjuvant chemotherapy), which of the standard options do you recommend and why?
- 6.Am I a candidate for FOLFIRINOX / mFOLFIRINOX, Gemcitabine + nab-paclitaxel, and what side effects should I expect?
- 7.How do the results of PREOPANC-1 / PREOPANC-2 apply to someone like me?
Radiotherapy after chemotherapy
- 8.For my situation (radiotherapy after chemotherapy), which of the standard options do you recommend and why?
- 9.Am I a candidate for Capecitabine, and what side effects should I expect?
Surgery
- 10.For my situation (surgery), which of the standard options do you recommend and why?
After surgery
- 11.For my situation (after surgery), which of the standard options do you recommend and why?
- 12.Am I a candidate for FOLFIRINOX / mFOLFIRINOX, Gemcitabine + nab-paclitaxel, Gemcitabine or related drugs, and what side effects should I expect?
Progression during neoadjuvant therapy
- 13.For my situation (progression during neoadjuvant therapy), which of the standard options do you recommend and why?
- 14.Am I a candidate for NALIRIFOX (liposomal irinotecan + oxaliplatin + 5-FU/LV), Daraxonrasib, and what side effects should I expect?
Any stage
- 15.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?
- 16.Would a second opinion at a high-volume centre change anything, and can you help arrange it?
- 17.What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?
- 18.I read that “Definitions of borderline disease differ between centres, so trial populations are not comparable”. How does that affect my plan?
- 19.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?
The words I may hear
- 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.
Tests and results to bring
Biomarker results to ask for: Pancreas-protocol CT with degrees of vessel contact (defines the category), CA 19-9 trend during neoadjuvant chemotherapy (falling levels predict a useful operation), Restaging CT after chemotherapy (stable disease is acceptable; shrinkage is often modest), Germline BRCA1, BRCA2, PALB2 and ATM status (platinum choice), Pathological response grade and margin status after resection, Circulating tumour DNA before surgery (investigational selection marker).
Scans and tests linked to this cancer: CT (computed tomography), Liquid biopsy (ctDNA), PDAC organoid pharmacotyping.
Bring copies of scan reports, pathology and blood results, and a list of every medicine and supplement.
The treatments I may be offered
- Neoadjuvant chemotherapy: 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). (FOLFIRINOX / mFOLFIRINOX, Gemcitabine + nab-paclitaxel, PREOPANC-1 / PREOPANC-2, CA 19-9, Neoadjuvant / adjuvant / perioperative)
- Surgery: 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. (Whipple procedure (pancreaticoduodenectomy), Resection margins (R0 / R1 / R2), Resectable, borderline resectable and unresectable, Robotic & minimally invasive surgery)
- After surgery: Complete six months of chemotherapy in total, usually with the regimen the tumour responded to. (FOLFIRINOX / mFOLFIRINOX, Gemcitabine + nab-paclitaxel, Gemcitabine, Capecitabine)
- Progression during neoadjuvant therapy: Manage as locally advanced or metastatic disease; switch chemotherapy backbone, RAS inhibitor trials, biliary stenting for jaundice. (NALIRIFOX (liposomal irinotecan + oxaliplatin + 5-FU/LV), Daraxonrasib, Biliary stenting and drainage)
- Radiotherapy after chemotherapy: Optional; conventional chemoradiation or stereotactic radiotherapy to secure an arterial margin in selected patients, with ALLIANCE A021501 as the caution against routine use. (Chemoradiation (chemoradiotherapy, CRT), SBRT / SABR (stereotactic radiotherapy), MR-guided adaptive radiotherapy, Capecitabine)
From the standard of care recorded for this cancer; which apply depends on your stage and biomarkers. Ask which the team recommends and why.
Answers and next steps
Saved in this browserWhat I was told
Agreed next steps, dates and who to call