Metastatic pancreatic ductal adenocarcinoma: lines of therapy

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6 standard-of-care settings across 5 lines and 2 biomarker subgroups. Rows come from the cancer page's standard of care; the grid places each on its line and subgroup.

Line	All comers	Fit
Advanced, first line	·	2
Maintenance	1	·
Second line	1	·
Special situations	1	·
Other settings	1	·

Advanced, first line

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
Fit	First line, fit patients	Modified FOLFIRINOX or NALIRIFOX (NAPOLI 3); gemcitabine plus nab-paclitaxel as the alternative, chosen by fitness, biliary drainage and neuropathy.	FOLFIRINOX / mFOLFIRINOXNALIRIFOX (liposomal irinotecan + oxaliplatin + 5-FU/LV)NAPOLI 3Gemcitabine + nab-paclitaxel	NCCN Guidelines: Pancreatic Adenocarcinoma	94
Fit	First line, less fit patients	Gemcitabine plus nab-paclitaxel at reduced dose or gemcitabine alone; best supportive care when chemotherapy would do harm.	Gemcitabine + nab-paclitaxelGemcitabineCancer cachexia	NCCN Guidelines: Pancreatic Adenocarcinoma	90

Maintenance

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	Maintenance and biomarker-directed therapy	Olaparib after at least sixteen weeks of platinum without progression in germline BRCA carriers (POLO); pembrolizumab for mismatch repair deficient tumours; zenocutuzumab for NRG1 fusions; NTRK and BRAF inhibitors where present.	OlaparibPOLOPembrolizumabZenocutuzumabLarotrectinibDabrafenib + trametinib	NCCN Guidelines: Pancreatic Adenocarcinoma	98

Second line

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	Second line	Daraxonrasib after first-line chemotherapy (RASolute 302); otherwise switch backbone, liposomal irinotecan with fluorouracil after gemcitabine or a gemcitabine-based regimen after FOLFIRINOX.	DaraxonrasibRASolute 302Irinotecan (and liposomal irinotecan)Fluorouracil (5-FU)Gemcitabine + nab-paclitaxel	NCCN Guidelines: Pancreatic Adenocarcinoma	89

Special situations

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	Supportive care throughout	Biliary stenting, pancreatic enzyme replacement, dietetic support, early palliative care, anticoagulation for thrombosis and coeliac plexus block for pain.	Biliary stenting and drainageCancer cachexiaObstructive jaundice and biliary obstruction	NCCN Guidelines: Pancreatic Adenocarcinoma	40

Other settings

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
All comers	Clinical trials	First-line daraxonrasib with or without chemotherapy; G12D inhibitors with chemotherapy; KRAS vaccines; claudin 18.2 and mesothelin-directed antibodies and CAR-T; platform trials such as Precision Promise.	Study of Daraxonrasib and Daraxonrasib + GnP as First-line Treatment in Patients With Metastatic Pancreatic AdenocarcinomaZoldonrasibStudy of Zoldonrasib (RMC-9805) Plus Daraxonrasib (RMC-6236) Versus Gemcitabine and Nab-Paclitaxel as First-Line Treatment in Metastatic KRAS G12D-MutELI-002 7PA Multicenter Study of IBI343 Monotherapy Versus Placebo in Subjects With Previously Treated, Claudin (CLDN) 18.2-positive, Pancreatic Cancer(G-HOPE-002)Claudin18.2 CAR-T (CT041) in Patients With Gastric, Pancreatic Cancer, or Other Specified Digestive CancersPrecision Promise	NCCN Guidelines: Pancreatic Adenocarcinoma	50

Lines and subgroups are parsed from the setting text of each standard-of-care row and can misclassify an unusual phrasing; the row’s own setting is always shown. Guideline chips reflect the NCCN category and ESMO-MCBS grade recorded on the cancer page, checked on its stated date. Not medical advice.