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Enter the class the team gave your scan (resectable, borderline resectable, locally advanced or metastatic), whether you have jaundice, and how well you are, and read the statements that apply, quoted word for word from NICE NG85, the NICE appraisals and UK patient pages. An educational aid to prepare for the conversation with your team, not advice. Nothing you enter leaves this page.
Answer the 3 questions and the statement that applies to that combination appears here, quoted word for word from NICE NG85: pancreatic cancer in adults, diagnosis and management, recommendations (February 2018, with later notes) and the sources listed below, with a plain line on what it means and the questions to take to your surgeon.
Without JavaScript, every statement the aid can show is listed further down the page. This is an educational aid, not advice.
The aid picks from these 17 cards; each quotes its source word for word. Read them all here, with or without the questions above.
“Only consider neoadjuvant therapy for people with resectable pancreatic cancer as part of a clinical trial.”
“Surgery is the best treatment for people with pancreatic cancer that has not spread outside the pancreas. It can help people live longer. Cancer that can be removed by surgery is called resectable or operable cancer.”
“Resectable / borderline: Neoadjuvant mFOLFIRINOX (borderline; increasingly resectable), surgery, then adjuvant mFOLFIRINOX to complete ~6 months (PRODIGE 24); gemcitabine/capecitabine if unfit. Chemoradiation selectively (PREOPANC).”
What this means: When the scan shows no contact with the main arteries and no spread, and you are fit for a major operation, NICE's order is surgery first (usually a Whipple procedure for the head of the pancreas), then six months of chemotherapy. Chemotherapy before the operation is being tested in trials and the OnCo record notes it is used increasingly, so ask whether a trial is open to you and what your unit does; the question is unresolved, not settled.
“Offer resectional surgery rather than preoperative biliary drainage to people who: have resectable pancreatic cancer and obstructive jaundice and are well enough for the procedure and are not enrolled in a clinical trial that requires preoperative biliary drainage.”
“For people with obstructive jaundice and suspected pancreatic cancer, offer a pancreatic protocol CT scan before draining the bile duct.”
What this means: A stent placed before surgery adds a procedure and a route for infection, so when the operation can happen soon the guideline goes straight to it and the operation relieves the jaundice. The CT scan comes before any drainage so the surgeon sees the tumour undisturbed. If the operation cannot be soon, the next card applies.
“If biliary drainage is needed in a person who has resectable pancreatic cancer and obstructive jaundice and is not yet fit enough for resectional surgery, offer endoscopically placed self‑expanding metal stents.”
“For people with suspected pancreatic cancer who may need their stent removed later on, consider endoscopically placed self-expanding fully covered metal stents.”
What this means: When fitness has to be built up first, the bile duct is drained with a metal stent placed through the mouth at ERCP; a fully covered one can be removed at the operation. Pancreatic Cancer UK says most people feel better within a couple of days and the jaundice clears over two to three weeks.
“Only consider neoadjuvant therapy for people with borderline resectable pancreatic cancer as part of a clinical trial.”
“You might have chemotherapy first to try to reduce the size of the cancer and make an operation more successful. This is called neo adjuvant chemotherapy.”
“Because the best treatment for borderline resectable pancreatic cancer is uncertain, your doctor might offer you treatment as part of a clinical trial.”
“Resectable / borderline: Neoadjuvant mFOLFIRINOX (borderline; increasingly resectable), surgery, then adjuvant mFOLFIRINOX to complete ~6 months (PRODIGE 24); gemcitabine/capecitabine if unfit. Chemoradiation selectively (PREOPANC).”
What this means: Borderline means the tumour touches a main vein or artery, so an operation straight away would probably leave cancer behind. UK practice, and the OnCo record, is chemotherapy first (usually modified FOLFIRINOX for two to four months, sometimes with radiotherapy), a repeat scan and CA 19-9, then surgery for those whose disease has not spread; Pancreatic Cancer UK says the operation usually follows 6 to 8 weeks after chemotherapy ends. NICE places this within trials because the evidence was still forming when it wrote; ask which trial, if any, is open.
“You may have a stent put in to treat jaundice if you are going to have chemotherapy before surgery.”
“Treating the jaundice may mean you can start or continue treatment for the cancer.”
“For people with suspected pancreatic cancer who may need their stent removed later on, consider endoscopically placed self-expanding fully covered metal stents.”
What this means: Chemotherapy cannot be given safely while bilirubin is high, so the bile duct is drained first, usually with a metal stent placed by ERCP; a fully covered one can be taken out if you later go on to an operation. Expect the yellowing and itch to take two to three weeks to clear.
“You also need to be fit and well enough to have surgery and will have tests to check this. Some hospitals offer programmes to help people get fit enough. This is called prehabilitation. It focuses on diet and physical activity, and can help you recover more quickly after surgery.”
“Health problems might mean you can’t have some treatments including surgery. Before you have surgery you have tests to check how fit you are including heart and lung tests.”
What this means: A Whipple operation is among the biggest in cancer surgery, so heart and lung tests and an anaesthetic assessment come first. If you are not fit enough now, ask whether that can change with prehabilitation (exercise, nutrition, enzymes, stopping smoking) and time, and what the plan is meanwhile; if it cannot, the treatment follows the unresectable cards and the team should say so plainly.
“Start adjuvant therapy once the person has had time to recover from surgery and as soon as they are well enough to tolerate all 6 cycles.”
“Offer adjuvant gemcitabine plus capecitabine to people who have had sufficient time to recover after pancreatic cancer resection.”
“Consider adjuvant gemcitabine for people who are not well enough to tolerate combination chemotherapy.”
“Resectable / borderline: Neoadjuvant mFOLFIRINOX (borderline; increasingly resectable), surgery, then adjuvant mFOLFIRINOX to complete ~6 months (PRODIGE 24); gemcitabine/capecitabine if unfit. Chemoradiation selectively (PREOPANC).”
What this means: Chemotherapy after surgery is what turns the operation into a real chance of cure. NICE names gemcitabine with capecitabine; since PRODIGE 24 (2018) modified FOLFIRINOX is the OnCo record's standard for fit patients, with gemcitabine-based treatment for those who are not. Pancreatic Cancer UK and Cancer Research UK say it should start within 12 weeks of surgery, so eating, weight, enzymes and blood sugar are sorted out in those weeks.
“During attempted resection for pancreatic cancer, consider surgical biliary bypass if the cancer is found to be unresectable.”
“During attempted resection for head of pancreas cancer, consider prophylactic gastrojejunostomy if the cancer is found to be unresectable.”
What this means: Scans miss small deposits on the liver or the lining of the abdomen, so a minority of operations end without removing the cancer. When that happens the surgeon may join the bile duct and the stomach to the small bowel so that jaundice and a blocked duodenum are prevented; it does not treat the cancer, and Pancreatic Cancer UK says your surgeon will discuss this possibility before the operation.
“Offer systemic combination chemotherapy to people with locally advanced pancreatic cancer who are well enough to tolerate it.”
“Consider gemcitabine for people with locally advanced pancreatic cancer who are not well enough to tolerate combination chemotherapy.”
“When using chemoradiotherapy, consider capecitabine as the radiosensitiser.”
“After 6 months of chemotherapy, if the scans show you can’t have surgery you may have radiotherapy. This completes your treatment and is called consolidation radiotherapy.”
What this means: The tumour has wrapped around the arteries or blocked the main vein without spreading elsewhere. Chemotherapy comes first (modified FOLFIRINOX or gemcitabine with nab-paclitaxel on the OnCo record), with scans every few months; a minority shrink enough for an operation, and radiotherapy (SBRT over five sessions, or chemoradiotherapy with capecitabine tablets) may follow to consolidate. The record also lists tumour treating fields with gemcitabine and nab-paclitaxel (approved 2026) for this stage.
“Consider gemcitabine for people with locally advanced pancreatic cancer who are not well enough to tolerate combination chemotherapy.”
“You will be referred to a special team of doctors and nurses called the palliative care team or symptom control team.”
What this means: Gemcitabine alone, given weekly, is the gentler option NICE names; Cancer Research UK adds that radiotherapy on its own can be used when chemotherapy is not possible. Whatever is chosen, the symptom control team, enzymes, nutrition and pain relief are part of the treatment, not an alternative to it.
“Offer FOLFIRINOX to people with metastatic pancreatic cancer and an Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 1.”
“Metastatic, first line: 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.”
What this means: For people who are up and about and largely independent, the strongest combination is offered: FOLFIRINOX every two weeks, usually at modified doses in the UK. The OnCo record puts NALIRIFOX beside it for fit patients and gemcitabine with nab-paclitaxel as the alternative; NHS funding for NALIRIFOX follows NICE appraisals, so ask what applies where you are treated. A germline BRCA result, an NRG1 fusion or mismatch repair deficiency each open a different drug on the record.
“Consider gemcitabine combination therapy for people who are not well enough to tolerate FOLFIRINOX.”
“Paclitaxel as albumin-bound nanoparticles (nab‑paclitaxel) with gemcitabine is recommended as an option for untreated metastatic adenocarcinoma of the pancreas in adults, only if: other combination chemotherapies are unsuitable and they would otherwise have gemcitabine monotherapy and the company provides nab‑paclitaxel with the discount agreed in the patient access scheme.”
What this means: Gemcitabine with nab-paclitaxel (weekly for three weeks in four) or gemcitabine with capecitabine are the usual combinations here. NICE funds nab-paclitaxel on the NHS only when other combinations are unsuitable and gemcitabine alone would otherwise be given, which describes many people at this fitness level; the trade is hair loss and nerve damage against a longer control of the cancer than gemcitabine alone.
“Offer gemcitabine to people who are not well enough to tolerate combination chemotherapy.”
“For people who can’t have surgery or other treatments you will have treatment to help control symptoms.”
“You will be referred to a special team of doctors and nurses called the palliative care team or symptom control team.”
What this means: Gemcitabine alone is gentle enough for many people who could not have a combination, and for some people the honest choice is symptom control without chemotherapy. Either way the palliative care team, enzymes, nutrition, pain relief and a stent for jaundice are the treatment, and Pancreatic Cancer UK says having treatment is your decision and you do not have to decide anything straight away.
“Offer endoscopically placed self-expanding metal stents rather than surgical biliary bypass to people with unresectable pancreatic cancer.”
“You should start feeling better quickly, normally within a couple of days of having the stent put in.”
“The stent may get blocked and the symptoms you had before may come back.”
What this means: The bile duct is opened with a metal stent placed through the mouth at ERCP (or through the skin if that fails), and chemotherapy can start once the bilirubin falls. Metal stents stay open longer than plastic; if the yellowing, itch or fever return the stent is checked and can be cleared or replaced the same way it went in.
“Consider oxaliplatin-based chemotherapy as second-line treatment for people who have not had first-line oxaliplatin.”
“Consider gemcitabine-based chemotherapy as second-line treatment for people whose cancer has progressed after first-line FOLFIRINOX.”
“Pegylated liposomal irinotecan, in combination with 5‑fluorouracil and leucovorin, is not recommended, within its marketing authorisation, for treating metastatic adenocarcinoma of the pancreas in adults whose disease has progressed after gemcitabine-based therapy.”
What this means: The usual move is to switch backbone: a gemcitabine-based regimen after FOLFIRINOX, an oxaliplatin-based one after gemcitabine. Liposomal irinotecan with fluorouracil is licensed after gemcitabine but not NICE-recommended. The OnCo record's second-line row names daraxonrasib after first-line chemotherapy (RASolute 302), so ask about that and about trials before the first treatment stops working.
“Offer enteric-coated pancreatin for people with unresectable pancreatic cancer.”
“Consider enteric-coated pancreatin before and after pancreatic cancer resection.”
“Consider EUS-guided or image-guided percutaneous neurolytic coeliac plexus block to manage pain for people with pancreatic cancer who: have uncontrolled pancreatic pain or are experiencing unacceptable opioid adverse effects or are receiving escalating doses of analgesics.”
“Throughout the person's care, assess the psychological impact of: fatigue pain gastrointestinal symptoms (including changes to appetite) nutrition anxiety depression.”
What this means: Pancreatic enzyme capsules with every meal, a dietitian early, pain relief that can include a nerve block, and attention to mood are in the guideline for everyone, not only for those who cannot have surgery. Ask for the enzymes and the dietitian at the first appointment: they are the most fixable causes of feeling terrible.
“A specialist pancreatic cancer multidisciplinary team should make a shared decision with the person about the care that is needed.”
“For people with newly diagnosed pancreatic cancer who have not had a pancreatic protocol CT scan, offer a pancreatic protocol CT scan that includes the chest, abdomen and pelvis.”
“Some people might want to get a second opinion before starting treatment. You can ask your specialist or GP to refer you to a doctor or surgeon specialising in pancreatic cancer.”
What this means: The class your scan is given is a judgement made by a specialist team on a pancreas-protocol CT, and Pancreatic Cancer UK says different teams can disagree about whether surgery is possible. Ask for the plan in writing, the name and number of your clinical nurse specialist, and, if the class is borderline or uncertain, whether a specialist pancreatic centre has looked at the scan.
Each combination of answers maps to a fixed set of cards, and every card quotes the statement it implements with the page it was read from; nothing is scored or inferred. Where the sources disagree, both are quoted. The mapping is data in the OnCo repository and is tested against every combination of answers. Checked 2026-09-24.
This is an educational aid to prepare for a conversation with your surgical team. It is not medical advice, and it cannot see your scans or your history. OnCo is orientation, not medical advice.