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NCCN
GUIDELINESFOR PATIENTS

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2019

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Pancreatic
CancerPresented with support from:

Available online at NCCN.org/patientsÜPancreatic Cancer

It's easy to
get lost in thecancer world

Let
NCCN Guidelines
for Patients®
be your guide

9Step-by-step guides to the cancer care options likely to have the best results
9Based on treatment guidelines used by health care providers worldwide
9Designed to help you discuss cancer treatment with your doctors

NCCN Guidelines for Patients®:
Pancreatic Cancer, 20191

AboutNCCN Guidelines for Patients® are developed by
the National Comprehensive Cancer Network® (NCCN®)
		

		

NCCN®

 An alliance of leading

cancer centers across theUnited States devoted topatient care, research, andeducation

Cancer centersthat are part of NCCN:
NCCN.org/cancercenters		

NCCN Clinical Practice
Guidelines in Oncology(NCCN Guidelines®)

 Developed by doctors fromNCCN cancer centers using
the latest research and yearsof experience For providers of cancer careall over the world Expert recommendations forcancer screening, diagnosis,
and treatment



NCCN Guidelines
for Patients®

 Present information from the

NCCN Guidelines in an easyto-learn format

 For people with cancer andthose who support them

 Explain the cancer care

options likely to have thebest results

Free online at
NCCN.org/patientguidelines

Free online at
NCCN.org/guidelines

and supported by funding from NCCN Foundation®
These guidelines are based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Pancreatic Adenocarcinoma(Version 3.2019, July 2, 2019).
© 2019 National Comprehensive Cancer Network, Inc. All rights reserved.
NCCN Guidelines for Patients® and illustrations herein may not be reproduced
in any form for any purpose without the express written permission of NCCN. No
one, including doctors or patients, may use the NCCN Guidelines for Patients forany commercial purpose and may not claim, represent, or imply that the NCCN
Guidelines for Patients that have been modified in any manner are derived from,based on, related to, or arise out of the NCCN Guidelines for Patients. The NCCN
Guidelines are a work in progress that may be redefined as often as new significant
data become available. NCCN makes no warranties of any kind whatsoever
regarding its content, use, or application and disclaims any responsibility for its
application or use in any way.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

NCCN Foundation® seeks to support the millions of patients and their families
affected by a cancer diagnosis by funding and distributing NCCN Guidelines forPatients®. NCCN Foundation is also committed to advancing cancer treatment
by funding the nation’s promising doctors at the center of innovation in cancer
research. For more details and the full library of patient and caregiver resources,
visit NCCN.org/patients. We rely solely on donations to fund the NCCN Guidelines
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2

Supporters

Endorsed by
The National Pancreas Foundation

Let’s Win! Pancreatic Cancer

The NCCN Guidelines for Patients are the gold standard
for pancreatic cancer treatment information. The
guidelines provide comprehensive explanations of thedisease, stages, and treatments options in language
patients can understand. Let’s Win! Pancreatic Cancer
has included a link to the NCCN Pancreatic Cancer
Patient Guidelines since our launch. letswinpc.org

The National Pancreas Foundation provides hope forthose suffering from pancreatitis and pancreatic cancer
through funding cutting edge research, advocating for
new and better therapies, and providing support andeducation for patients, caregivers, and health care
professionals. pancreasfoundation.org

Lustgarten Foundation

Pancreatic Cancer Action Network(PanCAN)As the world’s largest private funder of pancreaticcancer research, we are honored to endorse the NCCN
Guidelines for Patients®: Pancreatic Cancer. Receivinga pancreatic cancer diagnosis is both overwhelming
and life-altering for patients and their loved ones, andhaving the most up-to-date, comprehensive information
contained in these guidelines is crucial for navigating
through this disease. These NCCN Patient Guidelines
are a valuable resource for helping everyone impacted
by pancreatic cancer to better understand the disease,evaluate treatment options, and make informed
decisions. lustgarten.org

As an organization dedicated to attacking pancreaticcancer on all fronts to improve patient outcomes, thePancreatic Cancer Action Network (PanCAN) supports
the NCCN Guidelines for Patients on pancreatic cancer.
This evidence-based resource is a valuable tool to help
patients talk to their healthcare team about the best
options for treating and managing their disease.
pancan.org

With generous support from•

Ken & Lisa Ganiszewski in honor of Debbie Hampton.

•

Barbara C. Slack in honor of Paul R. Slack.

•

The Rev. Sean and Dr. Laura Slack in honor of Paul R. Slack and all those fighting pancreatic cancer.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 20193

NCCN Guidelines for Patients®:
Pancreatic Cancer, 20194

Pancreatic Cancer

Contents
6

Pancreatic cancer basics

13

Testing for pancreatic cancer

25

Pancreatic cancer treatment

35

Supportive and palliative care

40

Treatment guide: Resectable

49

Treatment guide: Borderline resectable

53

Treatment guide: Locally advanced

60

Treatment guide: Metastatic

67

Making treatment decisions

76

Words to know

79

NCCN Contributors

80

NCCN Cancer Centers

82

Index

NCCN Guidelines for Patients®:
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1

Pancreatic cancer basics
7

The pancreas

9Types of pancreatic cancer

10

Risk factors

11

Symptoms

11

How cancer spreads

12

Review

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1

Pancreatic cancer basics

The pancreas

Learn the basics about pancreaticcancer. This will help you prepare andplan for treatment.

Other organs found near the pancreas can beaffected by pancreatic cancer. These include
the liver, spleen, stomach, gallbladder, andsmall intestine. The duodenum is the first partof the small intestine. The jejunum is the middle
part of the small intestine. The liver is locatedclose to the pancreas, above the gallbladder.
The small intestine is wrapped along the wide
end of the pancreas. The spleen is found at the
tail end of the pancreas. See Figure 1.

The pancreas
The pancreas is a large gland found in yourabdomen behind the stomach. A gland is anorgan that makes fluids or chemicals the bodyneeds. The pancreas is about 6 inches long.

Figure 1. Pancreas and nearby organs

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Pancreatic cancer basics

The pancreas
part of the pancreas might put you at riskfor diabetes. If you have diabetes, it mightmake it worse.

The pancreas has 3 parts:
Wide end called the head (includes neckand uncinate)Middle part called the bodyNarrow end called the tailThe pancreas does 2 things:


It makes hormones (insulin and glucagon)that control the amount of sugar (glucose)in your blood. This helps your body use
and store energy from food. Removing

Figure 2. Pancreas, gallbladder, and ducts

NCCN Guidelines for Patients®:
Pancreatic Cancer, 20198

It makes a powerful substance calledpancreatic enzymes that helps digest foodin your small intestine. Removing part ofthe pancreas can decrease the amountof these enzymes. This can cause oily
diarrhea (watery stool), stools that float,
abdominal pain, bloating, gas, and weight
loss.

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Pancreatic cancer basics

Types of pancreatic cancer

Types of pancreatic cancer

What the pancreas does is important. The
pancreas makes hormones, such as insulin.
It also makes proteins, called enzymes, which
help to digest food.

Cancer is a disease that starts in the cells ofyour body. Most cancer is named after the cellfrom which it formed. Pancreatic cancer starts
in exocrine or endocrine cells of the pancreas.
Cancer that forms in the ampulla of Vater (ducts
from the liver and pancreas that enter at thesmall intestine) is often mistaken for pancreaticcancer.

Endocrine cells of the pancreas makehormones. These are released directly into thebloodstream.
Exocrine cells release substances into a duct.
Enzymes made by exocrine cells are released
into the small ducts of the pancreas. Ducts aretiny tubes or vessels that fluids pass through.
The small ducts connect to the main pancreatic
duct that extends from the tail to the head of thepancreas.

Endocrine

Information onneuroendocrine tumors
can be found in NCCN
Guidelines for Patients®:
Neuroendocrine Tumors,available atwww.nccn.org/patients.

The pancreas lies behind the stomach andacross the spine. It is in close contact with theliver, gallbladder, spleen, and duodenum (firstpart of the small intestine). The liver removes
waste from blood and makes bile. Bile is a
fluid that helps to digest food. The gallbladderstores bile from the liver. The common bile
duct carries bile from the liver into the main
pancreatic duct. From the main pancreatic duct,
bile and enzymes empty into the duodenum.
The duodenum is the first part of the small
intestine, which absorbs nutrients from food you
eat.

Exocrine

An exocrine cell makes or secretes an enzyme
into the small intestine that helps digest food.
Sometimes, pancreatic cancer is also called
exocrine cancer. About 9 out of 10 pancreaticcancers start in exocrine cells that line small
tubes called ducts of the pancreas. Theseducts carry fluid that contain enzymes into themain pancreatic duct and then into the small
intestine. Most pancreatic cancers are ductal
adenocarcinomas. An adenocarcinoma iscancer in the cells that secrete fluids or othersubstances.

Depending on the size of the tumor and its
location, surgery can be very difficult. Surgery
will likely affect nearby organs, ducts, andtissues described above. See Figure 2.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

Exocrine pancreatic cancer is called pancreatic
ductal adenocarcinoma (PDAC) and is thefocus of this book. PDAC can grow anywherein the pancreas, but it is most often found in thehead of the pancreas.

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Pancreatic cancer basics

Risk factors

Risk factors

Genetics can increase the risk for pancreaticcancer. Genetic means that it is passed downfrom parent to child through genes. Genes
tell cells what to become and what to do. In
a process called mutation something goes
wrong in the genetic code. Mutations may
be present before you are born (inherited)or may be caused later in life by genetic
damage (acquired). People with inherited
genetic mutations have a higher risk for certain
cancers, but that doesn’t mean they willdevelop cancer.

Anything that increases your chances ofcancer is called a risk factor. Risk factors canbe activities that people do, things you havecontact with in the environment, or traits passed
down from parents to children through genes.
Genes are coded instructions for your cells.
Risk factors for pancreatic cancer can be foundin Guide 1.

Guide 1. Risk factors

Certain syndromes may put someone at riskfor pancreatic cancer. Share what you know
about your family history with your doctor. Askquestions about your risk for cancer.

Risk factors for pancreatic cancer
Tobacco smoking

Some cancer-related syndromes that increase
the risk for pancreatic cancer include:

Heavy alcohol use
High body mass index (BMI) or excess fat
Lack of exercise
Genetics
Pre-diabetes
Chronic pancreatitis
Long-term diabetes

Peutz-Jeghers syndrome

Melanoma-pancreatic cancer syndrome

Lynch syndrome

Hereditary breast-ovarian cancer
syndromeYour health care provider might refer you forgenetic testing to learn more about your cancer.
A genetic counselor will speak to you about theresults.

Periodontal disease
Family history of pancreatitis
Family history of pancreatic cancer
Contact with chemicals and heavy metals

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Pancreatic Cancer, 2019



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Pancreatic cancer basics

Symptoms | How cancer spreads

Symptoms

How cancer spreads

There are no early warning signs of pancreaticcancer. It is important to tell your health careprovider how you are feeling. Doctors needto assess your health and learn about yoursymptoms. If your doctor suspects pancreaticcancer, you will have blood and imaging tests.

Unlike normal cells, cancer cells can spreadand form tumors in other parts of the body. The
spread of cancer makes it dangerous.
Cancer that has spread is called a metastasis.
Cancer that has spread to a nearby bodypart is called a local metastasis or locallyadvanced.

Cancer that has spread to a body part far
from the primary tumor is called a distantmetastasis.

For a list of possible symptoms of pancreaticcancer, see Guide 2.
Having these symptoms does not mean you
have pancreatic cancer. There are other healthconditions that can cause the same symptoms.

Locally advanced pancreatic cancer means thecancer has spread to nearby blood vessels andit may be in nearby lymph nodes.

Guide 2. Symptoms

Cancer can spread to distant sites throughblood. Two major blood vessels lie behindthe pancreas. The superior mesenteric artery
supplies the intestines with blood. The superior
mesenteric vein returns blood to the heart.
Pancreatic cancer can travel through theseblood vessels and metastasize in the liver,spleen, stomach, lungs, and other structures.

Symptoms of pancreatic cancer
Weight loss
Floating stools

NauseaVomiting
Jaundice (yellowing of the skin and eyes)

Cancer can also spread through the lymphatic
system. The lymphatic system has a clear fluid
called lymph. Lymph gives cells water andfood. It also has white blood cells that fightgerms. Lymph nodes filter lymph and remove
the germs. Lymph travels throughout the bodyin vessels like blood does. Lymph vessels andnodes are found everywhere in the body.

Indigestion (eg, heartburn, pain, fullness in belly)
Pain in the abdomen or backSometimes pancreatitis
Trouble controlling diabetes
New-onset diabetes

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Pancreatic cancer basics

Review

Review
Helpful tips:



The pancreas helps digest food andcontrol blood sugar.

Anything that increases your chances ofcancer is called a risk factor.

3 Keep a list of contact information of all

Pancreatic cancer often starts in the
exocrine cells that line the ducts of thepancreas.

3 Ask a caregiver to help you plan yourCancer cells can spread to other bodyparts through blood or lymph.

keep track of your upcoming tests andof your health care providers.
appointments.

3 Use a calendar or day planner todoctors’ appointments.

“

Ask the doctors lots of questions about your type of cancer.
Take good notes. The more you know about your cancer, thebetter you can deal with it.
- SeanNCCN Guidelines for Patients®:
Pancreatic Cancer, 201912

2

Testing for pancreatic cancer
14

General health tests

15

Imaging tests

18

Blood tests

19

Tissue tests

21

Staging tests

23

Genetic tests

24

Test results

24

Review

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2

Testing for pancreatic cancer

General health tests

Treatment planning starts with testing.
Testing is used to confirm (diagnose)
pancreatic cancer. This chapter outlines
tests used to diagnose and treat
pancreatic cancer.

Physical exam

A physical exam is a study of your body.
Doctors should perform a thorough physicalexam along with a complete health history. A
doctor will check your body for signs of disease.
A health care provider may:

General health tests

Check your temperature, blood pressure,pulse, and breathing rate

Medical history



Weigh you

Listen to your lungs and heart

Look in your eyes, ears, nose, and throatFeel and apply pressure to parts of yourbody to see if organs are of normal size,
are soft or hard, or cause pain whentouched. Tell your doctor if you feel pain.

Feel for enlarged lymph nodes in yourneck, underarm, and groin. Tell the doctor
if you have felt any lumps or have any
pain.

Before and after cancer treatment, your doctor
will look at your medical history. A medical
history is a record of your past and current
medical problems and treatments. Your doctor
will ask about all health issues and treatments
you have had in your life. Be prepared to list
any illness or injury and when it happened.
Bring a list of old and new medicines and any
over-the-counter medicines, herbs, or othersupplements you take. Tell your doctor about
any symptoms you have. A medical history will
help determine which cancer treatment is bestfor you.

Your doctor will also check for jaundice.
Jaundice is a yellowing of the skin and eyes
due to a buildup of bilirubin in the body. Bilirubin
is a yellow-brown substance in bile that isformed when red blood cells are broken down.
Bilirubin is part of bile. Bile is a chemical madeby the liver that helps digest fat. It flows throughbile ducts in the liver into the intestines. A tumor
in the pancreas can cause jaundice by blocking
the main bile duct.

Family history

Some cancers and other diseases can run infamilies. Your doctor will ask about the healthhistory of family members who are blood
relatives. This information is called a family
history. You can ask family members about
their health issues like heart disease, cancer,
and diabetes, and at what age they werediagnosed.

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Testing for pancreatic cancer

Imaging tests

Imaging tests

There is more than one type of imaging scanthat may be used for pancreatic cancer. Images
can be made with scanning machines orscoping tools. The images may show if there isa tumor in your pancreas as well as the tumor
size and location.

Imaging tests take pictures (images) of theinside of your body. These tests are used in
the diagnosis and follow-up after treatment ofcancer. Doctors can see the primary tumor, or
where the cancer started, and look for cancer
that has spread to other parts of your body.
Imaging tests are used to find and confirm(diagnose) pancreatic cancer. They are also
used to assess the extent of the cancer to help
plan treatment.

The types of imaging scans recommended forpancreatic cancer are described next.

A radiologist, who is an expert that looks atpatients’ images, will review your images andwrite a report. The radiologist will send thisreport to your doctor. Your doctor will discuss
this report with you. Feel free to ask as manyquestions as you like.

Your medical records

3 Your doctors will order tests andschedule visits to talk about yourcare plan.

Common imaging tests:


X-rays use low-dose radiation to take one
picture at a time.

Ultrasounds use high-energy sound waves
to make pictures.

Computed tomography (CT) scans
use x-rays to take pictures from many
angles or cross-sections to create threedimensional or real-looking images.

Magnetic resonance imaging (MRI) scans
use radio waves and strong magnets tomake detailed pictures.

Positron emission tomography (PET)
scans use a radioactive drug called a
tracer to find disease and take threedimensional or real-looking pictures. A
tracer is a substance put in your body tosee how cancer is growing and where it isin the body. Cancer cells show up as brightspots on PET scans.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

3 It is helpful to keep track of your test
results at all times. Ask your doctors
questions about the results.

3 Online patient portals are a great
way to view your test results andother records.

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Testing for pancreatic cancer

Imaging tests

CT scanA special type of CT scan, called a pancreatic
protocol CT scan, is recommended forpancreatic cancer. A protocol is a detailed planof a medical study, treatment, or procedure. A
pancreatic protocol CT is done in a certain way
so that all of the pictures focus on the pancreas
and nearby area. This special CT scanallows doctors to clearly see the pancreas,
nearby blood vessels, and very small tumors
elsewhere in your abdomen.

Before the CT scan, you may be given contrast
injected into a vein in your arm. A CT scan with
contrast uses contrast materials to improve
the quality of pictures inside the body. Contrast
materials are not dyes, but substances that
help certain areas in the body stand out. Tell
your doctors if you have had bad reactions tocontrast in the past. This is important. Contrast
might not be used if you have a serious allergy
or if your kidneys aren’t working well.

MRI scanA CT (or CAT) scan uses hundreds of x-rays
and computer technology to take pictures frommany angles to create real-looking imagesof the inside of your body. All of the slice-likepictures are combined to make one detailed
picture. This type of scan is very good atshowing tumors in the pancreas. A CT scan isoften the first test given for pancreatic cancer. It
is used for tumor staging. See Figure 3.

An MRI scan uses radio waves and powerfulmagnets to take pictures of the inside of the
body. It does not use x-rays. An MRI may cause
your body to feel a bit warm. Like a CT scan,a contrast material is often used to make thepictures clearer. An MRI is commonly used tolook for liver metastasis.

Figure 3.
CT machine
A CT machine is large andhas a tunnel in the middle.
During the test, you will lie
on a table that moves slowly
through the tunnel.

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Testing for pancreatic cancer

Imaging tests

A special type of MRI scan, called a pancreatic
protocol MRI scan, is recommended forpancreatic cancer. A pancreatic protocol MRI
scan is done in a certain way so that it focuseson the pancreas and nearby areas. This special
MRI scan allows doctors to clearly see thepancreas, nearby blood vessels, and very small
tumors. For some people, a pancreatic protocol
MRI scan may be used instead of CT to view
the pancreas.

ScopesSome imaging tests use a thin, tube-shaped
tool called a scope that is inserted into the bodyto take pictures. One end of the scope has asmall light and camera lens to see inside yourbody. The image is sent to a television monitor.
This will guide your doctor in a biopsy, stentplacement, or other tasks.
The scope is guided into the body through anatural opening, such as the mouth or nose. It
may also be inserted through a small surgical
cut.

MRCP

A magnetic resonancecholangiopancreatography (MRCP) is a type of
MRI scan that makes very clear pictures of thepancreas and bile ducts. No contrast is usedbecause bile and other fluids act as their own
contrast. An MRCP usually done with an MRI
scan.

More than one type of scope may be used for
imaging tests. The type of scope often used
for pancreatic cancer is called an endoscope.
An endoscope is often guided into the bodythrough the mouth. See Figure 4.

Figure 4.
Endoscope
An endoscope is a thin, tubeshaped tool with a light andcamera. It is inserted throughyour mouth and used to lookinside your body.

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Testing for pancreatic cancer

Blood tests
An ERCP is used to open a blocked bile ductcaused by a tumor in the pancreas. During an
ERCP, biopsy samples may be taken from thecommon bile duct. Samples are removed with asmall brush at the end of the endoscope. Thesesamples are called brushings. Brushings aretaken before stent placement.

There are 3 types of imaging tests with scopes
used for pancreatic cancer:Endoscopic ultrasound (EUS)

Endoscopic retrograde
cholangiopancreatography (ERCP)

Laparoscopy

An ERCP is done under sedation to keep you
comfortable during the procedure. It might bedone with an EUS.

EUS

An EUS uses an endoscope that has a small
ultrasound probe at the end. The endoscope isinserted through your mouth and guided down
your throat and stomach to the first part of thesmall intestine (duodenum). The ultrasoundprobe bounces sound waves off your pancreas
and other organs to make pictures of the insideof your body.

Laparoscopy

This test is a type of surgery that allows yourdoctors to see organs in your abdomen. It uses
a tool like an endoscope called a laparoscope
to look for metastases. For this test, thelaparoscope will be inserted through a tiny
cut in your abdomen. Laparoscopy is done
under general anesthesia. This is a controlled
loss of wakefulness from drugs. A pancreatictumor might be biopsied during surgery orlaparoscopy.

EUS is used to guide a biopsy of your pancreas
and to stage a tumor. Sometimes an EUS candetect small lesions in the pancreas that are
difficult to see on a CT or MRI scan.
An EUS is done under sedation to keep you
comfortable during the procedure. It might bedone with an ERCP.

Blood tests
Blood tests check for signs of disease, how wellorgans are working, and treatment results. One
common blood test is a complete blood count(CBC). A CBC measures the number of red
blood cells, white blood cells, and platelets inyour blood. Your doctor will want to know if you
have enough red blood cells to carry oxygen
throughout your body, white blood cells to fightinfection, and platelets to control bleeding.

ERCP

An ERCP uses an endoscope and x-rays tomake moving pictures of the inside of the
body. For this test, the endoscope will beinserted through your mouth and guided down
your throat and stomach to the duodenum.
Next, a thinner tube called a catheter will bepassed through the middle of the endoscope.
The catheter will be used to inject a contrast
material into the pancreatic and bile ducts. The
contrast material allows the ducts to be clearlyseen on the x-ray pictures.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

A blood chemistry test is another common typeof blood test. This test measures the levelsof different chemicals in the blood. Cancer orother diseases can cause levels that are too
low or too high.

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Tissue tests

Tissue tests

Your doctor may change your treatment plan
based on the results of blood tests. How often
you have blood tests depends on the cancer
treatments you receive among other factors.

In order to confirm cancer, your doctor will doa biopsy. A biopsy is the removal of a tissue
or group of cells by a surgeon. A biopsy orbrushings look for cancerous cells. Your doctor
will order a biopsy to learn more about yourcancer and share the results with you.

Other blood tests may include liver function
tests and CA 19-9.

Liver function tests

A pathologist is an expert who will test thebiopsy for cancer and write a report called apathology report. The pathologist may perform
other tests to see if the cancer cells havespecific genes or proteins. This information will
help choose the best treatment plan for yourtype of cancer. Ask questions about your biopsy
results and what it means for your cancer
treatment.

Liver function tests look at the health of yourliver by measuring chemicals that are made orprocessed by the liver. Levels that are too highor low signal that the liver is not working well or
the bile ducts might be blocked.
One of the liver function tests that is measured
is bilirubin, a chemical that gives bile its
color. There may be too much bilirubin in the
blood if a tumor is blocking a bile duct andpreventing the free flow of bile from the liver
into the intestines. Too much bilirubin causes ayellowing of the eyes and skin called jaundice.

If no cancer cells are found, a biopsy may
be taken from another part of the pancreas.
Biopsies are the final step in a cancer
diagnosis. You might need more than one
biopsy and more than one type of biopsy. Ask
your health care provider about the type ofbiopsy you will have and what you can do to
get ready.

CA 19-9

CA 19-9 is a substance found in blood that isoften high in people with pancreatic cancer.
This test is not used by itself to diagnosepancreatic cancer. A CA 19-9 blood test might
be used to see if the treatment is working.
It may also be measured before and after
surgery.

There are different types of biopsies. One typeis a fine-needle aspiration (FNA) biopsy.

FNA biopsy

Other health problems besides pancreaticcancer can cause high levels of CA 19-9.

An FNA biopsy uses a very thin needle toremove the tissue sample. It is the mostcommon type of biopsy used to confirm
pancreatic cancer.
There are 2 types of FNA biopsies:

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19



EUS



CT or ultrasound-guided

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Testing for pancreatic cancer

Tissue tests
CT or ultrasound-guided FNA
In a CT or ultrasound-guided FNA biopsy, a thinneedle is inserted through the skin and into thetumor using a CT scan or ultrasound as a guideto find the right spot. The CT scan takes many
pictures of a part of the body from different
angles using x-rays. An ultrasound is a test thatuses sound waves to take pictures of the insideof the body. Your doctor will use these pictures
to find the tumor in your pancreas and guidethe needle to the right spot. For this type ofbiopsy you will be given local anesthesia. It iscalled local because this anesthesia causes aloss of feeling in a small area of the body.

EUS-FNA
An EUS-guided FNA biopsy or EUS-FNA
uses a thin needle attached to the end of theendoscope. An endoscope uses a lighted scope
passed through the mouth and throat down
into your stomach. An ultrasound probe at theend of the endoscope bounces sound waves
off organs and tissues to make a picture of theinside of your body. Your doctor uses thesepictures to guide the endoscope and needle
to the right spot. Then the needle is inserted
through your stomach or duodenum and into
the tumor in your pancreas to remove a tissue
sample. You might have more than one EUSguided biopsy.

Guide 3. Pancreatic cancer groups based on pre-surgery imaging tests
Group

What does it mean?

Can surgery be done?

Why?

Resectable

Cancer has not spreadoutside the pancreas.

Yes, tumor can beremoved completely
with surgery.

Tumor has not grown into
nearby arteries or veins.

Borderline
resectable

It is hard to tell from imaging
tests if the cancer has spreadto nearby tissues.

It is unclear if the tumor
can be removed withsurgery.

Tumor may or may not havegrown into nearby arteries
and veins.

Locallyadvanced

There is cancer (metastasis)in nearby lymph nodes andtissues.

Tumor may or may not
be removed with surgery.
Lymph nodes may beresectable.

Tumor has grown into
nearby lymph nodes andtissues.

No, tumor cannot be
removed with surgery.

Tumor has grown into
surrounding tissues and has
spread to distant parts ofthe body.

Metastatic(unresectable)

Cancer has spread to distantparts of the body.

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Testing for pancreatic cancer

Staging tests

Staging tests

with imaging tests. You might have a staging
laparoscopy to rule out metastases not foundon imaging tests. Sometimes, cancer cells are
too small to be seen. These cells can grow into
cancer later.

Staging tests are used to measure the sizeof the primary tumor, to see if and where thecancer has spread, and to look at the pancreas
and nearby tissues. In pancreatic cancer,
staging is done using a CT scan and otherimaging tests. You will have imaging tests tosee if surgery is an option.

Staging is needed for treatment. Pancreaticcancer is very difficult to treat because it isusually found when it has already advanced.
Even when found early, pancreatic cancer islikely to have already metastasized. You will
have imaging tests throughout your treatment
to see how the cancer is responding.

If surgery is an option, your cancer isresectable (can be removed completely withsurgery). If surgery is not an option, then yourcancer is unresectable (cannot be removed
by surgery). Sometimes, imaging tests cannot
clearly show one way or the other. In thiscase, pancreatic cancer is called borderline
resectable. In borderline resectable pancreaticcancer, the tumor involves nearby veins andarteries. See Guide 3.

When your doctor suspects pancreatic canceror there might be an issue with your pancreaticor bile ducts, a pancreatic protocol CT isusually the first test. A pancreatic protocol CT
is a special type of CT scan with contrast thattakes pictures as the contrast moves throughthe arteries and veins of the pancreas. These
clear and detailed images of your pancreas
and nearby blood vessels allow doctors to see
where the tumor is in the pancreas and if thetumor involves any veins, arteries, or organs. A
pancreatic protocol will also help to see if there
are metastases. See Guide 4.

A team of doctors will need to look at your test
results and agree on the best way to treat yourcancer. They will discuss if surgery is an option.
Cancer that has spread the liver, spleen, lymph
nodes, and other tissues that line and cover
the organs in your abdomen are hard to see

Guide 4. When your doctor suspects pancreatic cancer
What could it be?

What test do I need?

What is next?

Pancreatic cancer
orDilated (enlarged) pancreatic duct
and/orÜ

Pancreatic protocol CT• if it is metastatic or
non-metastatic cancer• if surgery is an option

Narrowing of bile duct

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019Ü

If it is cancer, a team of doctors
will need to agree on:21

2

Testing for pancreatic cancer

Staging tests

Certain tests are recommended to confirm(diagnose) pancreatic cancer and to see how
far it has spread. A CT of the chest and pelvis
are needed to fully stage pancreatic cancer.
Tests will be based on if there are or aren’t
metastases. Results from these tests will help
guide your treatment plan. See Guide 5.

PS 0 means you are fully active.



PS 1 means you are still able to perform
light to moderate activity.

PS 2 means you can still care for yourself
but are not active.

PS 3 means you are limited to the chair or
bed more than half of the time.

PS 4 means you need someone to carefor you and are limited to a chair or bed.

Performance status

Performance status (PS) is a person’s generallevel of fitness. Your state of general healthwill be rated using a PS scale called ECOG
(Eastern Cooperative Oncology Group). PS
scale scores or grades range from 0 to 4.
This score helps doctors decide what kind of
pancreatic cancer treatment is best for you.

In pancreatic cancer treatment, PS will bereferred to as good or poor. Good PS is usually
PS 0 or PS 1. Supportive care, or palliative
care, is recommended for those with a poor
performance status (PS 2, PS 3, or PS 4).
Supportive care is health care that relieves
symptoms caused by cancer and improves
quality of life.

Guide 5. Tests to confirm pancreatic cancer based on if there are metastases
Metastases

Next tests

Possible tests

Test results
If no tumor or cancer notconfirmed, then follow-up at
high-volume center.

• Chest and pelvic CTNo
metastases

Ü

• EUS

• Liver function test

• MRI

• Baseline CA 19-9
after good biliary
drainage• ERCP with stent• PET/CTÜ• Germline testing

Resectable
Borderline resectable
Locally advanced
Metastatic

Metastases

Ü• Biopsy metastases toconfirm cancer• Germline testing

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

• Gene testing of
tumor

22

Ü

Metastatic

2

Testing for pancreatic cancer

Genetic tests

Genetic tests

Tumor testing

A sample from a biopsy of your tumor will betested to look for biomarkers or proteins. This
information is used to choose the best treatment
for you. Tumor testing is recommended forpatients with locally advanced or metastatic
disease. It is sometimes called gene profiling or
molecular testing.

Your health care provider might refer you forgenetic testing to learn more about your cancer.
A genetic counselor will speak to you about theresults.
There are 2 types of genetic tests used inpancreatic cancer:Germline testing

Tumor testing

MSI testing
Microsatellites are short, repeated strings ofDNA (the information inside genes). Whenerrors or defects occur, they are fixed. Somecancers prevent these errors from being fixed.
This is called microsatellite instability (MSI).
Knowing this can help plan treatment.

Germline testing

Germline testing is done using blood or saliva(spitting into a cup). The goal is to look for
germline mutations. Germline mutations are
passed down from parent to child. They are
inherited. Types of germline mutations forpancreatic cancer include:


BRCA1



BRCA2



PALB2

MMR testing
Mismatch repair (MMR) helps fix mutations incertain genes. When MMR is lacking, thesemutations may lead to cancer. Knowing thiscan help plan treatment or predict how welltreatment will work with your type of tumor.

If you have one or more of these germline
mutations, your doctor might choose aplatinum-based systemic therapy or a treatmentthat is known to work better for your mutation.
You might notice that some of the germline
mutations like BRCA1 or BRCA2 are related
to other cancers such as breast, ovarian,
prostate, colorectal, or melanoma skin cancer.
This is because some mutations can put you
at risk for more than one type of cancer. You
can pass these genes on to your children. Also,
family members might carry these mutations.
Germline testing is recommended for anyone
with confirmed pancreatic cancer.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019Germline testingis recommended
for anyone
with confirmed
pancreatic cancer.

23

2

Testing for pancreatic cancer

Test results | Review

Test results

Review

Results from your blood tests, imaging studies,and biopsy will determine your treatment plan.
It is important you understand what these tests
mean. Ask questions and keep copies of yourtest results. Online patient portals are a great
way to access your test results.
Whether you are going for a second opinion,
test, or office visit, keep these things in mind:Bring someone with you to doctor visits.
Encourage this person to ask questions
and take notes.
Write down questions and take notes
during appointments. Don’t be afraid to
ask your care team questions. Get to know
your care team and let them get to knowyou.
Get copies of blood tests, imaging results,
and reports about the specific type ofcancer you have. It will be helpful when
getting a second opinion.

Organize your papers. Create files for
insurance forms, medical records, and test
results.



Keep a list of contact information foreveryone on your care team.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201924



Tests are used to plan treatment andcheck how well treatment is working.

In pancreatic cancer, staging is first doneusing imaging tests.



A biopsy is needed to confirm pancreaticcancer.



Pancreatic cancer that can be removed
completely with surgery and has not
spread outside the pancreas is called
resectable.

When it is unclear if pancreatic cancer
can be removed with surgery it is calledborderline resectable.



Pancreatic cancer that has spread tonearby blood vessels and lymph nodes iscalled locally advanced. It may or may not
be resectable.



Pancreatic cancer that has spreadto distant parts of the body is called
metastatic. It is unresectable.



Performance status (PS) indicates aperson’s general level of fitness and isused in making treatment decisions.

3

Pancreatic cancer treatment
26

Local treatments

30

Systemic treatments

32

Clinical trials

33

Treatment team34

Review

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201925

3

Pancreatic cancer treatment

Local treatments

There is more than one treatment
for pancreatic cancer. This chapter
describes treatment options and what toexpect. Discuss with your doctor which
treatment might be best for you.

Local treatments

Pancreatic cancer is rarely cured. The goals oftreatment are to control cancer growth, reduce
symptoms, and extend life. Treatment can belocal, systemic, or a combination of both. Local
therapies target specific areas of the body that
contain cancer cells. Systemic therapies attack
cancer cells throughout the body.

Surgery

Local treatments remove or destroy individual
tumors or cancerous tissues. This type oftreatment can be surgery or radiation. It treats a
specific area of the body.
Surgery is a form of local treatment. It
is an operation or procedure to remove
cancer from the body. Sometimes, surgery canbe used as the main or primary treatment toremove cancer in the pancreas. This is only
one part of a treatment plan.

There are 2 types of treatment:

Local therapy focuses on a certain area.
It includes surgery and radiation therapy.



Systemic therapy works throughout the
body. It includes chemotherapy, targeted
therapy, and immunotherapy. Systemic
therapy is used in all stages of pancreaticcancer.

Surgery can be used to:remove all of the tumor

remove a section or debulk the tumor



provide supportive care (relieve pain or
discomfort)

NCCN experts recommend that surgery forpancreatic cancer should be done at a center
that does at least 15 to 20 pancreatic surgeries
each year. Hospitals that perform manypancreatic surgeries often have better results.
The type of surgery you receive depends on
size and location of the tumor in the pancreas.
It also depends on if there is cancer in any
surrounding organs and tissues.
There are 2 types of surgery:

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201926

Open surgery



Minimally invasive surgery (laparoscopic
or robotic surgery)3

Pancreatic cancer treatment

Local treatments

Open surgery
Open surgery removes tissue through one large
surgical cut below your ribs. The large cut lets
your doctor directly view and access the tumor
in your pancreas to remove it. Open surgery
may take several hours or longer. After thesurgery, you will need to stay in the hospital forseveral days or longer to recover.

Surgery

3 Pancreatic resections should bedone at hospitals that perform atleast 15 to 20 each year. This is
known as a high-volume center.

Minimally invasive surgery
Minimally invasive surgery uses a few small
incisions or cuts instead of one large one.
Small tools are inserted through each incision
to perform the surgery. One of the tools, calleda laparoscope, is a long tube with a video
camera at the end. The camera lets your doctor
see your pancreas and other tissues inside
your abdomen. Other tools are used to remove
the tumor. Laparoscopic surgery can also bedone using robotic arms to control the surgicaltools. This is called robot-assisted laparoscopic
surgery.

Pancreatic surgery takes a great dealof skill. Hospitals that perform manypancreatic surgeries often have better
results.

The goal of surgery or tumor resection is toremove all of the cancer. To do so, the tumor isremoved along with some normal-looking tissue
around its edge. The normal-looking tissue iscalled the surgical margin. A clear or negative
margin (R0) is when no cancer cells are foundin the tissue around the edge of the tumor.
In a positive margin cancer cells are found innormal-looking tissue around the tumor. R0 isvery difficult in pancreatic cancer. Even with an
R0 resection, chance of cancer recurrence ishigh.

Tumor resection
Imaging tests will be ordered to see if yourcancer is resectable (can be removed
completely by surgery) or unresectable (cannot
be removed by surgery). Sometimes, imaging
tests cannot clearly show one way or theother. In this case, pancreatic cancer is calledborderline resectable. In borderline resectablepancreatic cancer, the tumor involves nearby
veins and arteries.

A negative margin (R0) is the best result.
Your surgeon will look carefully for cancer not
only along the surgical margin, but in othernearby areas. If your doctor does not feel anegative margin is possible, you might receivea systemic treatment before surgery called
neoadjuvant therapy. Neoadjuvant therapy
will help shrink the size of the tumor and theamount of cancer in the body.

Tumors in the head or body of the pancreas areusually more advanced and are not resectable.
Unresectable tumors also tend to be locallyadvanced or metastatic pancreatic cancer.
Cancer in the neck of the pancreas is avery difficult surgery. Find a surgeon who isexperienced in this type of surgery if yourcancer is in the neck of the pancreas.
NCCN Guidelines for Patients®:
Pancreatic Cancer, 201927

3

Pancreatic cancer treatment

Local treatments
Whipple procedure
If the tumor is in the head of your pancreas,
you will have a pancreaticoduodenectomy(said pancreatico-duod-enectomy) or Whipple
procedure. See Figure 5.

There are 3 types of surgery used to treat
pancreatic cancer:Pancreaticoduodenectomy - Surgery
that removes the head of the pancreas,
gallbladder, duodenum (first part of thesmall intestine), part of the bile duct,
nearby lymph nodes, and often part ofthe stomach. This is known as a Whipple
procedure. This surgery can be open or
minimally invasive.

Distal pancreatectomy – Surgery thatremoves the body and tail of the pancreas,and sometimes the entire spleen(splenectomy). This surgery can be open
or minimally invasive.



Total pancreatectomy – Surgery thatremoves the whole pancreas, part of thesmall intestine, part of the stomach, thecommon bile duct, the gallbladder, thespleen, and nearby lymph nodes. It is
usually done as open surgery.

A Whipple procedure is surgery that removes
the head of the pancreas, the gallbladder,
duodenum (first part of the small intestine), partof the bile duct, and often part of the stomach.
Lymph nodes near your pancreas will be
removed to test for cancerous cells. Once thecancer has been removed, your surgeons willreconnect your organs so you can digest food.
Possible life-threatening complications of thissurgery are infection, pancreatic leaks, andfistulas (an opening between organs).
A Whipple procedure can be open or minimallyinvasive. It requires a great deal of skill. Bloodvessels might have to be removed or pieces cut
out and sewn back together. Parts of organs
might have to be removed and sewn back
together. All of the cancer must be removed inorder to achieve a negative margin resection(R0). This might not be possible based on thetype and stage of pancreatic cancer.

Your team will gather as much information as
possible before surgery. Often, it is very hard
to know until surgery how much cancer there
is and if there is cancer in any veins, arteries,
and other organs. Complex decisions must be
made during surgery. Ask your surgeon whatmight be removed during surgery and what thismeans. Sometimes, a tumor will be found to
be unresectable during surgery. At this time, abiopsy will be done if one was not done before.
A biopsy will help with treatment options.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201928

3

Pancreatic cancer treatment

Local treatments
Total pancreatectomy
A total pancreatectomy removes the wholepancreas, part of the small intestine, partof the stomach, the common bile duct, thegallbladder, nearby lymph nodes, and thespleen (splenectomy). This surgery is rare. It isdone when there are multiple tumors or there iscancer throughout the pancreas.

Distal pancreatectomy
A distal pancreatectomy (said dis-tull pancreeuh-teck-toe-mee) is a surgery to remove thebody and tail of the pancreas. It is possible
the entire spleen will have to be removed(splenectomy) if there is cancer in the spleenor its vessels. Other blood vessels might haveto be removed or pieces cut out and sewn
back together. A distal pancreatectomy isused for a resectable-only tumor in the tail ofthe pancreas. Even with R0 resection, local
recurrence is possible.This surgery is difficult
because the cancer in this part of the pancreas
is usually more advanced.

Figure 5. Whipple procedure
The image on the left shows cancer in the head of the pancreas. The image on the right shows how
the organs might be reconnected during a Whipple procedure.
Hepatic ductsof liverHepatic ductsof liverStomachGallbladder

Small
intestine

Pancreas

Pancreas
StomachDuodenum(first partof smallintestine)

Small
intestine
Small
intestine

Cancer inpancreas

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201929

3

Pancreatic cancer treatment

Systemic treatments

Systemic treatments

Radiation therapy

Radiation therapy uses high-energy
radiation from x-rays, gamma rays,
protons, and other sources to kill cancer cells
and shrink tumors. It is given over a certain
period of time. It is a local form of treatment.

A cancer treatment that affects the whole bodyis called systemic therapy. Chemotherapy
used to be the most common type of systemic
therapy. Now, there are other cancer treatments
like targeted therapy and immunotherapy.
Each works differently to shrink the tumor andprevent recurrence. Systemic treatments may
be used alone or together.

In pancreatic cancer, radiation therapy is usedas supportive care to help ease discomfort
or pain in locally advanced and metastatic
pancreatic cancer. Radiation therapy can also
be given before, during, or after surgery to treat
or slow the growth of cancer. Radiation might
be given with lower dose chemotherapy.

Systemic therapies that might be used include:

Stereotactic body radiation therapy
Stereotactic body radiation therapy (SBRT)
uses high-energy radiation beams to treat
cancers. It is used as a treatment option
for locally advanced pancreatic cancer andfor cancer that has returned after surgery(recurrence).

Relieve symptoms such as pain caused bypancreatic cancer metastases

Treat pancreatic cancer in patients
who cannot have surgery as a primary
treatment due to other health conditions



Shrink tumorsPrevent recurrence

Targeted therapy – focuses on specific or
unique feature of cancer cells

Immunotherapy – uses your body’s
natural defenses to find and destroy
cancer cells

Systemic therapy is an option for all stages ofpancreatic cancer. A biopsy is needed before
treatment can start. Systemic therapy forpancreatic cancer can be given as a pill taken
by mouth or as a liquid that is slowly injected
into a vein called an infusion. You might gohome with an infusion pump that will give acontinuous infusion of systemic therapy over alonger period of time.

SBRT uses a machine to aim radiation beams
at tumors in the body. With this method you
will receive high-dose radiation for 1 to 5
treatments. SBRT is very precise, and thereby
reduces the chance of damage to nearby
tissues.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

Chemotherapy – attacks rapidly dividing
cells in the body

Often, more than one drug is used to treat
cancer. This gives you a better chance ofgetting rid of the cancer, but it also puts healthy
cells at risk for damage. Cell damage can leadto harmful side effects. In some cases, you may
have to stop or delay treatment. Your doctor
may change the systemic treatment approachor lower the dosage. Ask your doctor about thegoal of systematic therapy for your stage ofpancreatic cancer. Be clear about your wishes.

SBRT may be used to:




30

3

Pancreatic cancer treatment

Systemic treatments

Chemotherapy

Immunotherapy is a type of systemic treatmentthat increases the activity of your immune
system. By doing so, it improves your body’s
ability to find and destroy cancer cells.
Immunotherapy can be given alone or withother types of treatment. It is usually given as
an infusion.

Chemotherapy is the use of drugs
to treat cancer. All chemotherapy
drugs affect the instructions (genes) thattell cancer cells how and when to grow anddivide. Chemotherapy kills fast-growing cells
throughout the body, including cancer cells andnormal cells.

Chemoradiation

Chemotherapy is given in cycles of treatmentdays followed by days of rest. Cycles vary inlength depending on which drugs are used. You
will have tests before starting chemotherapy
and during chemotherapy to see how well thetreatment is working.

Treatment that combines
chemotherapy with radiation therapy
is called chemoradiation. Chemotherapy may
improve how well radiation works, and that is
why they are sometimes used together. It is acombination of systemic and local therapies.

Targeted therapy

Targeted therapy is a form of systemictreatment that works throughout yourbody. It is treatment with drugs that focus onor target a specific or unique feature of cancer
cells.

Did you know?

Targeted therapies seek out how cancer
cells grow, divide, and move in the body.
These drugs stop the action of molecules that
help cancer cells grow. As a result, targeted
therapies are less likely to damage healthy
cells or cause side effects. Targeted therapies
might be in pill form or given through a vein orIV (intravenous). Targeted therapy can be given
alone or with other types of treatment.

The terms “chemotherapy” and“systemic therapy” are often usedinterchangeably, but they are not
the same. Chemotherapy, targeted
therapy, and immunotherapy are alltypes of systemic therapy.

Immunotherapy

The immune system is the body’s
natural defense against infection
and disease. It is a complex network of cells,
tissues, and organs. The immune system
includes many chemicals and proteins. Thesechemicals and proteins are made naturally inyour body.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201931

3

Pancreatic cancer treatment

Clinical trials

Clinical trials

Ask your treatment team if there is an open
clinical trial that you can join. There may beclinical trials where you’re getting treatment orat other treatment centers nearby. Discuss therisks and benefits of joining a clinical trial withyour care team. Together, decide if a clinical
trial is right for you.

Clinical trials study how safe and helpful tests
and treatments are for people. Clinical trials
find out how to prevent, diagnose, and treat a
disease like cancer. Because of clinical trials,
doctors find safe and helpful ways to improveyour care and treatment of pancreatic cancer.

NCCN experts encourage patients to join aclinical trial, when possible.

Clinical trials have 4 phases.
Phase I trials aim to find the safest andbest dose of a new drug. Another aim is tofind the best way to give the drug with thefewest side effects.

Phase II trials assess if a drug works for a
specific type of cancer.

Phase III trials compare a new drug to a
standard treatment.

Phase IV trials test drugs approved by the
U.S. FDA (Food and Drug Administration)
to learn more about side effects with longterm use.

Finding a clinical trial•

database for clinical trials. It includes publicly
and privately funded clinical trials, who tocontact, and how to enroll. Look for an open

To join a clinical trial, you must meet theconditions of the study. Patients in a clinical
trial are often alike in terms of their cancer
and general health. This helps ensure that any
change is from the treatment and not becauseof differences between patients.

clinical trial for your specific type of cancer.
Go to ClinicalTrials.gov.
•

The National Cancer Institute’s Cancer
Information Service (CIS) provides up-to-date
information on clinical trials. You can call,e-mail, or chat live. Call 1.800.4.CANCER

If you decide to join a clinical trial, you will needto review and sign a paper called an informed
consent form. This form describes the study indetail, including the risks and benefits. Even
after you sign a consent form, you can stoptaking part in a clinical trial at any time.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

Search the National Institutes of Health (NIH)(800.422.6237) or go to cancer.gov.

32

3

Pancreatic cancer treatment

Treatment teamTreatment teamTreating pancreatic cancer takes a teamapproach. NCCN recommends that treatment
decisions involve a multidisciplinary teamor a team of doctors from different fields of
medicine. Some members of your care teamwill be with you throughout your entire cancer
treatment, while others will only be there forparts of it. Get to know your care team and letthem get to know you.
Your primary care doctor handles
medical care not related to your cancer.
This person can help you express yourfeelings about treatments to your cancer
care team.

A medical oncologist treats cancer in
adults using systemic therapy. Often, thisperson will lead the overall treatment teamand keep track of tests and exams doneby other specialists.

Oncology nurses provide your handson care, like giving systemic therapy,
managing your care, answering questions,and helping you cope with side effects.

An anesthesiologist who gives
anesthesia, a medicine so you do not feelpain during surgery or proceduresA diagnostic radiologist who reads theresults of x-rays and other imaging tests

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019



A pathologist who reads tests and studies
the cells, tissues, and organs removed
during a biopsy or surgeryA radiation oncologist who prescribes
and plans radiation therapy to treat cancer
and provide palliative care

A surgical oncologist who performs
operations to remove cancerHow you feelWhat you needWhat is working and what is not

Keep a list of names and contact informationfor each member of your team. This will makeit easier for you and anyone involved in yourcare to know who to contact with questions orconcerns.

Depending on your diagnosis, your team might
include:

A dietitian or nutritionist who gives
nutritional advice and helps you plan
menus to meet your nutritional needs
during cancer treatment

You know your body better than anyone. Helpother team members understand:A gastroenterologist is an expert indiseases of the digestive system andan expert in endoscopic proceduresfor diagnostic, therapeutic, or palliative
purposes.



Get to know yourcare team and letthem get to know
you.

33

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Pancreatic cancer treatment

Review

Review


Surgery removes the tumor along withsome normal-looking tissue around its
edge called a surgical margin.

The goal of surgery (tumor resection) is anegative margin (R0).



Radiation kills cancer cells or stops newcancer cells from being made.



Systemic therapy is used in all stages ofpancreatic cancer.

Order of treatments
Most people with pancreatic cancer will receive
more than one type of treatment. Next is an
overview of the order of treatments and what
they do.
•Neoadjuvant (before) treatment is given toshrink the tumor before primary treatment

A clinical trial is a type of research thatstudies a treatment to see how safe itis and how well it works. Sometimes, aclinical trial is the preferred treatment
option for pancreatic cancer.

(surgery). This might change a borderline
resectable tumor into a resectable tumor.
•

Primary treatment is the main treatment
given to rid the body of cancer. Surgery isusually the main treatment for resectablepancreatic cancer.

•

Adjuvant (after) treatment is given after
primary treatment to rid the body of any
cancer cells left behind from surgery. It isalso used when the risk of cancer returning(recurrence) is felt to be high.

•First-line treatment is the first set oftreatments given.

•

Second-line treatment is the next set oftreatments given after the first treatment has
failed.

Talk to your doctor about your treatment plan
and what it means for your stage of pancreaticcancer.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

34

1
4

Chapter titleandSupportive
initialpalliative
cap only
care
x
36
36
37
38
x
38
x

Blockedhere
Headerbile initialduct cap only
Guide
1
Blocked stomach
Guide 2
Pain
Guide 3
Depression
Header here initial cap onlyx
39

TroubleeatingHeader here
initial cap only
Pancreatic
Header hereexocrine
initial cap only
insufficiency
Header here initial cap only
Advance care planning

39

Review

38
x

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201935

4

Supportive and palliative care

Blocked bile duct | Blocked stomach

Supportive care is health care that
relieves your symptoms caused bycancer and improves your quality of life.

A blocked bile duct may be treated by placing abiliary stent or doing a biliary bypass. A biliary
stent is a tiny tube that is placed in the bile duct
to unblock it or keep it open. Before the stentcan be placed, bile may need to be drained
through an opening in the side of the body.
You may need a new or second stent during
or after cancer treatment if the tumor grows. A
biliary bypass is a surgery to re-route the flowof bile from the common bile duct into the small
intestine. The result is that the bile flow avoids(bypasses) the blocked part of the duct.

Supportive care is treatment given to relieve
symptoms caused by pancreatic cancer orcancer treatment. It is also referred to as
palliative care. Supportive care is an importantpart of care for pancreatic cancer. Don’t beafraid to ask for it.
Supportive care is not cancer treatment. It might
include pain relief (palliative care), emotionalor spiritual support, financial aid, or family
counseling. Pancreatic cancer can make it
difficult to eat or digest food. Tell your care team
how you are feeling and about any side effects.

Blocked stomach
A tumor in the pancreas may also grow large
enough to block food from passing out of yourstomach through the first part of the small
intestine (duodenum). This blockage can cause
pain, vomiting, weight loss, and other problems.
Treatments for a blocked stomach include
a stent, a PEG (percutaneous endoscopic
gastrostomy) tube, or a stomach-duodenum
bypass (gastrojejunostomy).

Best supportive care is used with othertreatments to improve quality of life for thosewith locally advanced and metastatic pancreaticcancer. It is also used when there is cancer
recurrence after surgery. Best supportive care,
supportive care, and palliative care are often
used interchangeably.

A stent is a tube that expands. It is placedin the small intestine to keep your stomach
open so food can pass through. A PEG tube
is a tube that is inserted through a cut in theabdomen and placed in the stomach. Food isgiven through this tube. A gastrojejunostomy isa surgery to re-route the path food takes fromthe stomach into the small intestine. The newpath from the stomach will avoid (bypass) theblocked part of the duodenum. This surgery
may also be done as a preventive measure
if there is a high risk that your stomach may
become blocked.

Blocked bile duct
A tumor in the pancreas may grow large
enough to block your bile duct. A bile duct is asmall tube that drains digestive fluid (bile) fromthe liver. The common bile duct carries bilefrom the liver through the pancreas and into
the first part of the small intestine (duodenum).
A blocked duct causes bile to build up in theliver. As a result, you may have pain, itching,discomfort, and jaundice. This blockage cancause an infection of the bile duct called
cholangitis.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201936

4

Supportive and palliative care

Pain

Pain

An EUS-guided celiac plexus neurolysis is anerve block. It uses an endoscope to place aneedle into the stomach. An injection is given to
the nerves that transmit pain from the pancreas
to the brain. This blocks the pain.

Pain is common in those with locally advanced
unresectable and metastatic pancreatic cancer.
Severe abdominal pain can occur when thetumor grows into nearby nerves or presses
against other organs. This pain is treated witharound-the-clock medicine such as morphine orother opioids.

Some patients may benefit from palliative
radiation therapy, with or without systemic
therapy, to help relieve the pain. During thistreatment, a radiation beam is focused on thetumor. See Figure 6.

When severe abdominal pain no longer
responds to pain medicine or the medicine iscausing side effects, there are 2 options:

EUS-guided celiac plexus neurolysis

Palliative radiation with or without systemic
therapy

Ask questions and seek information about
supportive and palliative care options for yourpain.

Figure 6.
Radiation therapy
Radiation therapy uses highenergy radiation from x-rays,
gamma rays, protons, andother sources to kill cancer
cells and shrink tumors. It isalso used to treat pain.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201937

4

Supportive and palliative care

Depression | Trouble eating | Insufficiency

Depression
Depression, anxiety, andsleeping problems arecommon in pancreaticcancer. Talk to yourdoctor and with thosewhom you feel most
comfortable about how
you are feeling. There
are services and people
who can help you. Support and counseling areavailable. It is recommended that all patients bescreened for depression.

Supportive care

3 Supportive care is given at any
stage of cancer. Ask for it!
Supportive care relieves symptoms ofcancer and side effects caused by its
treatment.

For more information about depression, readthe NCCN Guidelines for Patients®: Distress,
available at www.nccn.org/patients.

Pancreatic exocrine
insufficiency
There are two changes to your pancreas after
surgery that may require you to change yourdiet.

Trouble eating
Sometimes side effects from surgery,pancreatic cancer, or its treatment might cause
you to feel not hungry or sick to your stomach(nauseated). You might have abdominal cramps
or trouble digesting food. Healthy eating isimportant during treatment. It includes eating
a balanced diet, eating the right amount offood, and drinking enough fluids. A registereddietitian who is an expert in nutrition and foodcan help. Speak to your care team if you havetrouble eating.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

There are less digestive enzymes to break
down food.

There are less chemicals to control sugar(insulin and glucagon).

Pancreatic enzyme replacement medicine,
usually a pill taken by mouth, is given to replace
the loss of digestive enzymes. This loss canbe caused by surgery, a blocked duct, or fromthe tumor. You will have trouble digesting foodwithout enough of these enzymes. Ask yourdoctor how surgery might affect your ability todigest food.

38

4

Supportive and palliative care

Advance care planning | Review

Advance care planning

Review

Advance care planning is making decisions
now about the care you would want to betreated if you become unable to speak
for yourself. Advance care planning is foreveryone, not just for those who are very sick. It
is a way to ensure your wishes are understoodand respected.
Advance care planning starts with an honest
discussion with your doctor. Ask your doctor
about the course your cancer will take calleda cancer prognosis. Find out what you might
expect if your cancer spreads. Discuss the
medicines or therapies that will give you thebest quality of life. Include family and friends inyour advance care planning. Make your wishes
clear. It is important that everyone understands
what you want.
You don’t have to know the exact details of yourprognosis. Just having a general idea will help
with planning. With this information, you candecide if there is a point you might want to stop
cancer treatment. You can also decide what
treatments you would want for symptom relief,such as radiation therapy, surgery, or medicine.
You can change your advance care plan at
any time. It might be helpful to have this talkwith your doctor and/or friends and family morethan once during your treatment. Making yourwishes clear will ensure everyone knows what
you want.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201939

Supportive care is treatment given torelieve symptoms of cancer and the side
effects of cancer treatment.



A stent is a tiny tube that may be used to
unblock a bile duct or the stomach.

Pain may be treated with medication, anerve block, or radiation with or without
systemic therapy.

A registered dietitian who is an expert innutrition and food can help if it is hard for
you to eat or digest food.

Advance care planning starts with anhonest talk between you and your doctor.

5Treatment guide: Resectable
41

Before surgery

43

Surgery

44

After surgery

46

Recurrence

48

Review

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201940

5

Resectable

Before surgery

This chapter will guide you throughtreatment options for cancer that isfound only in the pancreas and canbe removed completely with surgery.
Together, you and your doctor shouldchoose a treatment plan that is best foryou.

neoadjuvant therapy, treatment at a hospitalthat specializes in pancreatic cancer ispreferred, when possible.
There are 2 treatment options for resectable
cancer:

Before surgery

Surgery, see Guide 6.
Neoadjuvant therapy before surgery, see
Guide 7.

You might have a test called a staging
laparoscopy. It is used to make sure there areno metastases in your abdomen. Your doctor
may consider this test if you are at higher risk of
having metastases.

Surgery is the primary treatment for resectablepancreatic cancer. Often, neoadjuvant therapy
is given before surgery to help shrink thetumor. If you and your doctor are considering

Guide 6. Resectable cancer with surgery option
Staging

ResultSurgery

Staging laparoscopy(as needed)ÜSurgery to remove(resect) tumor

ÜUnable to remove tumor during surgery.
Tumor is unresectable.
Tumor removed (see Guide 9)

Guide 7. Resectable cancer with neoadjuvant therapy before surgery
Treatment

Staging• Staginglaparoscopy(as needed)• EUS-guided
core biopsy

Ü

Neoadjuvant
therapy

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

Tests before surgery

Surgery• Repeat pancreatic
protocol CT or MRIÜ• Repeat chest CT• Repeat pelvic CT• Repeat CA 19-9
• Stent (as needed)41ÜSurgery toresect tumor

RResult
Unable to remove
tumor during
surgery. Tumor isunresectable.
Tumor removed(see Guide 9)

5

Resectable

Before surgery

Neoadjuvant treatment

Once neoadjuvant treatment is complete,imaging tests will be repeated to see if there
was any change in tumor size.

An EUS-guided core biopsy is recommended
before starting neoadjuvant therapy. A core
biopsy removes a larger sample of tissue usinga wide, hollow needle. In addition, a staging
laparoscopy might be done. After the biopsy
results, you will begin neoadjuvant treatment.
Neoadjuvant treatment options are found in
Guide 8.

They include:

The preferred neoadjuvant therapy options are:

FOLFIRINOXModified FOLFIRINOX

Gemcitabine with albumin-bound paclitaxelTreatment might be followed bychemoradiationPancreatic protocol CT or MRIChest CT

Pelvic CT

CA 19-9

When you have surgery to remove (resect)
the tumor, what happens next will be based onwhether or not the tumor was removed during
surgery.

There are different options if your tumor has a
BRCA1, BRCA2, or PALB2 mutation.

Guide 8. Neoadjuvant systemic therapy options for resectable cancer
Preferred options
One of the following:

For BRCA1, BRCA2, or PALB2 mutations only

• FOLFIRINOX

One of the following:• Modified FOLFIRINOX• FOLFIRINOX• Gemcitabine with albumin-bound paclitaxel• Modified FOLFIRINOX• Treatment might be followed by chemoradiation• Gemcitabine with cisplatin• Treatment might be followed by chemoradiation

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201942

5

Resectable

Surgery

Surgery

In a duodenal bypass (gastrojejunostomy), apath is created between the stomach and the
middle section of the small intestine. It may bedone if cancer is blocking the stomach or the
first part of the small intestine (duodenum). The
new path from the stomach will avoid (bypass)
the blocked part of the duodenum. This surgery
may be used as a preventive measure if there
is a high risk that your stomach may become
blocked.

Surgery is the primary treatment for resectablepancreatic cancer. Primary treatment refers to
the first or main treatment used to treat cancer.
Sometimes, treatment is given before surgery.
This is called neoadjuvant therapy.
A team of doctors will need to agree thatsurgery is the best choice in your case. When
deciding if surgery is possible, your doctor
should work with a team of experts at a hospitalthat does more than 15 to 20 pancreatic cancer
surgeries each year. This a high-volume center.

If you have or are at risk of developing
jaundice, you might have a biliary bypass to
re-route the flow of bile around the blocked partof the bile duct. A stent might be placed if you
have a blocked bile duct.

Pancreatic surgery is complex. The tumor might
have grown into veins and arteries in such a
way that makes it unsafe to remove. If yourdoctor finds that your tumor cannot be removed
during surgery, your resectable pancreaticcancer is now called unresectable.

If you have severe pain, the surgeon may
also inject alcohol (ethanol) into the nerves in
the abdomen (called celiac plexus) to destroy
them to relieve the pain. This is a nerve blockreferred to as celiac plexus neurolysis.

Cancer found unresectable

For cancer that cannot be removed by surgery,treatment is first based on if there is or isn’t
jaundice and then how far the cancer has
spread.
If there isn’t jaundice, treatment may include aGastrojejunostomy and/or

Celiac plexus neurolysis

If there is jaundice, treatment may include aBiliary bypass or stent and/or

Gastrojejunostomy and/or

Celiac plexus neurolysis

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Pancreatic Cancer, 201943

5

Resectable

After surgery

After surgery

Tests before adjuvant treatment

Before beginning adjuvant treatment, you will
have a CA 19-9 blood test and CT scan with
contrast of the chest, pelvis, and abdomen.
These tests are done to check for signs ofrecurrence and metastasis. You will havegermline testing if it hasn’t been done before.

Adjuvant therapy is treatment given after
surgery to rid the body of cancer cells andto help prevent recurrence. If surgery is
successful and all of the cancer can beremoved, you will have more treatment to try
to kill any remaining cancer cells. The tests
and treatments recommended after surgery
for resectable pancreatic cancer are found in
Guide 9.

If the tests do not show any signs ofmetastases or recurrence, then you will receive
adjuvant treatment. Adjuvant treatment should
only be started after you’ve fully recovered fromsurgery.

Guide 9. Adjuvant treatment options after surgery
Baseline tests

Neoadjuvant
therapy

Metastases

Treatment options
One of the following:• Clinical trial (preferred)Ü• CT of chest,
abdomen, andpelvisNo
metastasesorrecurrenceÜNo, I didn’t haveneoadjuvant therapy
before surgery

Ü  • Systemic therapy(see Guide 10)• Systemic therapy followedby chemoradiation withor without more systemic
therapy• CA 19-9• Germline testing(if not done before)ÜNo
metastasesorrecurrenceÜYes, there are metastases (see Guide 18)ÜYes, I had
neoadjuvant therapy
before surgery

ÜNote: Imaging tests should be done with contrast material, when possible.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201944

Consider more systemic
therapy5

Resectable

After surgery
Follow-up tests

Adjuvant treatment
There are 3 main adjuvant treatment options forresectable pancreatic cancer:Clinical trial (preferred)

Systemic therapySystemic therapy followed bychemoradiation

After completing adjuvant treatment, you will
have follow-up tests. Follow-up tests are given
to see how well treatment worked. These tests
look for signs of cancer return (recurrence) or
spread (metastasis) after treatment.
Follow-up tests are recommended every 3 to
6 months for 2 years, and then once every 6
to 12 months as needed. This period of time
is called surveillance. It is how your doctor will
check for recurrence or metastasis. A medical
history and physical exam can help to find signs
and symptoms of recurrent pancreatic cancer
early.

Adjuvant systemic therapy options are listed in
Guide 10. There are several options, but only
two that are preferred. Preferred drugs havethe best result with fewer side effects. The typeof therapy you receive will be based on if you
had neoadjuvant therapy and, if so, how you
responded to that neoadjuvant therapy.

Tests as needed include:

If you had neoadjuvant therapy, the preferredsystemic therapy options are:

Medical historyPhysical examGemcitabine with capecitabineCA 19-9

Modified FOLFIRINOXCT of chestCT of MRI of abdomen and pelvis

Guide 10. Adjuvant systemic therapy options
Preferred options

Other options (if you did not have neoadjuvant therapy)

One of the following:

One of the following:• Gemcitabine with capecitabine• Gemcitabine• Modified FOLFIRINOX• 5-FU with leucovorin• Continuous infusion 5-FU
• Capecitabine• Systemic therapy followed by chemoradiation• Systemic therapy followed by chemoradiation followed by morerounds of therapy and chemoradiation

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201945

5

Resectable

Recurrence

Recurrence

Treatment

When there is a recurrence of pancreaticcancer after surgery with adjuvant therapy,
treatment is based on whether the recurrenceis local or metastatic. Joining a clinical trial is
the preferred treatment choice in both local andmetastatic recurrence. See Guide 11.

Tests

First, you may have a biopsy to confirm return(recurrence) of pancreatic cancer. Based on
tests, your doctors will know how far the cancer
has spread. Cancer that came back in or near
the pancreas is called a local recurrence.
Cancer that has spread to sites far away fromthe pancreas is called metastatic cancer.

Guide 11. Therapy options for cancer recurrence after resection surgery
Recurrence therapy options

CancerPancreas onlyÜOne of the following:

Local recurrence(might need biopsy
to confirm cancer)• Surgery may be possible. A team of doctors should
agree on a treatment plan.

• Clinical trial (preferred)
Pancreas andarea nearbyÜ• Systemic therapy• Systemic therapy with chemoradiation• Systemic therapy with SBRT (if not done before)• SBRT• Palliative and best supportive careIt’s been 6months or moresince systemic
therapy ended

One of the following:Ü• Repeat systemic therapy used before• Systemic therapy not used before• Palliative and best supportive care

Metastaticwith or without
local recurrence(might need biopsy
to confirm cancer)• Clinical trial (preferred)

One of the following:It’s been less than
6 months sincesystemic therapy
ended• Clinical trial (preferred)Ü• Gemcitabine-based systemic therapy(if fluoropyrimidine-based used before)• Fluoropyrimidine-based systemic therapy(if gemcitabine-based used before)• Palliative and best supportive care

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201946

5

Resectable

Recurrence
Metastatic recurrence

Best supportive care without active cancer
treatment should also be considered.
Supportive care, also called palliative care, istreatment to relieve the symptoms of cancer
and side effects of cancer treatment. Other
treatment options for recurrence depend on
how far the cancer has spread.

For metastatic cancer, recurrence therapy
options depend on how long it has been since
your last treatment was completed.
If cancer recurrence is 6 months or moresince systemic therapy ended, then youroptions are:Local recurrence

For a local recurrence, surgery may be possible
if the cancer is found only in the pancreas. A
team of doctors will need to agree that surgery
is the best choice in your case.

Clinical trial (preferred)

Repeating a systemic therapy used beforeTrying a different systemic therapy thanwhat was used beforePalliative and best supportive care

Options for local recurrence in the pancreas
and nearby area are:

Clinical trial (preferred)

Systemic therapySystemic therapy with chemoradiation



Systemic therapy with SBRT, if not done
before

SBRT

Palliative and best supportive care

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

If cancer recurrence is less than 6 months
since systemic therapy ended, then youroptions are:47Clinical trial (preferred)

Try a different systemic therapy than what
you had beforePalliative and best supportive care5

Resectable

Review

Review

In resectable pancreatic cancer, surgery isused as the primary treatment to remove
the tumor. You might have neoadjuvant
therapy before surgery to shrink the tumor
and reduce the amount of cancer cells.



If the tumor was removed (resected)
during surgery, then you will have adjuvant
therapy to rid the body of cancer cells andto help prevent recurrence.



If your surgeon was unable to remove
your tumor, it is now called unresectable.
Biopsies and other tests will be done tosee if the cancer is locally advanced ormetastatic.

After finishing adjuvant therapy, you willgo through follow-up testing and enter aperiod of time called surveillance.



If your cancer returns (recurrence) after
you had surgery, treatment will be basedon how far the cancer has spread and how
long it has been since adjuvant therapy
ended.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

A preferredtreatment has thebest result and fewerside effects.

48

6Treatment guide: Borderline
resectable
50

Tests

51

Neoadjuvant treatment

52

Surgery52

Adjuvant treatment

52

Review

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201949

6

Borderline resectable

Tests

This chapter will guide you throughtreatment for cancer that is found in thepancreas and might involve nearby veins
and arteries. Together, you and yourdoctor should choose a treatment planthat is best for you.

For borderline resectable cancer, your doctor
may plan to give you treatment before surgery
called neoadjuvant therapy. The goal ofneoadjuvant therapy is to try to shrink the tumor
in order make it easier to remove during surgery.

In borderline resectable cancer, the cancer isfound only in the pancreas but might involve
nearby blood vessels or structures. When thetumor is wrapped around part of the hepatic
artery, superior mesenteric artery, or superior
mesenteric vein, and there is risk for a positive
margin, then surgery might not be the best option.

Tests
Consider testing at a hospital or cancer
center that treats more than 15 to 20 people
with pancreatic cancer each year. Tests forborderline resectable pancreatic cancer with nometastases can be found in Guide 12.

Surgery should only be used as primary
treatment if a team of doctors agree the cancer
can be completely removed with surgery.

Treatment cannot start without a biopsy toconfirm cancer. There is more than one typeof biopsy. In this case, an EUS-FNA biopsy is

Guide 12. Tests for borderline resectable cancer with no metastases
Tests

NNext steps

Is it cancer?

Result• SurgeryYes• Biopsy (EUS-FNA
preferred)• Core biopsy
recommended• Consider staging
laparoscopy• Consider
ERCP withstent• Start neoadjuvant
therapyÜ• Pancreatic
protocolCT or
MRI ofabdomen• Chest andpelvic CT• CA 19-9• Baseline
CA 19-9No• RepeatbiopsyNCCN Guidelines for Patients®:
Pancreatic Cancer, 2019ÜÜ

• Consider
staging
laparoscopy(if not done
before)• Surgery is
not an option• Cancer isspreadingÜÜTumor removed(see Guide 9)
Tumor not removed(see below)

Locally advanced(see Guide 13)
Metastatic(see Guide 18)

Cancer confirmed (follow above)
Cancer not confirmed (rule out
auto-immune pancreatitis)

50

Ü

Follow-up at ahigh-volume center

6

Borderline resectable

Neoadjuvant treatment

Neoadjuvant treatment

preferred and a core biopsy is recommended. A
core biopsy removes a larger sample of tissue
using a wide, hollow needle.

Once a biopsy confirms pancreatic cancer,
then you will begin neoadjuvant treatment. The
goal of neoadjuvant treatment is to shrink thecancer so all of the cancer can be removed
with surgery. The neoadjuvant options might befollowed by chemoradiation.

If the first biopsy doesn’t confirm cancer, thena repeat biopsy must be done. Neoadjuvant
treatment isn’t recommended until a cancer
diagnosis is confirmed by biopsy.

Preferred neoadjuvant options include:Your doctor may also do a staging laparoscopy
to make sure there are no metastases in yourabdomen that didn’t show up on other imaging
tests. This is considered if you are at higher riskof having metastases. If the cancer is blocking
a bile duct, then a stent using ERCP will beplaced to unblock it.
After neoadjuvant treatment is started, then thefollowing tests will be done:CA 19-9Pancreatic protocol CT or MRI of abdomen

Chest and pelvic CT

FOLFIRINOXModified FOLFIRINOX

Gemcitabine with albumin-bound paclitaxelTreatment might be followed bychemoradiation

Neoadjuvant systemic therapy options will
be different if you have a BRCA1, BRCA2, or
PALB2 mutation. Germline testing will show
if you have any of these mutations. Germline
testing is recommended for anyone withconfirmed pancreatic cancer.

These tests will show how the tumor is
responding to treatment. If test results show thecancer is shrinking, then surgery might be an
option. A staging laparoscopy is recommended(if not done already) before surgery. Treatment
after surgery (adjuvant therapy) will be basedon whether or not the tumor was removed(resected).

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019Preferred neoadjuvant options for BRCA1,
BRCA2, or PALB2 mutations include:

51



FOLFIRINOXModified FOLFIRINOX

Gemcitabine with cisplatin

Treatment might be followed bychemoradiation

6

Treatment guide:
Borderline
resectable
Borderline resectable
Surgery
Surgery| Adjuvant treatment | Review

Surgery

Review

If the follow-up tests don’t show any signs ofcancer growth or spread, then you will proceedwith an operation to remove the tumor.
During surgery, your doctor may find thatthe cancer has spread too far and cannot be
fully removed. In this case, surgery can’t becompleted. While you are in the operating
room, the doctor may still perform a biliary
bypass procedure and/or a duodenal bypass
to prevent your tumor from causing jaundice orintestinal obstruction in the future. Your doctor
may also do a nerve block to relieve severe
pain.
Adjuvant treatment will depend on how far thecancer has spread. Cancer that involves nearby
blood vessels or other structures that prevent itfrom being completely removed with surgery iscalled locally advanced unresectable pancreaticcancer. Cancer that has spread outside thepancreas to distant sites in the body is called
metastatic pancreatic cancer.

Adjuvant treatment
Treatment for borderline resectable cancer will
be based on the following:Tumor was removed (see Guide 10)Tumor was not removed (see below)



Tumor was not removed because it islocally advanced (see Guide 13)Tumor was not removed because it ismetastatic (see Guide 18)

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201952

Surgery should only be used as primary
treatment if a team of doctors agree thecancer can be completely removed withsurgery.



If you have a borderline resectablepancreatic cancer, you might haveneoadjuvant treatment before surgery.
Neoadjuvant treatment might be followedby chemoradiation.

Once a biopsy confirms pancreatic cancer,
then you will begin neoadjuvant treatment.



After neoadjuvant therapy, if the tumor has
shrunk, you might have surgery to remove
the tumor.

Adjuvant treatment is based on whether
the tumor was removed during surgery.

7

Treatment guide: Locallyadvanced
54

Tests

54

First-line therapy

57

Second-line therapy

59

Review

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201953

7

Treatment
Locallyadvancedguide: Locally advanced

Tests | First-line therapy

This chapter will guide you throughtreatment options for cancer that has
spread outside the pancreas to nearby
blood vessels or other tissues. Together,you and your doctor should choose atreatment plan that is best for you.

First-line therapy
First-line therapy is the first treatment or setof treatments given to control the cancer. It isbased on your performance status (PS). Your
PS is a rating by your doctor based on youroverall health, cancer symptoms, and ability to
do daily activities. Good PS is usually PS 0 or
PS 1. Poor PS is PS 2, PS 3, or PS 4. The goalof treatment for locally advanced pancreaticcancer is to stop the cancer from growing andspreading. See Guide 14.

Tests
Before beginning cancer treatment, a biopsy isneeded to confirm pancreatic cancer if not done
before. If a biopsy confirms pancreatic cancer,
then the next step is to treat symptoms, such as
jaundice, caused by the cancer. Tests that arerecommended for locally advanced pancreaticcancer are found in Guide 13.

Good PSFirst-line therapy options for good PS include
one from the list below:

A tumor can cause jaundice by blocking a ductthat drains bile and bilirubin from the liver. If
you have jaundice, then a stent will be placedin the bile duct using ERCP. This will relieve theblockage in your bile duct. When placing thebiliary stent, your doctor may also take samples(called brushings) of the duct to test for cancer.
Clinical trial (preferred)

Systemic therapyChemoradiation



SBRT

Poor PSFirst-line therapy options for poor PS include
palliative and best supportive care with:

If the first biopsy doesn’t confirm
pancreatic cancer, then another biopsy
will be done to try to confirm pancreaticcancer.



Systemic therapy orPalliative radiation therapy

Chemoradiation

If another type of cancer is found on
biopsy, seek treatment for that type ofcancer. Find more information at NCCN
Guidelines for Patients® at
NCCN.org/patientguidelines.

If your first-line treatment is chemoradiation, theoptions for those with good PS are:After confirming pancreatic cancer with abiopsy and treating jaundice, cancer treatment
can begin.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019



54



Capecitabine with radiation therapy(preferred)Continuous infusion 5-FU with radiation
therapy (preferred)Gemcitabine with radiation therapy

7

Locally advanced

First-line therapy

Guide 13. Tests for locally advanced cancer
BiopsyCancerResultNext tests

What’s next

If not done before• Germline testing
Pancreaticcancerconfirmed

Ü• Gene testingÜ

If needed

If jaundiced, thenself-expanding metal
stent using ERCPÜ

see Guide 14• MSI testing• MMR testing
Biopsy toconfirm cancer(if not done
before)Pancreatic cancer
confirmed
Cancer notconfirmed

Ü• Repeat biopsyÜ• If jaundiced, then
ERCP with stentCancer notconfirmed
Other cancer
confirmed

Othercancerconfirmed

Ü

Ü
Ü
Ü

see Guide 14
Follow-up at
high-volume
centerSee below

See NCCN Guidelines for Patients® at NCCN.org/patientguidelines

Guide 14. First-line therapy options for locally advanced cancer
Good performance status

One of the following:

Poor performance status
One of the following:• Clinical trial (preferred)• Palliative and best supportive care withsystemic therapy (see Guide 15)• Systemic therapy (see Guide 15)• Palliative and best supportive care withpalliative radiation therapy• Chemotherapy for 4 to 6 months followed bychemoradiation• Chemotherapy for 4 to 6 months followed by
SBRT• Chemoradiation• SBRT

Note: Imaging tests might be done to see how cancer is responding to treatment.
NCCN Guidelines for Patients®:
Pancreatic Cancer, 201955

7

Locally advanced

First-line therapy
Good PSFirst-line systemic therapy options for locallyadvanced pancreatic cancer are based on
performance status (PS). Preferred treatments
have the best result with fewer side effects.

Preferred first-line systemic therapy options:

See Guide 15.



FOLFIRINOXModified FOLFIRINOX

Gemcitabine with albumin-bound paclitaxel

Guide 15. First-line systemic therapy options for locally advanced cancer
Options

Good performance status

Poor performance status

One of the following:• FOLFIRINOX• Modified FOLFIRINOX• Gemcitabine with albumin-bound paclitaxel

Preferred

For BRCA1, BRCA2, or PALB2 mutations only
One of the following:

One of the following:• Gemcitabine• Capecitabine• Continuous infusion 5-FU

• FOLFIRINOX• Modified FOLFIRINOX• Gemcitabine with cisplatin• Consider olaparib

One of the following:• Gemcitabine with erlotinib• Gemcitabine with capecitabine• Gemcitabine
Other• Capecitabine___• Continuous infusion 5-FU
• Fixed-dose-rate gemcitabine with docetaxel andcapecitabine (GTX)• Oxaliplatin with 5-FU and leucovorin (OFF)• Capecitabine with oxaliplatin (CapeOx)
One of the following:

Used only insome cases• Systemic therapy followed by chemoradiation• Systemic therapy followed by SBRT• Chemoradiation• SBRT

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

56

___

7

Locally advanced

Second-line therapy

Second-line therapy

Preferred first-line options for good PS will
be different if you have a BRCA1, BRCA2, or
PALB2 mutation. Germline testing will show
if you have any of these mutations. Germline
testing is recommended for anyone withconfirmed pancreatic cancer.

When first-line treatment does not stop thegrowth or spread of cancer, then a second
treatment might be an option. Second-line
therapy is the next set of treatments given
when the first or previous treatments failed
to stop cancer growth. Treatment options are
based on your PS. In the case of good PS,
treatment depends on whether or not thecancer has grown or spread. For second-line
therapy options for locally advanced pancreaticcancer, see Guide 16.

Poor PS

Preferred first-line systemic therapy options:

GemcitabineCapecitabineContinuous infusion 5-FU

Guide 16. Second-line therapy options for locally advanced cancer
PerformancestatusSecond-line therapy options• Poor PS

Palliative and best supportive care with:• Cancer has
spread• Good PS• Cancer has
not grown or
spreadÜÜ• Systemic therapy (see Guide 17) or• Palliative radiation therapy
Consider resection (if possible)ÜAdjuvant therapy (if needed)• Surveillance or___• Clinical trial

One of the following:• Clinical trial (preferred)• Good PS• Cancerhas grownor spreadÜ

PS is worse• Systemic therapy (see Guide 17)• Chemoradiation (if not given
before and if only the primarytumor is growing)• SBRT (if not given before andif only the primary tumor is
growing)Ü• Good PS• Cancerhas grownor spread

Note: Imaging tests might be done to see how cancer is responding to treatment.
NCCN Guidelines for Patients®:
Pancreatic Cancer, 201957

ÜPalliativeand best
supportivecareÜClinical trial

7

Locally advanced

Second-line therapy

Preferred options

For good PS, there are no preferred systemic
therapy options. Other options are available
and are based on many factors. Likewise,for poor PS, if you chose to go with systemic
therapy for second-line treatment, no options
are preferred. Other options are available, but
it depends on many factors. Your wishes playa role. You can always decide not to continue
with systemic therapy. See Guide 17.

For locally advanced pancreatic cancer, joining
a clinical trial is preferred if you have good PS.
For poor PS, palliative and best supportive careshould be considered. Talk with your doctor
about what you want from treatment. Preferredsystemic therapy options are those that havethe best result and fewer side effects.

Guide 17. Second-line systemic therapy options for locally advanced cancer
Options

Good performance status

Poor performance status

Preferred

___

___

Other

If gemcitabine-based therapy
used before, then try one of
the following:

If fluoropyrimidine-based
therapy used before, then try
one of the following:

One of the following:• 5-FU with leucovorin andliposomal irinotecan• Gemcitabine• Continuous infusion 5-FU

• 5-FU with leucovorin andirinotecan (FOLFIRI)• Modified FOLFIRINOX• Oxaliplatin with 5-FU andleucovorin (OFF)• FOLFOX• Capecitabine withoxaliplatin• Capecitabine• Gemcitabine• Capecitabine• Gemcitabine with
albumin-bound paclitaxel• Gemcitabine with cisplatin(only for BRCA1, BRCA2,
or PALB2 mutations)• Gemcitabine with erlotinib• 5-FU with leucovorin
and liposomal irinotecan(if not had irinotecan
before)• Continuous infusion 5-FU

Used only
in somecases• Pembrolizumab (only for MSI-H or dMMR tumors)• Larotrectinib (if NTRK gene fusion positive)• Chemoradiation (if not used before)

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

58

___

7

Locally advanced

Review

Review

Poor PS

If your PS is poor, then you may benefit frompalliative and best supportive care with:

Systemic therapy orPalliative radiation therapy

Good PS

If your PS is good and cancer has not grown or
spread, your treatment options are:

Surgery may be possible



Surveillance

Clinical trial

If your PS is good and cancer has grown or
spread, your treatment options are:

Clinical trial (preferred)

Systemic therapyChemoradiation



SBRT



Germline testing is recommended foranyone with confirmed pancreatic cancer.

Treatment options are based on yourperformance status (PS).



If you have jaundice, a stent using ERCP
will be placed before starting treatment.



Those with poor PS may benefit frompalliative and best supportive care withsystemic therapy or palliative radiation
therapy.

Treatment options will be different if
you have a BRCA1, BRCA2, or PALB2
mutation.

A preferredtreatment has thebest result and fewerside effects.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201959

8Treatment guide: Metastatic
61

Tests

62

First-line therapy

64

Second-line therapy

66

Review

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Pancreatic Cancer, 201960

8

Metastatic

Tests

Tests

This chapter will guide you throughtreatment for cancer that has spread far
from the pancreas. Together, you andyour doctor should choose a treatment
plan that is best for you.

Before beginning treatment for the cancer,
your doctor will first test for and treat jaundice.
Jaundice is a yellowing of the skin and eyescaused by a buildup of bilirubin in the body.
Bilirubin is a yellow-brown substance in bile. It
is a digestive fluid made in the liver.

Metastatic pancreatic cancer is cancer that has
spread to distant sites in the body. Metastatic
tumors are formed when cancer cells spreadthrough the blood or lymphatic system to sites
or organs that are far away from the pancreas.

A tumor in the pancreas can cause jaundice byblocking the bile duct that drains bilirubin outof the liver. To relieve symptoms of jaundice,your doctors will place a stent in the bile duct
to relieve the blockage in your bile duct. You
will not need a stent if you had a biliary bypass
during a previous surgery or laparoscopy.

The goals of metastatic pancreatic cancer
treatment are:

symptom reliefquality of life

longer survival

If not done before, then germline testing andgene testing of the tumor is recommended.
Your doctor might order MSI and MMR testing.

See Guide 18.

Guide 18. Tests for metastatic cancer
Tests before start of treatment
If there’s jaundice,then self-expanding metal stent will be placed
If not done before:• Germline testing• Gene testing of tumor
If needed:• MSI testing• MMR testing

NCCN Guidelines for Patients®:
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8

Metastatic

First-line therapy

First-line therapy

Good PS

If your PS is good, your treatment options are:First-line treatment is the first treatment or setof treatments given to control the cancer. It isbased on your performance status (PS). Good
PS is usually PS 0 or PS 1. Poor PS is PS 2,
PS 3, or PS 4.



Clinical trial (preferred)

Systemic therapy

Poor PS

If your PS is poor, then you may benefit frompalliative and best supportive care with:

Metastatic pancreatic cancer is not treatedwith surgery. The first-line therapy options formetastatic pancreatic cancer are shown in
Guide 19.



Systemic therapy orPalliative radiation therapy

Guide 19. Therapy options for metastatic cancer
First-line therapy
options

Second-line therapy options• Poor PS

Good PSOne of the following:• Clinical trial(preferred)• Cancer has
spreadÜÜ• Systemic therapy

Palliative and best supportive care with:• Systemic therapy or• Radiation therapy
One of the following:• Good PS• Cancer has
spreadÜ• Clinical trial(preferred)• Systemic therapyÜ• Radiation therapy
Poor PS
Palliative and best
supportive care with:___• Systemic therapyor• Radiation therapy

Note: Imaging tests might be done to see how cancer is responding to treatment.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201962

• Palliative and best
supportive care or• Clinical trial

8

Metastatic

First-line therapy
Poor PSFirst-line systemic therapy options formetastatic pancreatic cancer are based on PS.
Preferred are those with the best result and thathave fewer side effects. See Guide 20.

If your PS is poor, the preferred options are:

Good PS

If your PS is good, the preferred options are:

FOLFIRINOXModified FOLFIRINOX

Gemcitabine with albumin-bound paclitaxel

GemcitabineCapecitabineContinuous infusion 5-FU

Guide 20. First-line systemic therapy options for metastatic cancer
Options

Good performance status

Poor performance status

One of the following:• FOLFIRINOX• Modified FOLFIRINOX• Gemcitabine with albumin-bound paclitaxel

Preferred

For BRCA1, BRCA2, or PALB2 mutations only
One of the following:

One of the following:• Gemcitabine• Capecitabine• Continuous infusion 5-FU

• FOLFIRINOX• Modified FOLFIRINOX• Gemcitabine with cisplatin• Consider olaparib
One of the following:• Gemcitabine with erlotinib• Gemcitabine
Other• Gemcitabine with capecitabine• Fixed-dose-rate gemcitabine with docetaxel andcapecitabine (GTX)• Oxaliplatin with 5-FU and leucovorin (OFF)• Capecitabine with oxaliplatin (CapeOx)

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

63

___

8

Metastatic

Second-line therapy

Second-line therapy

Good PSFor good PS, treatment options are:If first-line treatment doesn’t stop the cancerfrom growing, then a second-line treatment
might be an option. Second-line treatment is
the next set of treatments given to control thecancer when the first or previous treatments
failed to stop cancer growth. It is based onyour performance status (PS). You doctor will
choose a different type of systemic therapy
than you had before. See Guide 21.

Clinical trial (preferred)

Systemic therapyRadiation therapy

Followed by:Poor PS

Palliative and best supportive orClinical trial

If your PS is poor, then you may benefit frompalliative and best supportive care with:

Systemic therapy orPalliative radiation therapy

Guide 21. Second-line therapy options for metastatic cancer that has spread
Performance status

Poor PS

Second-line therapy options

Ü

Palliative and best supportive care with:• Systemic therapy or• Palliative radiation therapy

One of the following:
Good PSÜ• Clinical trial (preferred)• Systemic therapyÜ• Palliative and best supportive care or• Clinical trial• Radiation therapy
Note: Imaging tests might be done to see how cancer is responding to treatment.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201964

8

Metastatic

Second-line therapy

Preferred options

Preferred options are those with the best result
and that have fewer side effects. For goodPS, there are no preferred systemic therapy
options. Other options are available and are
based on many factors. Likewise, for poor PS,
if you choose to go with systemic therapy forsecond-line treatment, no options are preferred.
Other options are available, but it depends on
many factors. See Guide 22.

For metastatic pancreatic cancer or cancer
recurrence, joining a clinical trial is preferred if
you have good PS. Best supportive care should
be considered. Talk with your doctor about
what you want from treatment. You can always
decide not to continue with systemic therapy.

Guide 22. Second-line therapy options for metastatic cancer or recurrence
Options

Good performance status

Preferred

Other

Poor performance status
___

___

If gemcitabine-based therapy
used before, then try one of
the following:

If fluoropyrimidine-based
therapy used before, then try
one of the following:

One of the following:• 5-FU with leucovorin andliposomal irinotecan• Gemcitabine• Continuous infusion 5-FU

• 5-FU with leucovorin andirinotecan (FOLFIRI)• Modified FOLFIRINOX• Oxaliplatin with 5-FU andleucovorin (OFF)• FOLFOX• Capecitabine withoxaliplatin• Gemcitabine with albuminbound paclitaxel• Gemcitabine with cisplatin(only for BRCA1, BRCA2,
or PALB2 mutations)• Gemcitabine with erlotinib• 5-FU with leucovorin andliposomal irinotecan (if not
had irinotecan before)• Capecitabine• Continuous infusion 5-FU

Used only insome cases• Pembrolizumab (only for MSI-H or dMMR tumors)• Larotrectinib (if NTRK gene fusion positive)• Chemoradiation (if not used before)

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201965

• Gemcitabine• Capecitabine

8

Metastatic

Review

Before beginning treatment, your doctor
will first treat symptoms such as jaundice.

Germline and tumor testing arerecommended for all patients withconfirmed metastatic disease. MSI and
MMR testing are done as needed.

A clinical trial is the preferred first-line
treatment and second-line treatment
option for those with good performancestatus (PS).



Those with poor PS may benefit frompalliative and best supportive care withsystemic therapy or palliative radiation
therapy.

Talk to your doctor about what you wantfrom treatment. You can always decide notto continue with systemic therapy.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019“
Review

My husband had colon cancer and beatit. Years later, he got pancreatic cancer
and we thought he could beat this too.
My heart is with all the families who
are facing this difficult cancer.
- Barbara66

9Making treatment decisions
68

It’s your choice

68

Questions to ask your doctors

74

Websites

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201967

9

Making treatment decisions

It’s your choice

Choosing which cancer treatment is bestfor you can be difficult. It is important
to ask questions and engage in shareddecision-making with your doctor.

Things you can do to prepare:It’s your choice
In shared decision-making, you and yourdoctors share information, discuss the options,and agree on a treatment plan. Your doctors
know the science behind your plan, but
might not know what is important to you. Tell
your doctors your goals and concerns about
treatment. By working together, you can decide
on a plan that works best for you when it comesto your personal and health needs.

Check with your insurance company about
its rules on second opinions. You want toknow about out-of-pocket costs for doctors
who are not part of your insurance plan.



Make plans to have copies of all yourrecords sent to the doctor you will see foryour second opinion. If you run into trouble
having records sent, pick them up andbring them with you.

Support groups

Support groups often include people atdifferent stages of treatment. Some may bein the process of deciding while others may
be finished with treatment. At support groups,
you can ask questions and hear about theexperiences of other people with pancreaticcancer. If your hospital or community doesn’t
have support groups for people with pancreaticcancer, check out the websites in this book.

Second opinion

After finding out you have cancer, it is normal
to want to start treatment as soon as possible.
While cancer can’t be ignored, there is time tohave another doctor review your test results
and suggest a treatment plan. This is called
getting a second opinion, and it’s a normal partof cancer care.

You can also reach out to a social worker or acounselor. They can help you find ways to copeor refer you to support services. These services
may also be available to your family, friends,
and those with children, so they can connect
and get support. Seek out supportive careservices by asking your care team.

Even if you like and trust your doctor, geta second opinion. If the new doctor offers
other advice, make an appointment with yourfirst doctor to talk about the differences. Do
whatever you need to feel confident about yourdiagnosis and treatment plan. Ask questions
and take notes during doctor visits. Bringsomeone with you to appointments.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019Questions to ask your doctors
Possible questions to ask your doctors are on
the following pages. Feel free to use thesequestions or come up with your own. Be clear
about your goals for treatment and find out
what you should expect from treatment.

68

9

Making treatment decisions

Questions to ask your doctors

Questions to ask your doctors about testing and staging
1. What tests will I have?
2. When will I have a biopsy? Will I have more than one? What are the risks?
3. How soon will I know the results and who will explain them to me?
4. Who will talk with me about the next steps? When?
5. What genetic tests will I have? When?
6. What will you do to make me comfortable during testing?
7. Is my cancer resectable, borderline resectable, or unresectable?
8. Is my cancer locally advanced or metastatic?
9. Is the cancer in any other organs like my liver?
10. What does my stage mean in terms of survival?

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201969

9

Making treatment decisions

Questions to ask your doctors

Questions to ask your doctors about surgery
1. If my cancer is resectable, how much of my tumor will be removed?
2. What are the chances you can remove all of the tumor and I will have a negative
margin?
3. What happens if during surgery you find you can’t remove the tumor?
4. What other organs or tissues might be removed during surgery? What will this mean interms of my survival and recovery?
5. How long will it take me to recover from surgery?
6. How much pain will I be in? What will be done to manage my pain?
7. How many pancreatic cancer surgeries have you done? How many of your patients
have had complications? What are the complications?
8. What is the chance that this surgery will shorten my life?
9. Will I need a stent?
10. How will this surgery affect my ability to eat and digest food?

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201970

9Making treatment decisions

Questions to ask your doctors

Questions to ask your doctors about treatment
1. What are my treatment choices? What are the benefits and risks? Which treatment doyou recommend and why?
2. How will my age, performance status, cancer stage, and other health conditions limit mytreatment choices?
3. How long do I have to decide about treatment?
4. Does this hospital or center offer the best treatment for me?
5. When will I start treatment? How long will treatment take?
6. How much will the treatment cost? How much will my insurance pay for?
7. What are the chances my cancer will return? How will it be treated if it returns?
8. I would like a second opinion. Is there someone you can recommend?
9. Is a clinical trial an option for me?
10. Which treatment will give me the best quality of life?

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201971

9Making treatment decisions

Questions to ask your doctors

Questions to ask your doctors about side effects
1. What are the side effects of treatment?
2. What type of systemic therapy will I have? What are the side effects?
3. What are the side effects of surgery?
4. What are the side effects of a stent? A biliary bypass?
5. What are the side effects of pancreatic cancer?
6. How long will these side effects last?
7. When should I call the doctor about my side effects?
8. What medicines can I take to prevent or relieve side effects?
9. What else can I do to help with pain and other side effects?
10. Will you stop treatment if I have side effects?

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201972

9

Making treatment decisions

Questions to ask your doctors

Questions to ask your doctors about clinical trials
1. What clinical trials are available for my type and stage of pancreatic cancer?
2. What are the treatments used in the clinical trial?
3. What does the treatment do?
4. Has the treatment been used before? Has it been used for other types of cancer?
5. What are the risks and benefits of this treatment?
6. What side effects should I expect? How will the side effects be controlled?
7. How long will I be in the clinical trial?
8. Will I be able to get other treatment if this doesn’t work?
9. How will I know if the treatment is working?
10. Will the clinical trial cost me anything? If so, how much?

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201973

9Making treatment decisions

Websites

Websites
American Cancer Society

cancer.org/cancer/pancreatic-cancer.html

Let’s Win! Pancreatic Cancer
Foundation
https://letswinpc.org

Lustgarten Foundation for Pancreatic
Cancer Research
lustgarten.org

National Cancer Institutecancer.gov/types/pancreatic

National Coalition for Cancer
Survivorshipcanceradvocacy.org/toolbox/

National Hospice and Palliative Care
Organization

https://www.nhpco.org/patients-and-caregivers/

NCCN Find a clinical trial

nccn.org/patients/resources/clinical_trials/find_trials.aspx

NCCN Guidelines for Patients®
nccn.org/patients

Pancreatic Cancer Action Network(PanCAN)pancan.org

The National Pancreas Foundation
https://pancreasfoundation.org/

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201974Ü

Words to know

Words to know

chemotherapy
Drugs that kill fast-growing cells throughout thebody, including cancer cells and normal cells.

adjuvant
Treatment given after the main treatment used
to rid the body of cancer.

cholangitis
An infection of the bile ducts that drain digestive
fluids out of the liver.

best supportive care
Treatment to improve quality of life and relieve
discomfort.

common bile duct
A tiny tube that carries digestive fluid (bile) fromthe liver into the small intestine, which absorbs
nutrients from eaten food.

bile duct
A tiny tube or vessel in the body that drains
digestive fluid (bile) from the liver.

computed tomography (CT)A test that uses x-rays from many angles tomake a picture of the inside of the body.

biliary bypass
Surgery to re-route the flow of bile, digestive
fluid, from the common bile duct into the small
intestine.

contrast
A chemical put into your body to make clearer
pictures during imaging tests.
CT-guided FNA biopsy
Use of pictures from a CT (computed
tomography) scan to guide a thin needle to theright spot to remove a sample of tissue from thebody for testing.

biliary stent
A small plastic or metal tube-shaped device
used to unblock a bile duct.
bilirubin
A yellow-brown substance that is removed fromblood by the liver and is part of bile.

distal pancreatectomy
Surgery that removes the widest part (body)and narrow end (tail) of the pancreas as well asother nearby organs.

borderline resectable
Cancer that is confined to the pancreas but
approaches nearby structures or has severe
symptoms, raising concern that it might or
might not be possible to remove all the cancer
with surgery.

ductal adenocarcinoma
Cancer of the cells that line the pancreatic
ducts and small tubes that fluids pass through,and make proteins that digest food.

CA 19-9
Proteins made by cancer cells and found inblood.

duodenal bypass
Surgery to re-route the path that eaten foodtakes from the stomach to the small intestine,
which absorbs nutrients from food.

celiac plexus neurolysis
Ethanol is injected into the nerves of theabdomen to block pain.

endoscopic retrograde
cholangiopancreatography (ERCP)
A test that uses x-rays and a thin, lighted
tube that is inserted into the body to see thepancreatic ducts and bile ducts.

chemoradiation
Treatment that combines chemotherapy andradiation therapy.

NCCN Guidelines for Patients®:
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Words to know
jaundice
Yellowing of the skin and eyes due to a buildup
of bilirubin in the body.

endoscopic ultrasound (EUS)
A test that uses a thin, lighted tube guided
through the mouth and down the throat to takepictures of the inside of the body using soundwaves.

laparoscopy
A surgical test that uses a thin, lighted tube
inserted through a small cut in the belly(abdomen) to see inside the belly area andpossibly remove tissue for testing.

EUS-guided FNA biopsy
Use of pictures from sound waves and a thin,lighted tube inserted through the mouth toguide a thin needle to the right spot to remove asample of tissue from the body for testing. Also
called EUS-FNA.

liver function test
A blood test that measures chemicals that are
made or processed by the liver to check how
well the liver is working.

fine-needle aspiration (FNA)
Use of a thin needle to remove a small amountof tissue or fluid from the body to test for cancer
cells.

locally advanced pancreatic cancer
Cancer that started in the pancreas and has
grown into nearby blood vessels or tissues.

first-line treatment
The first drug or set of drugs given to treat a
disease. Might be followed by second-line ormore lines of treatment.

local recurrence
Cancer that came back after treatment. Foundin or near the pancreas.
magnetic resonancecholangiopancreatography (MRCP)
A test that uses radio waves and powerfulmagnets to make very clear pictures of thepancreas and bile ducts.

fluoropyrimidine-based therapy
A combination chemotherapy regimen in which
the main drug used is 5-FU (5-fluorouracil).
FOLFIRINOX
A combination chemotherapy regimen that
includes 5-FU, leucovorin, irinotecan, andoxaliplatin.

magnetic resonance imaging (MRI)
A test that uses radio waves and powerfulmagnets to make pictures of the inside of the
body showing the shape and function of bodyparts.

FOLFOX
A combination chemotherapy regimen that
includes 5-FU, leucovorin, and oxaliplatin.

main pancreatic duct
A small tube in the body that drains digestive
fluids from the pancreas into the first part of thesmall intestine (duodenum).

gastroenterologist
A doctor who’s an expert in diseases of thedigestive system. This system contains organs
that break down food for the body to use.

metastasis
Cancer that has spread from the first tumor
to another body part. Can be local (near the
primary tumor) or distant.

gastrojejunostomy
Surgery to bypass a blockage in the part of thestomach that empties into the small intestine.
gemcitabine-based therapy
A combination chemotherapy regimen in which
the main drug used is gemcitabine.
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Words to know
neoadjuvant
The treatment given before the main (primary)treatment used to rid the body of cancer.

recurrence
The return of cancer after treatment. Also called
relapse.

palliative radiation
Radiation used to relieve symptoms such as
pain caused by pancreatic cancer or cancer
treatment.

resectable
Cancer that can be completely removed withsurgery.
surveillance
Testing to watch for cancer growth. No
treatment is given during this time.

pancreatic duct
A small tube in the pancreas that digestive
fluids pass through.

stereotactic body radiation therapy (SBRT)
Radiation therapy given in higher doses tosmaller areas over 1 to 5 sessions of treatment.

pancreatic protocol CT
A CT scan that is done in a certain way sothat all of the pictures focus specifically on thepancreas to clearly show the pancreas, nearby
blood vessels, and very tiny tumors elsewhere
in your abdomen.

superior mesenteric artery
The large, tube-shaped vessel that carries
blood from the heart to the intestines—theorgan food passes through after leaving thestomach.

pancreatoduodenectomy
Surgery to remove the widest part (head) of
the pancreas and parts of other nearby organs.
Also called Whipple procedure.

superior mesenteric vein
The large, tube-shaped vessel that returns
blood from the intestines—organ food passes
through after leaving the stomach—back to theheart.

percutaneous endoscopic gastrostomy(PEG) tube
A tube inserted through a cut in the abdomen
and placed into the stomach to give food.

supportive care
Treatment given to relieve symptoms caused
by cancer or cancer treatment. Also called
palliative care.

performance status (PS)A rating of a person’s symptoms and ability to
do daily activities.

surgical margin
The normal-looking tissue around the edge ofthe tumor removed during surgery.

Positron emission tomography (PET)A test that uses two picture-making methods toshow the shape and function of tissue.

total pancreatectomy
Surgery to remove the entire pancreas andother nearby organs and tissues.

primary treatment
The main treatment used to rid the bodyof cancer. In resectable pancreatic cancer,
surgery is the primary treatment.

unresectable
Cancer that can’t be removed by surgery.

radiation therapy
The use of high-energy rays (radiation) to
destroy cancer cells.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

Whipple procedure
Surgery to remove the head of the pancreas
and parts of other nearby organs. Also calledpancreaticoduodenectomy.

78

NCCN Contributors

NCCN Contributors
This patient guide is based on the NCCN Clinical Practice Guidelines in Oncology (NCCN
Guidelines®) for Pancreatic Adenocarcinoma. It was adapted, reviewed, and published with help
from the following people:
Dorothy A. Shead, MS

Director, Patient Information
Operations

Laura J. Hanisch, PsyD
Medical Writer/Patient
Information Specialist

Rachael Clarke

Kim Williams

Tanya Fischer, MEd, MSLIS

Susan Kidney

Senior Medical Copyeditor

Erin Vidic, MA

Medical Writer

Medical Writer

Creative Services Manager
Design Specialist

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Pancreatic
Adenocarcinoma, Version 3.2019 were developed by the following NCCN Panel Members:
Margaret A. Tempero, MD
Chair

UCSF Helen Diller Family
Comprehensive Cancer Center

Mokenge P. Malafa, MD
Vice Chair
Moffitt Cancer Center*Mahmoud Al-Hawary, MD
University of Michigan
Rogel Cancer Center

Horacio Asbun, MD

Mayo Clinic Cancer Center

Stephen W. Behrman, MD
The University of Tennessee
Health Science Center

Al B. Benson III, MD

Vincent Chung, MD*Marco Del Chiaro, MD, PhD

UCSF Helen Diller Family
Comprehensive Cancer Center

Mary Dillhoff, MD*Noelle LoConte, MD
University of Wisconsin
Carbone Cancer Center

University of Colorado
Cancer Center

The Ohio State University
Comprehensive Cancer Center James Cancer Hospital andSolove Research Institute

Yale Cancer Center/
Smilow Cancer Hospital

UC San Diego
Moores Cancer Center*Cassadie Moravek

Cristina R. Ferrone, MD

Eric K. Nakakura, MD

George Fisher, MD, PhD

Amol K. Narang, MD

Fox Chase Cancer Center

Ellen Binder, MD

Charles Cha, MD

Andrew M. Lowy, MD

Efrat Dotan, MD

Stanford Cancer Institute

Vanderbilt-Ingram Cancer Center

Andrew H. Ko, MD

Duke Cancer Institute

Robert H. Lurie Comprehensive
Cancer Center of Northwestern
University

Dana B. Cardin, MD

Siteman Cancer Center at BarnesJewish Hospital and Washington
University School of Medicine*

Brian Czito, MD

Massachusetts General Hospital
Cancer Center

Siteman Cancer Center at BarnesJewish Hospital and Washington
University School of Medicine

William G. Hawkins, MD

City of Hope
National Medical Center

Pancreatic Cancer Action Network
UCSF Helen Diller Family
Comprehensive Cancer Center
The Sidney Kimmel
Comprehensive Cancer
Center at Johns Hopkins

Christos Fountzilas, MD

Roswell Park Comprehensive
Cancer Center

Eileen M. O’Reilly, MD
Memorial Sloan Kettering
Cancer Center

Jeffrey Hardacre, MD

Case Comprehensive Cancer
Center/University Hospitals
Seidman Cancer Center andCleveland Clinic Taussig
Cancer Institute*Jorge Obando, MD
Duke Cancer InstituteSushanth Reddy, MD

E. Gabriela Chiorean, MD

O’Neal Comprehensive
Cancer Center at UAB

Fred Hutchinson Cancer
Research Center/Seattle Cancer Care Alliance* Reviewed this patient guide.
For disclosures, visit www.nccn.org/about/disclosure.aspx.

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201979

Courtney Scaife, MD

Huntsman Cancer Instituteat the University of Utah

Sarah Thayer, MD

Fred & Pamela Buffet
Cancer Center

Robert A. Wolff, MD

The University of Texas
MD Anderson Cancer Center

Brian M. Wolpin, MD, MPH
Dana-Farber/Brigham and
Women’s Cancer Center

NCCN
Jennifer Burns

Guidelines Coordinator

Lydia Hammond, MBA

Guidelines Layout Specialist

Griselda Zuccarino-Catania,
PhD

Oncology Scientist/Medical Writer

NCCN Cancer Centers

NCCN Cancer Centers
Abramson Cancer Centerat the University of Pennsylvania
Philadelphia, Pennsylvania
800.789.7366
pennmedicine.org/cancer

Fred & Pamela Buffett Cancer Center
Omaha, Nebraska
800.999.5465
nebraskamed.com/cancer

Case Comprehensive Cancer Center/
University Hospitals Seidman Cancer
Center and Cleveland Clinic Taussig
Cancer InstituteCleveland, Ohio
800.641.2422 • UH Seidman Cancer Centeruhhospitals.org/services/cancer-services
866.223.8100 • CC Taussig Cancer Institutemy.clevelandclinic.org/departments/cancer
216.844.8797 • Case CCC
case.edu/cancer

City of Hope National Medical Center
Los Angeles, California
800.826.4673
cityofhope.org

Dana-Farber/Brigham and
Women’s Cancer Center
Massachusetts General Hospital
Cancer Center
Boston, Massachusetts
877.332.4294
dfbwcc.org
massgeneral.org/cancer

Duke Cancer InstituteDurham, North Carolina
888.275.3853
dukecancerinstitute.org

Fox Chase Cancer Center
Philadelphia, Pennsylvania
888.369.2427
foxchase.org

Huntsman Cancer Instituteat the University of Utah
Salt Lake City, Utah
877.585.0303
huntsmancancer.org

Fred Hutchinson Cancer
Research Center/Seattle
Cancer Care Alliance

Seattle, Washington
206.288.7222 • seattlecca.org
206.667.5000 • fredhutch.org

NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019The Sidney Kimmel Comprehensive
Cancer Center at Johns Hopkins
Baltimore, Maryland
410.955.8964
hopkinskimmelcancercenter.org

Robert H. Lurie Comprehensive
Cancer Center of Northwestern
University
Chicago, Illinois
866.587.4322
cancer.northwestern.edu

Mayo Clinic Cancer Center

Phoenix/Scottsdale, Arizona
Jacksonville, Florida
Rochester, Minnesota
800.446.2279 • Arizona
904.953.0853 • Florida
507.538.3270 • Minnesota
mayoclinic.org/departments-centers/mayoclinic-cancer-center

St. Jude Children’s Research Hospital
The University of Tennessee
Health Science Center
Memphis, Tennessee
888.226.4343 • stjude.org
901.683.0055 • westclinic.com

Stanford Cancer InstituteStanford, California
877.668.7535
cancer.stanford.edu

UC San Diego Moores Cancer Center
La Jolla, California
858.657.7000
cancer.ucsd.edu

UCSF Helen Diller Family
Comprehensive Cancer Center
San Francisco, California
800.689.8273
cancer.ucsf.edu

Memorial Sloan Kettering
Cancer Center

University of Colorado Cancer Center

Moffitt Cancer Center

University of Michigan
Rogel Cancer Center

New York, New York
800.525.2225
mskcc.org
Tampa, Florida
800.456.3434
moffitt.org

Aurora, Colorado
720.848.0300
coloradocancercenter.org

Ann Arbor, Michigan
800.865.1125
rogelcancercenter.org

The Ohio State University
Comprehensive Cancer Center James Cancer Hospital andSolove Research Institute
Columbus, Ohio
800.293.5066
cancer.osu.edu

O’Neal Comprehensive
Cancer Center at UAB

Birmingham, Alabama
800.822.0933
uab.edu/onealcancercenter

Roswell Park Comprehensive
Cancer Center
Buffalo, New York877.275.7724
roswellpark.org

The University of Texas
MD Anderson Cancer Center
Houston, Texas
800.392.1611
mdanderson.org

University of Wisconsin
Carbone Cancer Center
Madison, Wisconsin
608.265.1700
uwhealth.org/cancer

Vanderbilt-Ingram Cancer Center
Nashville, Tennessee
800.811.8480
vicc.org

Yale Cancer Center/
Smilow Cancer Hospital

Siteman Cancer Center at BarnesJewish Hospital and Washington
University School of Medicine
St. Louis, Missouri
800.600.3606
siteman.wustl.edu

80

New Haven, Connecticut
855.4.SMILOW
yalecancercenter.org

Notes

Notes

NCCN Guidelines for Patients®:
Pancreatic Cancer, 201981

Index

Index
best supportive care 36, 46–47, 54–55,
57–59, 62, 64–66
biliary bypass 36, 43, 52, 61
biopsy 18–24, 28, 30, 33, 41–42, 46, 50–52,
54–55
CA 19-9 19–20, 22, 41–42, 44–45, 50–51
chemotherapy 26, 30–31, 55
chemoradiation 31, 42, 44–47, 51–52, 54–59
clinical trial 32–34, 44–47, 54–59, 62, 64–66,
73
distal pancreatectomy 28–29
ductal adenocarcinoma 9
endoscopic retrograde
cholangiopancreatography (ERCP) 18, 22,
50–55, 59
endoscopic ultrasound (EUS) 18–20, 22,
37–38, 41–42, 50
laparoscopy 18, 21, 41–42, 50–51, 61
magnetic resonancecholangiopancreatography (MRCP) 17
pancreaticoduodenectomy 28
pancreatic protocol CT 16, 21, 41–42, 50–51
pancreatic protocol MRI 17
radiation therapy 26, 30–31, 33, 37–38,
54–55, 57, 59, 62, 64, 66, 76
stage/staging 21–22, 26, 28, 30, 34, 41–42,
50–51, 68–69
total pancreatectomy 28–29
Whipple procedure 28–29
NCCN Guidelines for Patients®:
Pancreatic Cancer, 2019

82

Ü

NCCN
GUIDELINESFOR PATIENTS®

Pancreatic
Cancer2019
NCCN Foundation® gratefully acknowledges our industry supporters AstraZeneca, Celgene Corporation, and Ipsen Biopharmaceuticals,Inc. for their support in making available these NCCN Guidelines for Patients®. NCCN independently develops and distributes the
NCCN Guidelines for Patients. Our supporters do not participate in the development of the NCCN Guidelines for Patients and are notresponsible for the content and recommendations contained therein.

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