New Guidelines Regarding the Role of Radiation Therapy in Pancreatic Cancer Treatment

The American Society for Radiation Oncology (ASTRO) provided recommendations on the use of radiation therapy (RT) to treat patients with pancreatic cancer. The recommendations, published in Practical Radiation Oncology, cover when radiation treatments are necessary, as well as optimal dosing and timing with these treatments.

ASTRO convened a task force to address seven key questions pertaining to RT, including dose fraction and treatment volumes, simulation and treatment planning, and prevention of radiation-associated toxicities. The team’s recommendations were based on conducting a systematic literature review and constructed using predefined methodology and a set system for grading evidence quality as well as recommendation strength.

Recommendations:

  • In the adjuvant/post-operative setting, conventionally fractionated radiation is recommended conditionally for patients with high-risk features such as positive lymph nodes and margins following surgical resection. SBRT is recommended only if the patient is enrolled in a clinical trial/data registry.
  • In the neoadjuvant/pre-operative setting, conventionally fractionated radiation therapy or SBRT is recommended conditionally following chemotherapy for patients with resectable disease. Neoadjuvant chemotherapy plus radiation (either conventional or stereotactic) is conditionally recommended following systemic therapy for select patients with borderline resectable disease.
  • For patients with locally advanced disease (who are not candidates for surgery), systemic chemotherapy followed by either chemoradiation or SBRT is recommended conditionally as an option for definitive treatment.

Further recommendations addressed:

  • optimal dosing and fractionation for different subgroups of patients;
  • sequencing of radiation with systemic chemotherapies in adjuvant, neoadjuvant and definitive settings;
  • simulation and setup strategies, such as image guidance and patient-specific motion management;
  • techniques for treatment planning and delivery, including a strong recommendation for the use of modulated radiation therapy to deliver treatment; and
  • treatment in the palliative setting, including a strong recommendation for palliative radiation therapy to either the primary tumor or select metastatic sites to help relieve the patient’s pain and other symptoms.

“The role of radiation in the management of pancreatic cancer is evolving in the adjuvant, neoadjuvant, and definitive settings, as is the use of dose escalation and ablative RT, with advances in motion management, target delineation, treatment planning, and image guidance,” the authors wrote in their conclusion.

“The role of RT is likely to become even more important as new systemic therapies are developed and there is increased focus on controlling local disease. It is critical that the nuances of available data are discussed with patients and families and that care for patients with pancreatic cancer be coordinated in a multidisciplinary fashion.”