Radiation Therapy for Pancreatic Cancer: An ASTRO Clinical Practice Guideline

This guideline provides evidence-based recommendations on the use of radiation therapy (RT) for the treatment of pancreatic cancer in a variety of clinical settings including patients with resectable, borderline resectable, locally advanced, metastatic, and symptomatic disease.

The American Society for Radiation Oncology convened a multidisciplinary task force to address 4 key questions: (1) indications for and timing of RT for patients with nonmetastatic pancreatic cancer; (2) appropriate RT dose-fractionation regimens and target volumes for nonmetastatic disease; (3) preferred RT planning and delivery techniques for nonmetastatic disease; and (4) indications for RT in the locally recurrent, metastatic, reirradiation, and palliative settings. Recommendations are based on a systematic literature review and were created using a predefined consensus-based methodology with a system for grading evidence quality and recommendation strength.

Multidisciplinary evaluation and decision-making are recommended for all patients. For patients with nonmetastatic pancreatic cancer, RT is conditionally recommended in the preoperative and postoperative settings for resectable disease. RT is recommended preoperatively for borderline resectable disease and definitively in the locally advanced setting. For preoperative RT, conventional fractionation or moderate hypofractionation is recommended. For postoperative RT, conventional fractionation is recommended. In the definitive setting, conventional fractionation is appropriate although emerging evidence supports dose escalation using either stereotactic body radiation therapy or moderate hypofractionation. Adaptive RT is recommended for dose-escalated stereotactic body radiation therapy. Elective coverage of at-risk anatomic regions is recommended for preoperative, postoperative, and definitive RT. In the locally recurrent setting, RT is recommended for patients without prior RT and conditionally recommended for those who have previously received RT. Palliative RT is recommended for patients with bleeding, pain, and obstruction. For patients with oligometastatic and oligoprogressive pancreatic cancer, RT is conditionally recommended to metastatic lesions and the primary tumor if not previously treated with definitive local therapy. Target volumes, simulation and planning techniques, and treatment recommendations are provided.

These evidence-based recommendations provide guidance on the optimal use of RT for pancreatic cancer. Ongoing and future studies should further refine RT indications, sequencing with other therapies, and impact on patient outcomes.