Pancreatic Cancer Treatment Protocols 

Updated: Aug 10, 2018
  • Author: Tomislav Dragovich, MD, PhD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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Treatment Protocols

Treatment protocols for pancreatic cancer are provided below, including the following:

  • Surgical resection and chemotherapy/chemoradiation
  • Treatment for metastatic disease
  • Special considerations

Surgical resection for pancreatic cancer

Considerations include the following:

  • Surgical resection is potentially the only curative treatment approach for pancreatic cancer; however, most patients will present with disease that will not be cured with resection.

  • Surgical resection depends on the size and location of the tumor and should involve multidisciplinary consultation.

  • Pancreatic cancer primary tumor size measurements are often discordant between CT and pathologic specimen after resection. Dimensions of the primary tumor are increasingly relevant in an era of highly conformal radiotherapy. [1]

Treatment recommendations for resectable local disease

Stages I-II:

Neoadjuvant therapy [2] :

  • No standard regimens currently exist for neoadjuvant treatment of resectable pancreatic cancer

  • Neoadjuvant therapy should be conducted on a clinical trial basis for patients with resectable tumors

  • Examples of neoadjuvant drug regimens include FOLFIRINOX (oxaliplatin, leucovorin, irinotecan, 5-fluorouracil [5-FU]) ± subsequent chemoradiation; gemcitabine + albumin-bound paclitaxel ± subsequent chemoradiation; and gemcitabine + cisplatin (≥2–six cycles) followed by chemoradiation (only for known BRCA1/2 mutations)

Adjuvant chemotherapy [3, 4, 5] :

  • Gemcitabine monotherapy has been the standard of care since the CONKO-001 trial in 2008 [4]
  • Gemcitabine 1000 mg/m 2 IV over 30 min weekly for 3 wk; every 4 wk for six cycles
  • Modified FOLFIRINOX (mFOLFIRINOX), in the Unicancer GI PRODIGE 24/CCTG PA.6 trial, demonstrated superior results compared with gemcitabine monotherapy (median overall survival of 54.5 versus 35 months, respectively) [6]
  • mFOLFIRINOX: Oxaliplatin 85 mg/m², leucovorin 400 mg/m², irinotecan 150 mg/m², 5-FU 2.4 g/m² over 46 hours) every 14 days for 12 cycles

Adjuvant chemotherapy and chemoradiation [7] :

  • Gemcitabine 1000 mg/m2 IV over 30 min weekly for 3 wk [8]

  • Concurrent chemoradiation starting 1-2 wk after gemcitabine: 5-fluorouracil (FU) 250 mg/m2/day continuous IV infusion via pump during radiation

  • Radiotherapy 1.8 Gy/day to a total of 50.4 Gy; then  3-5 wk after chemoradiation: gemcitabine 1000 mg/m2 IV over 30 min weekly; every 28 d for three cycles [7]

  • The above regimens may be preceded by capecitabine 800-900 mg/m2 PO BID plus radiation for 5-6 wk

Treatment recommendations for locally advanced, unresectable disease

Stage III:

Neoadjuvant therapy:

  • For patients with stage III unresectable, locally advanced pancreatic cancer, preoperative (neoadjuvant) chemotherapy can be considered, but the benefit in terms of downstaging is modest

  • Gemcitabine 1000 mg/m2 IV over 30 min weekly for 3 wk; every 28 d [4]  or

  • 5-FU 500 mg/m2/day IV bolus on days 1-3 and 29-31 with concurrent radiotherapy, 40 Gy [9]

Treatment recommendations for metastatic disease

Stage IV:

First-line treatment recommendations for advanced metastatic pancreatic cancer:

  • Paclitaxel protein bound 125 mg/m2 plus gemcitabine 1000 mg/m2 IV over 30-40 min on days 1, 8, and 15 of each 28-day cycle [10]

  • Gemcitabine 1000 mg/m2 IV over 30 min weekly for 7 wk, followed by 1 wk off, then weekly for 3 wk; every 28 d [11] or

  • Gemcitabine 1000 mg/m2 IV over 30 min on days 1 and 15 plus cisplatin 50 mg/m2 IV over 1 h on days 1 and 15; every 28 d [12] or

  • Gemcitabine 1000 mg/m2 IV weekly for 7 wk plus erlotinib 100 mg PO daily on days 1-56, followed by 1 wk off; then  gemcitabine 1000 mg/m2 IV on days 1, 8, and 15 every 28 d plus  erlotinib 100 mg PO daily on days 1-28 for up to four cycles [13] or

  • Gemcitabine 1000 mg/m2 IV weekly for 3 wk; every 28 d; plus capecitabine 1660 mg/m2/day weekly for 3 wk; every 28 d [14] or

  • For patients with stage IV disease, median overall survival on gemcitabine-based therapy is from 5.5 to 7 mo; the non–gemcitabine-based regimen FOLFIRINOX (5-FU/leucovorin, irinotecan, and oxaliplatin) showed improved survival of 11.1mo [15] : Oxaliplatin 85 mg/m2 IV on day 1 plus irinotecan 180 mg/m2 IV on day 1 plus leucovorin 400 mg/m2 IV on day 1, followed by 5-FU 400 mg/m2 IV bolus on day 1 and then 2400 mg/m2 IV infusion over 46 h on days 1 and 15

Second-line treatment recommendations for advanced metastatic pancreatic cancer:

  • Capecitabine 1250 mg/m2 PO BID for 14d; every 3 wk [16] or

  • Capecitabine 1000 mg/m2 PO BID for 14 d; every 3 wk plus  erlotinib 150 mg PO daily continuously [17] or

  • Irinotecan liposomal 70 mg/m2 IV infused over 90 min, followed by  leucovorin 400 mg/m2 IV infused over 30 min, followed by  fluorouracil 2400 mg/m2 IV infused over 46 h every 3 wk [18] or

  • 5-FU 2000 mg/m2 IV over 24 h on days 1, 8, 15, and 22 plus  leucovorin 200 mg/m2 IV over 30 min on days 1, 8, 15, and 22 plus  oxaliplatin 85 mg/m2 IV on days 8 and 22; every 42 d [19]

Special considerations

See the list below:

  • For patients whose disease progresses on first-line therapy, few options are available and median survival on therapy ranges between 3 and 7 mo

  • Because of generally poor outcomes with standard therapy, all patients with pancreatic cancer should be encouraged to participate in clinical trials