The American Society for Radiation Oncology (ASTRO) recently published a new clinical guideline on the use of radiation therapy to treat patients diagnosed with pancreatic cancer—the third leading cause of cancer death, with more than 45,000 deaths and 56,000 new diagnoses in 2019.

Manisha Palta, MD, a Duke radiation oncologist and co-chair of ASTRO’s guideline task force, says the guideline fills a gap in the literature about how and when radiation therapy should be utilized in the management of patients with pancreatic cancer. “The role of radiation therapy in pancreatic cancer is very nuanced, and there’s a lot of new data emerging on how it should be utilized,” she says. “This is the first guideline published specifically for treating pancreatic cancer.”

With a five-year relative survival rate of only 9%, treating such an aggressive cancer requires knowledge of appropriate radiation treatments in various settings; optimal dosing, timing, and fractionation; and strategies to mitigate common side effects of pancreatic radiation therapy.

The ASTRO taskforce comprised a multidisciplinary group of experts in radiation oncology, medical oncology, surgical oncology, and a patient representative that systematically reviewed more than 170 studies published over 10 years to formulate the guideline, which addresses the adjuvant, neoadjuvant, definitive, and palliative settings and provides recommendations on indications and technical considerations. The American Society of Clinical Oncology and Society of Surgical Oncology have endorsed the guideline.

The guideline addresses seven key questions in four main areas:

• use of radiation in neoadjuvant, adjuvant, definitive, and palliative treatment settings
• stereotactic vs. conventional radiation therapy
• technical aspects of radiation therapy simulation, treatment planning and treatment delivery
• mitigation of common side effects

Highlights from the guideline include recommendations on:

• conventionally fractionated or stereotactic body radiation for neoadjuvant and definitive therapies in certain patients and conventionally fractionated regimens for adjuvant therapy
• a range of appropriate dose-fractionation schemes
• target volumes and sequencing of radiation and chemotherapy
• motion management, daily image guidance, use of contrast, and treatment with modulated techniques
• prophylactic antiemetic medication and medications to reduce acid secretion

Palta encourages any provider who manages pancreatic cancer treatments to read the executive summary of the guideline, published in September 2019 in Practical Radiation Oncology, ASTRO’s clinical practice journal. The full text of the guideline can be downloaded from the executive summary.

The role of radiation in the management of pancreatic cancer is evolving, with many ongoing areas of active investigation, Palta says. Radiation therapy is likely to become even more important as new systemic therapies are developed and there is increased focus on controlling local disease, she adds. But, she stresses that one of the most important takeaways from the guideline is the emphasis on a patient-centric approach: “The most important thing for patients with pancreatic cancer is that they’re seen in a multidisciplinary fashion, in which surgical, medical, and radiation oncologists are all discussing and determining the best treatment for each patient.”