title: TTD consensus document on the diagnosis and management of exocrine pancreatic cancer.
abstract: Exocrine pancreatic cancer (PC) is a very aggressive and heterogeneous tumor with several cellular signaling pathways implicated in its pathogenesis and maintenance. Several risk factors increase the risk of developing PC. Therapeutic strategies used are dictated by the extent of disease. Supportive treatment is critical because of the high frequency of symptoms. For localized disease, surgery followed by adjuvant gemcitabine is the standard. Neoadjuvant and new adjuvant chemotherapy regimens are being evaluated. Locally advanced disease should respond best guided by a multidisciplinary team. Various treatment options are appropriate such as chemotherapy alone or chemoradiotherapy with integration of rescue surgery if the tumor becomes resectable. In metastatic disease, chemotherapy should be reserved for patients with ECOG 0-1 using Folfirinox or gemcitabine plus nab-paclitaxel as the most recommended options. Several therapeutic strategies targeting unregulated pathways are under evaluation with an unmet need for biomarkers to guide management.
authors.affiliation: Hospital Regional Universitario Carlos Haya, Málaga, Spain, manuel.benavides.sspa@juntadeandalucia.es.
authors.forename: M
authors.initials: M
authors.lastname: Benavides
authors.forename: A
authors.initials: A
authors.lastname: Abad
authors.forename: I
authors.initials: I
authors.lastname: Ales
authors.forename: A
authors.initials: A
authors.lastname: Carrato
authors.forename: E
authors.initials: E
authors.lastname: Díaz Rubio
authors.forename: J
authors.initials: J
authors.lastname: Gallego
authors.forename: J
authors.initials: J
authors.lastname: García-Foncillas
authors.forename: C
authors.initials: C
authors.lastname: Grávalos
authors.forename: B
authors.initials: B
authors.lastname: Laquente
authors.forename: C
authors.initials: C
authors.lastname: Pericay
authors.forename: F
authors.initials: F
authors.lastname: Rivera
authors.forename: J
authors.initials: J
authors.lastname: Tabernero
authors.forename: E
authors.initials: E
authors.lastname: Aranda
mesh_terms: D000230:Adenocarcinoma / Q000175:diagnosis / Q000628:therapy; D021441:Carcinoma, Pancreatic Ductal / Q000175:diagnosis / Q000628:therapy*; D003536:Cystadenocarcinoma / Q000175:diagnosis / Q000628:therapy*; D006801:Humans; D046790:Pancreas, Exocrine; D010190:Pancreatic Neoplasms / Q000175:diagnosis / Q000628:therapy*; D017410:Practice Guidelines as Topic
references.citation: Cancer Causes Control. 1996 Jan;7(1):69-82
references.pmid: 8850436
references.citation: Best Pract Res Clin Gastroenterol. 2010 Jun;24(3):337-47
references.pmid: 20510833
references.citation: Int J Radiat Oncol Biol Phys. 2005 Aug 1;62(5):1345-50
references.pmid: 16029791
references.citation: HPB (Oxford). 2014 Jan;16(1):70-4
references.pmid: 23496023
references.citation: J Clin Oncol. 1985 Mar;3(3):373-8
references.pmid: 3973648
references.citation: JAMA. 2013 Oct 9;310(14):1473-81
references.pmid: 24104372
references.citation: J Chronic Dis. 1978;31(6-7):433-44
references.pmid: 711835
references.citation: J Clin Oncol. 2007 Jun 20;25(18):2607-15
references.pmid: 17577041
references.citation: BMC Cancer. 2012 May 29;12:199
references.pmid: 22642850
references.citation: Gastroenterology. 2009 Jan;136(1):187-95
references.pmid: 18992248
references.citation: Life Sci. 2011 Jan 31;88(5-6):218-25
references.pmid: 21094171
references.citation: World J Gastroenterol. 2013 Apr 21;19(15):2368-73
references.pmid: 23613631
references.citation: Cancer. 2010 Nov 15;116(22):5200-6
references.pmid: 20669326
references.citation: J Clin Oncol. 2011 Dec 1;29(34):4548-54
references.pmid: 21969517
references.citation: J Clin Oncol. 2009 May 1;27(13):2269-77
references.pmid: 19307501
references.citation: Cancer. 2008 Nov 1;113(9):2448-56
references.pmid: 18823024
references.citation: Br J Cancer. 2009 Sep 15;101(6):908-15
references.pmid: 19690548
references.citation: Ann Surg Oncol. 2009 Jul;16(7):1751-6
references.pmid: 19390900
references.citation: Int J Radiat Oncol Biol Phys. 2004 Oct 1;60(2):437-43
references.pmid: 15380577
references.citation: J Clin Oncol. 2010 Aug 1;28(22):3617-22
references.pmid: 20606091
references.citation: Oncologist. 2006 Jun;11(6):612-23
references.pmid: 16794240
references.citation: Lancet Oncol. 2011 Mar;12(3):256-62
references.pmid: 21306953
references.citation: Cancer. 1981 Oct 15;48(8):1705-10
references.pmid: 7284971
references.citation: J Clin Oncol. 2010 Aug 1;28(22):3605-10
references.pmid: 20606093
references.citation: Clin Cancer Res. 2009 Apr 15;15(8):2913-9
references.pmid: 19318496
references.citation: Ann Surg. 1999 Sep;230(3):322-8; discussion 328-30
references.pmid: 10493479
references.citation: J Clin Oncol. 2011 Sep 10;29(26):3541-6
references.pmid: 21844506
references.citation: Arch Intern Med. 2010 May 10;170(9):791-802
references.pmid: 20458087
references.citation: Arch Surg. 1985 Aug;120(8):899-903
references.pmid: 4015380
references.citation: J Natl Cancer Inst. 1973 Mar;50(3):645-67
references.pmid: 4350660
references.citation: Cancer Res. 2009 Jun 1;69(11):4567-72
references.pmid: 19487279
references.citation: BMC Cancer. 2011 Aug 10;11:346
references.pmid: 21831266
references.citation: J Clin Oncol. 2010 Oct 10;28(29):4450-6
references.pmid: 20837948
references.citation: J Gastroenterol. 2010 May;45(5):537-43
references.pmid: 20033227
references.citation: Ann Surg Oncol. 2007 Jan;14(1):211-7
references.pmid: 17080236
references.citation: JAMA. 2010 Sep 8;304(10):1073-81
references.pmid: 20823433
references.citation: J Clin Oncol. 2007 May 20;25(15):1960-6
references.pmid: 17452677
references.citation: J Clin Oncol. 2008 Jul 20;26(21):3511-6
references.pmid: 18640932
references.citation: Surg Clin North Am. 2005 Apr;85(2):359-71
references.pmid: 15833477
references.citation: J Clin Oncol. 2007 Jan 20;25(3):319-25
references.pmid: 17235047
references.citation: N Engl J Med. 2011 May 12;364(19):1817-25
references.pmid: 21561347
references.citation: Ann Surg Oncol. 2006 Feb;13(2):150-8
references.pmid: 16418882
references.citation: Cochrane Database Syst Rev. 2013 Feb 28;(2):CD008533
references.pmid: 23450583
references.citation: J Clin Invest. 2012 Feb;122(2):639-53
references.pmid: 22232209
references.citation: N Engl J Med. 1981 Mar 12;304(11):630-3
references.pmid: 7453739
references.citation: N Engl J Med. 2004 Mar 18;350(12):1200-10
references.pmid: 15028824
references.citation: Int J Radiat Oncol Biol Phys. 2004 Aug 1;59(5):1454-60
references.pmid: 15275732
references.citation: Radiol Clin North Am. 2012 May;50(3):407-28
references.pmid: 22560689
references.citation: J Clin Oncol. 2009 Nov 20;27(33):5487-91
references.pmid: 19858387
references.citation: J Clin Oncol. 2011 Nov 1;29(31):4105-12
references.pmid: 21969502
references.citation: Cancer. 2007 Jul 1;110(1):47-55
references.pmid: 17538975
references.citation: J Clin Oncol. 2009 Nov 20;27(33):5660-9
references.pmid: 19858397
references.citation: Ann Surg. 1999 Dec;230(6):776-82; discussion 782-4
references.pmid: 10615932
references.citation: Int J Cancer. 2007 May 1;120(9):1993-8
references.pmid: 17266034
references.citation: J Clin Oncol. 2007 Jun 1;25(16):2212-7
references.pmid: 17538165
references.citation: Eur J Cancer. 2013 Aug;49(12):2633-42
references.pmid: 23642329
references.citation: JAMA. 2004 Mar 3;291(9):1092-9
references.pmid: 14996778
references.citation: J Clin Oncol. 2012 Nov 20;30(33):4077-83
references.pmid: 23008325
references.citation: Mol Cancer Ther. 2012 Sep;11(9):1999-2009
references.pmid: 22752426
references.citation: Int J Radiat Oncol Biol Phys. 2002 Apr 1;52(5):1293-302
references.pmid: 11955742
references.citation: Clin Cancer Res. 2012 Oct 1;18(19):5374-86
references.pmid: 22952347
references.citation: Cancer Cell. 2012 Mar 20;21(3):418-29
references.pmid: 22439937
references.citation: Am J Gastroenterol. 2006 Apr;101(4):735-42
references.pmid: 16635221
references.citation: J Clin Oncol. 2004 Apr 15;22(8):1430-8
references.pmid: 15084616
references.citation: Cochrane Database Syst Rev. 2006 Apr 19;(2):CD004200
references.pmid: 16625598
references.citation: Radiat Oncol. 2012 Mar 02;7:28
references.pmid: 22385572
references.citation: J Clin Oncol. 2009 Nov 20;27(33):5513-8
references.pmid: 19858379
references.citation: J Clin Oncol. 2008 Jul 20;26(21):3496-502
references.pmid: 18640930
references.citation: Eur J Cancer. 2011 Jul;47(11):1676-81
references.pmid: 21565490
references.citation: Strahlenther Onkol. 2009 Sep;185(9):557-66
references.pmid: 19756421
references.citation: J Clin Oncol. 2008 Mar 1;26(7):1178-9; author reply 1179
references.pmid: 18309957
references.citation: Surgery. 2012 Nov;152(5):851-62
references.pmid: 22682078
references.citation: Ann Surg Oncol. 2010 Jan;17(1):194-205
references.pmid: 19856029
references.citation: J Natl Cancer Inst. 1988 Jul 20;80(10):751-5
references.pmid: 2898536
references.citation: Nat Med. 2011 Apr;17(4):500-3
references.pmid: 21460848
references.citation: CA Cancer J Clin. 2008 Mar-Apr;58(2):71-96
references.pmid: 18287387
references.citation: Expert Opin Med Diagn. 2013 Jan;7(1):25-35
references.pmid: 23530842
references.citation: J Clin Oncol. 2013 Nov 20;31(33):4229-34
references.pmid: 24145341
references.citation: Ann Surg Oncol. 2009 Jul;16(7):1727-33
references.pmid: 19396496
references.citation: Ann Oncol. 2012 Nov;23(11):2834-2842
references.pmid: 22700995
references.citation: BMC Cancer. 2008 Mar 28;8:82
references.pmid: 18373843
references.citation: Cancer Res. 2010 Jun 1;70(11):4528-38
references.pmid: 20460539
references.citation: J Clin Oncol. 2005 May 20;23(15):3509-16
references.pmid: 15908661
references.citation: J Clin Oncol. 2007 Jan 20;25(3):326-31
references.pmid: 17235048
references.citation: Future Oncol. 2008 Feb;4(1):41-50
references.pmid: 18240999
references.citation: J Clin Oncol. 2013 May 1;31(13):1640-8
references.pmid: 23547081
references.citation: Mol Cancer Res. 2004 Apr;2(4):215-24
references.pmid: 15140943
references.citation: Ann Surg Oncol. 2007 Jul;14(7):2088-96
references.pmid: 17453298
references.citation: J Clin Oncol. 1997 Jun;15(6):2403-13
references.pmid: 9196156
references.citation: Presse Med. 2013 Sep;42(9 Pt 1):1171-5
references.pmid: 23182238
references.citation: Ann Oncol. 2012 Nov;23(11):2799-2805
references.pmid: 22771827
references.citation: J Gastroenterol Hepatol. 2011 Mar;26 Suppl 2:12-6
references.pmid: 21323992
references.citation: Gut. 2011 Jun;60(6):861-8
references.pmid: 20966025
references.citation: JAMA. 2008 Mar 5;299(9):1019-26
references.pmid: 18319412
references.citation: Cancer Radiother. 2011 Jun;15(3):182-91
references.pmid: 21315644
references.citation: Int J Radiat Oncol Biol Phys. 2002 May 1;53(1):146-50
references.pmid: 12007953
references.citation: JAMA. 2007 Jan 17;297(3):267-77
references.pmid: 17227978
references.citation: J Clin Oncol. 2008 Jul 20;26(21):3503-10
references.pmid: 18640931
references.citation: Science. 2008 Sep 26;321(5897):1801-6
references.pmid: 18772397
references.citation: Cancer Lett. 2013 Jul 10;335(1):41-51
references.pmid: 23402814
references.citation: Gut. 2010 Nov;59(11):1527-34
references.pmid: 20947887
references.citation: N Engl J Med. 2013 Oct 31;369(18):1691-703
references.pmid: 24131140
references.citation: J Clin Oncol. 2009 Aug 10;27(23):3778-85
references.pmid: 19581537
references.citation: Cancer Res. 2008 Apr 15;68(8):2841-9
references.pmid: 18413752
references.citation: J Clin Oncol. 2009 May 1;27(13):2231-7
references.pmid: 19307500
references.citation: J Clin Oncol. 2008 May 20;26(15):2526-31
references.pmid: 18487569
references.citation: Am J Epidemiol. 2009 May 1;169(9):1043-51
references.pmid: 19299403