title: Metastatic Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline.
abstract: To provide evidence-based recommendations to oncologists and others for the treatment of patients with metastatic pancreatic cancer.
  
  
  
  American Society of Clinical Oncology convened an Expert Panel of medical oncology, radiation oncology, surgical oncology, gastroenterology, palliative care, and advocacy experts to conduct a systematic review of the literature from April 2004 to June 2015. Outcomes were overall survival, disease-free survival, progression-free survival, and adverse events.
  
  
  
  Twenty-four randomized controlled trials met the systematic review criteria.
  
  
  
  A multiphase computed tomography scan of the chest, abdomen, and pelvis should be performed. Baseline performance status and comorbidity profile should be evaluated. Goals of care, patient preferences, treatment response, psychological status, support systems, and symptom burden should guide decisions for treatments. A palliative care referral should occur at first visit. FOLFIRINOX (leucovorin, fluorouracil, irinotecan, and oxaliplatin; favorable comorbidity profile) or gemcitabine plus nanoparticle albumin-bound (NAB) -paclitaxel (adequate comorbidity profile) should be offered to patients with Eastern Cooperative Oncology Group performance status (ECOG PS) 0 to 1 based on patient preference and support system available. Gemcitabine alone is recommended for patients with ECOG PS 2 or with a comorbidity profile that precludes other regimens; the addition of capecitabine or erlotinib may be offered. Patients with an ECOG PS ≥ 3 and poorly controlled comorbid conditions should be offered cancer-directed therapy only on a case-by-case basis; supportive care should be emphasized. For second-line therapy, gemcitabine plus NAB-paclitaxel should be offered to patients with first-line treatment with FOLFIRINOX, an ECOG PS 0 to 1, and a favorable comorbidity profile; fluorouracil plus oxaliplatin, irinotecan, or nanoliposomal irinotecan should be offered to patients with first-line treatment with gemcitabine plus NAB-paclitaxel, ECOG PS 0 to 1, and favorable comorbidity profile, and gemcitabine or fluorouracil should be offered to patients with either an ECOG PS 2 or a comorbidity profile that precludes other regimens. Additional information is available at www.asco.org/guidelines/MetPC and www.asco.org/guidelineswiki.
authors.affiliation: Davendra P.S. Sohal and Alok A. Khorana, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Manish A. Shah, The Weill Cornell Medical Center; Philip A. Philip, Karmanos Cancer Institute, Detroit; Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI; Eileen M. O'Reilly, Memorial Sloan Kettering Cancer Center; Joseph T. Ruggiero, Weill Cornell Medical College, New York, NY; Hope E. Uronis, Duke University, Durham, NC; Ramesh K. Ramanathan, Mayo Clinic, Scottsdale; Michelle Lau, Community Hospital Based Cancer Center, Tempe, AZ; Christopher H. Crane, The University of Texas MD Anderson Cancer Center, Houston, TX; Anitra Engebretson, Patient Representative, Portland, OR; Mehmet S. Copur, St Francis Medical Center, Grand Island, NE; and Daniel Laheru, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.
authors.forename: Davendra P S
authors.initials: DP
authors.lastname: Sohal
authors.affiliation: Davendra P.S. Sohal and Alok A. Khorana, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Manish A. Shah, The Weill Cornell Medical Center; Philip A. Philip, Karmanos Cancer Institute, Detroit; Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI; Eileen M. O'Reilly, Memorial Sloan Kettering Cancer Center; Joseph T. Ruggiero, Weill Cornell Medical College, New York, NY; Hope E. Uronis, Duke University, Durham, NC; Ramesh K. Ramanathan, Mayo Clinic, Scottsdale; Michelle Lau, Community Hospital Based Cancer Center, Tempe, AZ; Christopher H. Crane, The University of Texas MD Anderson Cancer Center, Houston, TX; Anitra Engebretson, Patient Representative, Portland, OR; Mehmet S. Copur, St Francis Medical Center, Grand Island, NE; and Daniel Laheru, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.
authors.forename: Pamela B
authors.initials: PB
authors.lastname: Mangu
authors.affiliation: Davendra P.S. Sohal and Alok A. Khorana, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Manish A. Shah, The Weill Cornell Medical Center; Philip A. Philip, Karmanos Cancer Institute, Detroit; Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI; Eileen M. O'Reilly, Memorial Sloan Kettering Cancer Center; Joseph T. Ruggiero, Weill Cornell Medical College, New York, NY; Hope E. Uronis, Duke University, Durham, NC; Ramesh K. Ramanathan, Mayo Clinic, Scottsdale; Michelle Lau, Community Hospital Based Cancer Center, Tempe, AZ; Christopher H. Crane, The University of Texas MD Anderson Cancer Center, Houston, TX; Anitra Engebretson, Patient Representative, Portland, OR; Mehmet S. Copur, St Francis Medical Center, Grand Island, NE; and Daniel Laheru, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.
authors.forename: Alok A
authors.initials: AA
authors.lastname: Khorana
authors.affiliation: Davendra P.S. Sohal and Alok A. Khorana, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Manish A. Shah, The Weill Cornell Medical Center; Philip A. Philip, Karmanos Cancer Institute, Detroit; Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI; Eileen M. O'Reilly, Memorial Sloan Kettering Cancer Center; Joseph T. Ruggiero, Weill Cornell Medical College, New York, NY; Hope E. Uronis, Duke University, Durham, NC; Ramesh K. Ramanathan, Mayo Clinic, Scottsdale; Michelle Lau, Community Hospital Based Cancer Center, Tempe, AZ; Christopher H. Crane, The University of Texas MD Anderson Cancer Center, Houston, TX; Anitra Engebretson, Patient Representative, Portland, OR; Mehmet S. Copur, St Francis Medical Center, Grand Island, NE; and Daniel Laheru, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.
authors.forename: Manish A
authors.initials: MA
authors.lastname: Shah
authors.affiliation: Davendra P.S. Sohal and Alok A. Khorana, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Manish A. Shah, The Weill Cornell Medical Center; Philip A. Philip, Karmanos Cancer Institute, Detroit; Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI; Eileen M. O'Reilly, Memorial Sloan Kettering Cancer Center; Joseph T. Ruggiero, Weill Cornell Medical College, New York, NY; Hope E. Uronis, Duke University, Durham, NC; Ramesh K. Ramanathan, Mayo Clinic, Scottsdale; Michelle Lau, Community Hospital Based Cancer Center, Tempe, AZ; Christopher H. Crane, The University of Texas MD Anderson Cancer Center, Houston, TX; Anitra Engebretson, Patient Representative, Portland, OR; Mehmet S. Copur, St Francis Medical Center, Grand Island, NE; and Daniel Laheru, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.
authors.forename: Philip A
authors.initials: PA
authors.lastname: Philip
authors.affiliation: Davendra P.S. Sohal and Alok A. Khorana, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Manish A. Shah, The Weill Cornell Medical Center; Philip A. Philip, Karmanos Cancer Institute, Detroit; Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI; Eileen M. O'Reilly, Memorial Sloan Kettering Cancer Center; Joseph T. Ruggiero, Weill Cornell Medical College, New York, NY; Hope E. Uronis, Duke University, Durham, NC; Ramesh K. Ramanathan, Mayo Clinic, Scottsdale; Michelle Lau, Community Hospital Based Cancer Center, Tempe, AZ; Christopher H. Crane, The University of Texas MD Anderson Cancer Center, Houston, TX; Anitra Engebretson, Patient Representative, Portland, OR; Mehmet S. Copur, St Francis Medical Center, Grand Island, NE; and Daniel Laheru, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.
authors.forename: Eileen M
authors.initials: EM
authors.lastname: O'Reilly
authors.affiliation: Davendra P.S. Sohal and Alok A. Khorana, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Manish A. Shah, The Weill Cornell Medical Center; Philip A. Philip, Karmanos Cancer Institute, Detroit; Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI; Eileen M. O'Reilly, Memorial Sloan Kettering Cancer Center; Joseph T. Ruggiero, Weill Cornell Medical College, New York, NY; Hope E. Uronis, Duke University, Durham, NC; Ramesh K. Ramanathan, Mayo Clinic, Scottsdale; Michelle Lau, Community Hospital Based Cancer Center, Tempe, AZ; Christopher H. Crane, The University of Texas MD Anderson Cancer Center, Houston, TX; Anitra Engebretson, Patient Representative, Portland, OR; Mehmet S. Copur, St Francis Medical Center, Grand Island, NE; and Daniel Laheru, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.
authors.forename: Hope E
authors.initials: HE
authors.lastname: Uronis
authors.affiliation: Davendra P.S. Sohal and Alok A. Khorana, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Manish A. Shah, The Weill Cornell Medical Center; Philip A. Philip, Karmanos Cancer Institute, Detroit; Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI; Eileen M. O'Reilly, Memorial Sloan Kettering Cancer Center; Joseph T. Ruggiero, Weill Cornell Medical College, New York, NY; Hope E. Uronis, Duke University, Durham, NC; Ramesh K. Ramanathan, Mayo Clinic, Scottsdale; Michelle Lau, Community Hospital Based Cancer Center, Tempe, AZ; Christopher H. Crane, The University of Texas MD Anderson Cancer Center, Houston, TX; Anitra Engebretson, Patient Representative, Portland, OR; Mehmet S. Copur, St Francis Medical Center, Grand Island, NE; and Daniel Laheru, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.
authors.forename: Ramesh K
authors.initials: RK
authors.lastname: Ramanathan
authors.affiliation: Davendra P.S. Sohal and Alok A. Khorana, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Manish A. Shah, The Weill Cornell Medical Center; Philip A. Philip, Karmanos Cancer Institute, Detroit; Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI; Eileen M. O'Reilly, Memorial Sloan Kettering Cancer Center; Joseph T. Ruggiero, Weill Cornell Medical College, New York, NY; Hope E. Uronis, Duke University, Durham, NC; Ramesh K. Ramanathan, Mayo Clinic, Scottsdale; Michelle Lau, Community Hospital Based Cancer Center, Tempe, AZ; Christopher H. Crane, The University of Texas MD Anderson Cancer Center, Houston, TX; Anitra Engebretson, Patient Representative, Portland, OR; Mehmet S. Copur, St Francis Medical Center, Grand Island, NE; and Daniel Laheru, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.
authors.forename: Christopher H
authors.initials: CH
authors.lastname: Crane
authors.affiliation: Davendra P.S. Sohal and Alok A. Khorana, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Manish A. Shah, The Weill Cornell Medical Center; Philip A. Philip, Karmanos Cancer Institute, Detroit; Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI; Eileen M. O'Reilly, Memorial Sloan Kettering Cancer Center; Joseph T. Ruggiero, Weill Cornell Medical College, New York, NY; Hope E. Uronis, Duke University, Durham, NC; Ramesh K. Ramanathan, Mayo Clinic, Scottsdale; Michelle Lau, Community Hospital Based Cancer Center, Tempe, AZ; Christopher H. Crane, The University of Texas MD Anderson Cancer Center, Houston, TX; Anitra Engebretson, Patient Representative, Portland, OR; Mehmet S. Copur, St Francis Medical Center, Grand Island, NE; and Daniel Laheru, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.
authors.forename: Anitra
authors.initials: A
authors.lastname: Engebretson
authors.affiliation: Davendra P.S. Sohal and Alok A. Khorana, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Manish A. Shah, The Weill Cornell Medical Center; Philip A. Philip, Karmanos Cancer Institute, Detroit; Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI; Eileen M. O'Reilly, Memorial Sloan Kettering Cancer Center; Joseph T. Ruggiero, Weill Cornell Medical College, New York, NY; Hope E. Uronis, Duke University, Durham, NC; Ramesh K. Ramanathan, Mayo Clinic, Scottsdale; Michelle Lau, Community Hospital Based Cancer Center, Tempe, AZ; Christopher H. Crane, The University of Texas MD Anderson Cancer Center, Houston, TX; Anitra Engebretson, Patient Representative, Portland, OR; Mehmet S. Copur, St Francis Medical Center, Grand Island, NE; and Daniel Laheru, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.
authors.forename: Joseph T
authors.initials: JT
authors.lastname: Ruggiero
authors.affiliation: Davendra P.S. Sohal and Alok A. Khorana, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Manish A. Shah, The Weill Cornell Medical Center; Philip A. Philip, Karmanos Cancer Institute, Detroit; Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI; Eileen M. O'Reilly, Memorial Sloan Kettering Cancer Center; Joseph T. Ruggiero, Weill Cornell Medical College, New York, NY; Hope E. Uronis, Duke University, Durham, NC; Ramesh K. Ramanathan, Mayo Clinic, Scottsdale; Michelle Lau, Community Hospital Based Cancer Center, Tempe, AZ; Christopher H. Crane, The University of Texas MD Anderson Cancer Center, Houston, TX; Anitra Engebretson, Patient Representative, Portland, OR; Mehmet S. Copur, St Francis Medical Center, Grand Island, NE; and Daniel Laheru, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.
authors.forename: Mehmet S
authors.initials: MS
authors.lastname: Copur
authors.affiliation: Davendra P.S. Sohal and Alok A. Khorana, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Manish A. Shah, The Weill Cornell Medical Center; Philip A. Philip, Karmanos Cancer Institute, Detroit; Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI; Eileen M. O'Reilly, Memorial Sloan Kettering Cancer Center; Joseph T. Ruggiero, Weill Cornell Medical College, New York, NY; Hope E. Uronis, Duke University, Durham, NC; Ramesh K. Ramanathan, Mayo Clinic, Scottsdale; Michelle Lau, Community Hospital Based Cancer Center, Tempe, AZ; Christopher H. Crane, The University of Texas MD Anderson Cancer Center, Houston, TX; Anitra Engebretson, Patient Representative, Portland, OR; Mehmet S. Copur, St Francis Medical Center, Grand Island, NE; and Daniel Laheru, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.
authors.forename: Michelle
authors.initials: M
authors.lastname: Lau
authors.affiliation: Davendra P.S. Sohal and Alok A. Khorana, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Manish A. Shah, The Weill Cornell Medical Center; Philip A. Philip, Karmanos Cancer Institute, Detroit; Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI; Eileen M. O'Reilly, Memorial Sloan Kettering Cancer Center; Joseph T. Ruggiero, Weill Cornell Medical College, New York, NY; Hope E. Uronis, Duke University, Durham, NC; Ramesh K. Ramanathan, Mayo Clinic, Scottsdale; Michelle Lau, Community Hospital Based Cancer Center, Tempe, AZ; Christopher H. Crane, The University of Texas MD Anderson Cancer Center, Houston, TX; Anitra Engebretson, Patient Representative, Portland, OR; Mehmet S. Copur, St Francis Medical Center, Grand Island, NE; and Daniel Laheru, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.
authors.forename: Susan
authors.initials: S
authors.lastname: Urba
authors.affiliation: Davendra P.S. Sohal and Alok A. Khorana, Cleveland Clinic, Cleveland, OH; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Manish A. Shah, The Weill Cornell Medical Center; Philip A. Philip, Karmanos Cancer Institute, Detroit; Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI; Eileen M. O'Reilly, Memorial Sloan Kettering Cancer Center; Joseph T. Ruggiero, Weill Cornell Medical College, New York, NY; Hope E. Uronis, Duke University, Durham, NC; Ramesh K. Ramanathan, Mayo Clinic, Scottsdale; Michelle Lau, Community Hospital Based Cancer Center, Tempe, AZ; Christopher H. Crane, The University of Texas MD Anderson Cancer Center, Houston, TX; Anitra Engebretson, Patient Representative, Portland, OR; Mehmet S. Copur, St Francis Medical Center, Grand Island, NE; and Daniel Laheru, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD.
authors.forename: Daniel
authors.initials: D
authors.lastname: Laheru
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D021441:Carcinoma, Pancreatic Ductal / Q000000981:diagnostic imaging / Q000556:secondary* / Q000628:therapy*; D003142:Communication; D019317:Evidence-Based Medicine; D006801:Humans; D059408:Pain Management; D010166:Palliative Care; D010190:Pancreatic Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology* / Q000628:therapy*; D010347:Patient Care Planning; D010348:Patient Care Team; D063189:Symptom Assessment