title: Locally Advanced, Unresectable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline.
abstract: To provide evidence-based recommendations to oncologists and others for treatment of patients with locally advanced, unresectable pancreatic cancer.
  
  
  
  American Society of Clinical Oncology convened an Expert Panel of medical oncology, radiation oncology, surgical oncology, gastroenterology, palliative care, and advocacy experts and conducted a systematic review of the literature from January 2002 to June 2015. Outcomes included overall survival, disease-free survival, progression-free survival, and adverse events.
  
  
  
  Twenty-six 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. The goals of care, patient preferences, psychological status, support systems, and symptoms should guide decisions for treatments. A palliative care referral should occur at first visit. Initial systemic chemotherapy (6 months) with a combination regimen is recommended for most patients (for some patients radiation therapy may be offered up front) with Eastern Cooperative Oncology Group performance status 0 or 1 and a favorable comorbidity profile. There is no clear evidence to support one regimen over another. The gemcitabine-based combinations and treatments recommended in the metastatic setting (eg, fluorouracil, leucovorin, irinotecan, and oxaliplatin and gemcitabine plus nanoparticle albumin-bound paclitaxel) have not been evaluated in randomized controlled trials involving locally advanced, unresectable pancreatic cancer. If there is local disease progression after induction chemotherapy, without metastasis, then radiation therapy or stereotactic body radiotherapy may be offered also with an Eastern Cooperative Oncology Group performance status ≤ 2 and an adequate comorbidity profile. If there is stable disease after 6 months of induction chemotherapy but unacceptable toxicities, radiation therapy may be offered as an alternative. Patients with disease progression should be offered treatment per the ASCO Metastatic Pancreatic Cancer Treatment Guideline. Follow-up visits every 3 to 4 months are recommended. Additional information is available at www.asco.org/guidelines/LAPC and www.asco.org/guidelines/MetPC and www.asco.org/guidelineswiki.
authors.affiliation: Edward P. Balaban, Cancer Care Partnership, State College; Edward P. Balaban and Nelson S. Yee, Penn State Hershey Cancer Institute, Hershey, PA; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Alok A. Khorana, Cleveland Clinic; Jennifer R. Eads, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH; Manish A. Shah, The Weill Cornell Medical Center; Peter Allen, Memorial Sloan Kettering Cancer Center, New York, NY; Somnath Mukherjee, University of Oxford, Oxford, United Kingdom; Christopher H. Crane and Milind M. Javle, The University of Texas MD Anderson Cancer Center, Houston, TX; Andrew H. Ko, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA; Anitra Engebretson, Patient Representative, Portland, OR; Joseph M. Herman, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; John H. Strickler, Duke University Medical Center, Durham, NC; Al B. Benson III, Lurie Comprehensive Cancer Center of Northwestern, Chicago, IL; and Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI.
authors.forename: Edward P
authors.initials: EP
authors.lastname: Balaban
authors.affiliation: Edward P. Balaban, Cancer Care Partnership, State College; Edward P. Balaban and Nelson S. Yee, Penn State Hershey Cancer Institute, Hershey, PA; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Alok A. Khorana, Cleveland Clinic; Jennifer R. Eads, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH; Manish A. Shah, The Weill Cornell Medical Center; Peter Allen, Memorial Sloan Kettering Cancer Center, New York, NY; Somnath Mukherjee, University of Oxford, Oxford, United Kingdom; Christopher H. Crane and Milind M. Javle, The University of Texas MD Anderson Cancer Center, Houston, TX; Andrew H. Ko, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA; Anitra Engebretson, Patient Representative, Portland, OR; Joseph M. Herman, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; John H. Strickler, Duke University Medical Center, Durham, NC; Al B. Benson III, Lurie Comprehensive Cancer Center of Northwestern, Chicago, IL; and Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI.
authors.forename: Pamela B
authors.initials: PB
authors.lastname: Mangu
authors.affiliation: Edward P. Balaban, Cancer Care Partnership, State College; Edward P. Balaban and Nelson S. Yee, Penn State Hershey Cancer Institute, Hershey, PA; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Alok A. Khorana, Cleveland Clinic; Jennifer R. Eads, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH; Manish A. Shah, The Weill Cornell Medical Center; Peter Allen, Memorial Sloan Kettering Cancer Center, New York, NY; Somnath Mukherjee, University of Oxford, Oxford, United Kingdom; Christopher H. Crane and Milind M. Javle, The University of Texas MD Anderson Cancer Center, Houston, TX; Andrew H. Ko, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA; Anitra Engebretson, Patient Representative, Portland, OR; Joseph M. Herman, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; John H. Strickler, Duke University Medical Center, Durham, NC; Al B. Benson III, Lurie Comprehensive Cancer Center of Northwestern, Chicago, IL; and Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI.
authors.forename: Alok A
authors.initials: AA
authors.lastname: Khorana
authors.affiliation: Edward P. Balaban, Cancer Care Partnership, State College; Edward P. Balaban and Nelson S. Yee, Penn State Hershey Cancer Institute, Hershey, PA; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Alok A. Khorana, Cleveland Clinic; Jennifer R. Eads, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH; Manish A. Shah, The Weill Cornell Medical Center; Peter Allen, Memorial Sloan Kettering Cancer Center, New York, NY; Somnath Mukherjee, University of Oxford, Oxford, United Kingdom; Christopher H. Crane and Milind M. Javle, The University of Texas MD Anderson Cancer Center, Houston, TX; Andrew H. Ko, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA; Anitra Engebretson, Patient Representative, Portland, OR; Joseph M. Herman, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; John H. Strickler, Duke University Medical Center, Durham, NC; Al B. Benson III, Lurie Comprehensive Cancer Center of Northwestern, Chicago, IL; and Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI.
authors.forename: Manish A
authors.initials: MA
authors.lastname: Shah
authors.affiliation: Edward P. Balaban, Cancer Care Partnership, State College; Edward P. Balaban and Nelson S. Yee, Penn State Hershey Cancer Institute, Hershey, PA; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Alok A. Khorana, Cleveland Clinic; Jennifer R. Eads, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH; Manish A. Shah, The Weill Cornell Medical Center; Peter Allen, Memorial Sloan Kettering Cancer Center, New York, NY; Somnath Mukherjee, University of Oxford, Oxford, United Kingdom; Christopher H. Crane and Milind M. Javle, The University of Texas MD Anderson Cancer Center, Houston, TX; Andrew H. Ko, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA; Anitra Engebretson, Patient Representative, Portland, OR; Joseph M. Herman, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; John H. Strickler, Duke University Medical Center, Durham, NC; Al B. Benson III, Lurie Comprehensive Cancer Center of Northwestern, Chicago, IL; and Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI.
authors.forename: Somnath
authors.initials: S
authors.lastname: Mukherjee
authors.affiliation: Edward P. Balaban, Cancer Care Partnership, State College; Edward P. Balaban and Nelson S. Yee, Penn State Hershey Cancer Institute, Hershey, PA; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Alok A. Khorana, Cleveland Clinic; Jennifer R. Eads, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH; Manish A. Shah, The Weill Cornell Medical Center; Peter Allen, Memorial Sloan Kettering Cancer Center, New York, NY; Somnath Mukherjee, University of Oxford, Oxford, United Kingdom; Christopher H. Crane and Milind M. Javle, The University of Texas MD Anderson Cancer Center, Houston, TX; Andrew H. Ko, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA; Anitra Engebretson, Patient Representative, Portland, OR; Joseph M. Herman, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; John H. Strickler, Duke University Medical Center, Durham, NC; Al B. Benson III, Lurie Comprehensive Cancer Center of Northwestern, Chicago, IL; and Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI.
authors.forename: Christopher H
authors.initials: CH
authors.lastname: Crane
authors.affiliation: Edward P. Balaban, Cancer Care Partnership, State College; Edward P. Balaban and Nelson S. Yee, Penn State Hershey Cancer Institute, Hershey, PA; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Alok A. Khorana, Cleveland Clinic; Jennifer R. Eads, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH; Manish A. Shah, The Weill Cornell Medical Center; Peter Allen, Memorial Sloan Kettering Cancer Center, New York, NY; Somnath Mukherjee, University of Oxford, Oxford, United Kingdom; Christopher H. Crane and Milind M. Javle, The University of Texas MD Anderson Cancer Center, Houston, TX; Andrew H. Ko, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA; Anitra Engebretson, Patient Representative, Portland, OR; Joseph M. Herman, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; John H. Strickler, Duke University Medical Center, Durham, NC; Al B. Benson III, Lurie Comprehensive Cancer Center of Northwestern, Chicago, IL; and Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI.
authors.forename: Milind M
authors.initials: MM
authors.lastname: Javle
authors.affiliation: Edward P. Balaban, Cancer Care Partnership, State College; Edward P. Balaban and Nelson S. Yee, Penn State Hershey Cancer Institute, Hershey, PA; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Alok A. Khorana, Cleveland Clinic; Jennifer R. Eads, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH; Manish A. Shah, The Weill Cornell Medical Center; Peter Allen, Memorial Sloan Kettering Cancer Center, New York, NY; Somnath Mukherjee, University of Oxford, Oxford, United Kingdom; Christopher H. Crane and Milind M. Javle, The University of Texas MD Anderson Cancer Center, Houston, TX; Andrew H. Ko, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA; Anitra Engebretson, Patient Representative, Portland, OR; Joseph M. Herman, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; John H. Strickler, Duke University Medical Center, Durham, NC; Al B. Benson III, Lurie Comprehensive Cancer Center of Northwestern, Chicago, IL; and Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI.
authors.forename: Jennifer R
authors.initials: JR
authors.lastname: Eads
authors.affiliation: Edward P. Balaban, Cancer Care Partnership, State College; Edward P. Balaban and Nelson S. Yee, Penn State Hershey Cancer Institute, Hershey, PA; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Alok A. Khorana, Cleveland Clinic; Jennifer R. Eads, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH; Manish A. Shah, The Weill Cornell Medical Center; Peter Allen, Memorial Sloan Kettering Cancer Center, New York, NY; Somnath Mukherjee, University of Oxford, Oxford, United Kingdom; Christopher H. Crane and Milind M. Javle, The University of Texas MD Anderson Cancer Center, Houston, TX; Andrew H. Ko, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA; Anitra Engebretson, Patient Representative, Portland, OR; Joseph M. Herman, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; John H. Strickler, Duke University Medical Center, Durham, NC; Al B. Benson III, Lurie Comprehensive Cancer Center of Northwestern, Chicago, IL; and Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI.
authors.forename: Peter
authors.initials: P
authors.lastname: Allen
authors.affiliation: Edward P. Balaban, Cancer Care Partnership, State College; Edward P. Balaban and Nelson S. Yee, Penn State Hershey Cancer Institute, Hershey, PA; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Alok A. Khorana, Cleveland Clinic; Jennifer R. Eads, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH; Manish A. Shah, The Weill Cornell Medical Center; Peter Allen, Memorial Sloan Kettering Cancer Center, New York, NY; Somnath Mukherjee, University of Oxford, Oxford, United Kingdom; Christopher H. Crane and Milind M. Javle, The University of Texas MD Anderson Cancer Center, Houston, TX; Andrew H. Ko, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA; Anitra Engebretson, Patient Representative, Portland, OR; Joseph M. Herman, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; John H. Strickler, Duke University Medical Center, Durham, NC; Al B. Benson III, Lurie Comprehensive Cancer Center of Northwestern, Chicago, IL; and Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI.
authors.forename: Andrew H
authors.initials: AH
authors.lastname: Ko
authors.affiliation: Edward P. Balaban, Cancer Care Partnership, State College; Edward P. Balaban and Nelson S. Yee, Penn State Hershey Cancer Institute, Hershey, PA; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Alok A. Khorana, Cleveland Clinic; Jennifer R. Eads, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH; Manish A. Shah, The Weill Cornell Medical Center; Peter Allen, Memorial Sloan Kettering Cancer Center, New York, NY; Somnath Mukherjee, University of Oxford, Oxford, United Kingdom; Christopher H. Crane and Milind M. Javle, The University of Texas MD Anderson Cancer Center, Houston, TX; Andrew H. Ko, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA; Anitra Engebretson, Patient Representative, Portland, OR; Joseph M. Herman, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; John H. Strickler, Duke University Medical Center, Durham, NC; Al B. Benson III, Lurie Comprehensive Cancer Center of Northwestern, Chicago, IL; and Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI.
authors.forename: Anitra
authors.initials: A
authors.lastname: Engebretson
authors.affiliation: Edward P. Balaban, Cancer Care Partnership, State College; Edward P. Balaban and Nelson S. Yee, Penn State Hershey Cancer Institute, Hershey, PA; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Alok A. Khorana, Cleveland Clinic; Jennifer R. Eads, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH; Manish A. Shah, The Weill Cornell Medical Center; Peter Allen, Memorial Sloan Kettering Cancer Center, New York, NY; Somnath Mukherjee, University of Oxford, Oxford, United Kingdom; Christopher H. Crane and Milind M. Javle, The University of Texas MD Anderson Cancer Center, Houston, TX; Andrew H. Ko, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA; Anitra Engebretson, Patient Representative, Portland, OR; Joseph M. Herman, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; John H. Strickler, Duke University Medical Center, Durham, NC; Al B. Benson III, Lurie Comprehensive Cancer Center of Northwestern, Chicago, IL; and Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Herman
authors.affiliation: Edward P. Balaban, Cancer Care Partnership, State College; Edward P. Balaban and Nelson S. Yee, Penn State Hershey Cancer Institute, Hershey, PA; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Alok A. Khorana, Cleveland Clinic; Jennifer R. Eads, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH; Manish A. Shah, The Weill Cornell Medical Center; Peter Allen, Memorial Sloan Kettering Cancer Center, New York, NY; Somnath Mukherjee, University of Oxford, Oxford, United Kingdom; Christopher H. Crane and Milind M. Javle, The University of Texas MD Anderson Cancer Center, Houston, TX; Andrew H. Ko, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA; Anitra Engebretson, Patient Representative, Portland, OR; Joseph M. Herman, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; John H. Strickler, Duke University Medical Center, Durham, NC; Al B. Benson III, Lurie Comprehensive Cancer Center of Northwestern, Chicago, IL; and Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI.
authors.forename: John H
authors.initials: JH
authors.lastname: Strickler
authors.affiliation: Edward P. Balaban, Cancer Care Partnership, State College; Edward P. Balaban and Nelson S. Yee, Penn State Hershey Cancer Institute, Hershey, PA; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Alok A. Khorana, Cleveland Clinic; Jennifer R. Eads, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH; Manish A. Shah, The Weill Cornell Medical Center; Peter Allen, Memorial Sloan Kettering Cancer Center, New York, NY; Somnath Mukherjee, University of Oxford, Oxford, United Kingdom; Christopher H. Crane and Milind M. Javle, The University of Texas MD Anderson Cancer Center, Houston, TX; Andrew H. Ko, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA; Anitra Engebretson, Patient Representative, Portland, OR; Joseph M. Herman, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; John H. Strickler, Duke University Medical Center, Durham, NC; Al B. Benson III, Lurie Comprehensive Cancer Center of Northwestern, Chicago, IL; and Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI.
authors.forename: Al B
authors.initials: AB
authors.lastname: Benson
authors.affiliation: Edward P. Balaban, Cancer Care Partnership, State College; Edward P. Balaban and Nelson S. Yee, Penn State Hershey Cancer Institute, Hershey, PA; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Alok A. Khorana, Cleveland Clinic; Jennifer R. Eads, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH; Manish A. Shah, The Weill Cornell Medical Center; Peter Allen, Memorial Sloan Kettering Cancer Center, New York, NY; Somnath Mukherjee, University of Oxford, Oxford, United Kingdom; Christopher H. Crane and Milind M. Javle, The University of Texas MD Anderson Cancer Center, Houston, TX; Andrew H. Ko, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA; Anitra Engebretson, Patient Representative, Portland, OR; Joseph M. Herman, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; John H. Strickler, Duke University Medical Center, Durham, NC; Al B. Benson III, Lurie Comprehensive Cancer Center of Northwestern, Chicago, IL; and Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI.
authors.forename: Susan
authors.initials: S
authors.lastname: Urba
authors.affiliation: Edward P. Balaban, Cancer Care Partnership, State College; Edward P. Balaban and Nelson S. Yee, Penn State Hershey Cancer Institute, Hershey, PA; Pamela B. Mangu, American Society of Clinical Oncology, Alexandria, VA; Alok A. Khorana, Cleveland Clinic; Jennifer R. Eads, University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH; Manish A. Shah, The Weill Cornell Medical Center; Peter Allen, Memorial Sloan Kettering Cancer Center, New York, NY; Somnath Mukherjee, University of Oxford, Oxford, United Kingdom; Christopher H. Crane and Milind M. Javle, The University of Texas MD Anderson Cancer Center, Houston, TX; Andrew H. Ko, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA; Anitra Engebretson, Patient Representative, Portland, OR; Joseph M. Herman, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; John H. Strickler, Duke University Medical Center, Durham, NC; Al B. Benson III, Lurie Comprehensive Cancer Center of Northwestern, Chicago, IL; and Susan Urba, University of Michigan Cancer Center, Ann Arbor, MI.
authors.forename: Nelson S
authors.initials: NS
authors.lastname: Yee
mesh_terms: D006801:Humans; D008495:Medical Oncology; D010190:Pancreatic Neoplasms / Q000628:therapy*; D017410:Practice Guidelines as Topic; D012955:Societies, Medical; D014481:United States