Pancreatic Cancer Evaluation and Management Clinical Practice Guidelines (2019)

National Comprehensive Cancer Network

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

June 05, 2019

In 2019, the National Comprehensive Cancer Network released a guideline update on pancreatic cancer evaluation and treatment.[1]

All patients with pancreatic cancer should be considered for germline testing. The importance of this analysis stems from pancreatic cancer's association with numerous hereditary syndromes.

Moreover, it is recommended that first- and second-degree relatives be screened in the presence of familial pancreatic cancer—which can strike multiple generations, despite the absence of typical genetic mutations—with these individuals undergoing either annual ultrasonography or magnetic resonance cholangiopancreatography.

Patients with metastatic disease should be considered candidates for molecular tumor analysis.

Although KRAS is the primary driver mutation, molecular profiling can identify many additional potentially actionable mutations.

Through whole-exome sequencing, almost 50% of tumors have been found to have theoretically actionable genomic lesions, with such sequencing leading to a clinical management change in up to 30% of cases.

To carry out tumor profiling, the diagnostic tumor sample must contain sufficient tissue.

Adjuvant treatment with modified FOLFIRINOX (leucovorin/5-FU/irinotecan/oxaliplatin) should be considered in patients capable of tolerating it.

FOLFIRINOX and gemcitabine/albumin-bound nab-paclitaxel, as well as (for patients with BRCA1/2 and PALB2 mutations) gemcitabine/cisplatin, remain first-line treatment regimens.

Although FOLFIRINOX may be somewhat superior to nab-paclitaxel/gemcitabine in terms of response rate and progression-free and overall survival, the regimen is difficult and best administered to fit patients.

Treatment is selected based on patient preference, comorbidities, treatment goals, compatibility with investigational agents, and predictive biomarkers.

Poly (ADP-ribose) polymerase (PARP) inhibitors have shown therapeutic efficacy in patients with ovarian cancer and mutations in genes (such as BRCA1/2) for DNA damage repair; approval for use of these agents against other tumors is expected.

Mismatch repair deficiency (dMMR) and microsatellite instability–high (MSI-H) status can be detected via molecular profiling. Approved for use against metastatic cancer of any type and dMMR/MSI-H status, pembrolizumab can prove effective in patients with this phenotype.

For more information, please go to Pancreatic Cancer and Pancreatic Cancer Treatment Protocols.

For more Clinical Practice Guidelines, please go to Guidelines.

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