From the Guidelines
Radiotherapy is indicated for pancreatic cancer in several clinical scenarios, including locally advanced unresectable pancreatic cancer, borderline resectable disease, and resectable cases with positive margins or node-positive disease, as supported by the most recent evidence from 1.
Indications for Radiotherapy
- Locally advanced unresectable pancreatic cancer: often used in combination with chemotherapy (chemoradiation) with regimens like gemcitabine or FOLFIRINOX, followed by radiation doses of 45-54 Gy delivered over 5-6 weeks.
- Borderline resectable disease: neoadjuvant chemoradiation may be employed to downstage tumors before surgery, improving resectability rates, as suggested by 1 and 1.
- Resectable cases with positive margins (R1 or R2 resections) or node-positive disease: adjuvant radiotherapy may be considered, typically starting 4-8 weeks after surgery, as mentioned in 1 and 1.
Radiotherapy Techniques
- Palliative radiotherapy at lower doses (20-30 Gy in fewer fractions) is valuable for symptom management, particularly for pain control from locally advanced disease or metastatic sites.
- Stereotactic body radiation therapy (SBRT) is an emerging approach delivering higher doses (33-40 Gy) in just 5 fractions, offering shorter treatment times with potentially fewer side effects.
Rationale for Radiotherapy
The rationale for radiotherapy is to improve local control, reduce tumor burden, and alleviate symptoms by directly damaging cancer cell DNA, while modern techniques like intensity-modulated radiation therapy help minimize damage to surrounding healthy tissues, as supported by 1 and 1. Some key points to consider when deciding on radiotherapy for pancreatic cancer include:
- The patient's overall health and performance status
- The stage and location of the tumor
- The potential benefits and risks of radiotherapy
- The availability of other treatment options, such as surgery or chemotherapy It is essential to weigh these factors carefully and consider the latest evidence, such as that from 1, when making decisions about radiotherapy for pancreatic cancer.
From the Research
Indications of Radiotherapy in Pancreas Cancer
The indications of radiotherapy in pancreas cancer are varied and depend on the stage and resectability of the tumor. Some of the key indications include:
- Neoadjuvant chemoradiotherapy (CRT) to downstage borderline resectable disease and make resection possible, which could translate to a survival benefit 2, 3, 4
- Adjuvant CRT for patients with incompletely resected tumors (R1) to improve survival 3
- Chemoradiation for patients with locally advanced tumors to reduce the rate of local relapse 3
- Preoperative chemotherapy and radiotherapy for patients with borderline resectable or locally advanced pancreatic cancer to improve treatment outcomes 4
Settings for Radiotherapy
Radiotherapy can be used in various settings, including:
- Neoadjuvant setting: to downstage the tumor and make resection possible 2, 3, 4
- Adjuvant setting: to improve survival in patients with incompletely resected tumors (R1) 3
- Definitive setting: to treat patients with locally advanced tumors who are not candidates for surgery 3, 5
- Palliative setting: to relieve symptoms and improve quality of life in patients with advanced disease 6
Techniques and Modalities
Various radiotherapy techniques and modalities can be used to treat pancreas cancer, including:
- Intensity modulated radiation therapy (IMRT) to reduce doses to organs at risk 3, 5
- Stereotactic body radiation therapy (SBRT) as a neoadjuvant or exclusive treatment 3, 5
- Magnetic resonance-guided radiation therapy and particle therapy, which are emerging concepts that may change the role of radiation in the future 5