Clinical decision-making in pancreaticcancer

Abstract

The management of pancreatic cancer relies on clinical staging for the majority ofpatients. High-quality cross-sectional imaging, and in some cases adjunctive stagingmodalities, partitions pancreatic cancer into one of four categories: localizedand potentially resectable, borderline resectable, locally advanced/unresectable, ormetastatic. Subsequent decisions regarding specific anticancer therapies and palliativeinterventions should be based on patient-centered, defined goals of care. Clinical decision-making should be evidence based, accounting for the patient'sperformance status and psychosocial circumstances, and developed with multidisciplinaryinput. Presently, surgical resection provides the only meaningfulchance for long-term survival and, in general, is relevant only to those patientswith potentially resectable or borderline resectable disease. However, there appearsto be an expanding subset of patients with locally advanced disease who mayeventually be considered surgical candidates. Nevertheless, surgical resection withcurative intent should be linked to the delivery of additional therapy either asadjuvant therapy or neoadjuvant treatment. Enrollment in prospective clinical trialsis always encouraged provided participation is not an undue burden on the patientor caregivers. Lastly, patients in need of expert clinical services should be encouragedto seek cancer care in pancreatic cancer centers of excellence as currentevidence suggests improved outcomes in these settings.