Revisions made to NCCN pancreatic adenocarcinoma guidelines

Changes in guidelines emphasize the importance of individualized management.

Recently updates were made to the National Comprehensive Cancer Network Guidelines for Pancreatic Adenocarcinoma including the recommendation of an individualized approach to management, clarification of required diagnostic imaging and an overall emphasis on systemic therapy at all stages of disease.

Margaret A. Tempero, MD, of the University of California at San Francisco’s Helen Diller Family Comprehensive Cancer Center and chair of the NCCN Pancreatic Adenocarcinoma Panel, presented these updates at the NCCN 14th Annual Conference in Hollywood, Fla.

“We made very subtle changes in these guidelines,” Tempero told HemOnc Today. “Physicians will see when they go into these guidelines that we are looking at a more individualized management, especially and potentially with resectable disease. We are trying to put more emphasis on diagnostic imaging and interdisciplinary coordination and making decisions about surgery.”

Summary of changes

In the section on diagnostic imaging in patients with pancreatic cancer, NCCN recommends for a pancreatic CT scan to be performed according to a defined pancreas protocol, such as triphasic cross-sectional imaging. If CT results are unclear, a PET scan may be used.

As for making the decision about disease management and resectability, NCCN suggests having close, multidisciplinary cooperation. “One of the concerns is that some patients are being rushed into surgery too quickly and some people who may be destined to have metastatic disease — and therefore not really benefit from their surgery — may be disadvantaged by this,” Tempero said. “So trying to figure out who these people are and perhaps treat them differently or use additional therapy prior to surgery is prudent, but this is tricky because right now we are unsure as to how to approach this. This is why we put more of an emphasis on thoughtfulness and individualized management.”

For those patients with disabling symptoms, who have had evasive CT and were considered to have resectable disease at presentation, laparoscopy is recommended before laparotomy, but after neoadjuvant therapy.

For patients with metastatic disease, Tempero summarized the updated recommendations as follows, “Single agent gemcitabine (Gemzar, Eli Lilly and Company) or selected gemcitabine combinations followed by a fluorinated pyrimidine plus oxaliplatin is the standard of care. Eighty percent of patients with pancreatic cancer relapse systematically even with adjuvant therapy … clinicians must keep this in mind as we treat our patients.”

In addition, fluorinated pyrimidine-based therapy with oxaliplatin (Eloxatin, Sanofi-Aventis) is now recommended as a second-line option for patients with advanced disease and good performance status.

Tempero further highlighted the importance of upfront systemic therapy prior to administration of chemoradiation therapy. “Radiation is important for a subset of patients with local disease only, but systemic chemotherapy should be given first.” For those patients most likely to benefit from subsequent chemoradiation, upfront systemic therapy will control disease.

“Hopefully someday the science will get to the point where we can actually say that ‘this person should go directly to surgery and this person should have a somewhat different approach’,” Tempero said. “With the highest quality imaging, some of these decisions become a little clearer. Patients should really have their surgery in a high volume center where there is a lot of dedicated expertise.” – by Jennifer Southall