ASTRO expands radiation’s role across pancreatic cancer spectrum

Clinical takeaway: Consider radiation therapy as an increasingly important component of multidisciplinary pancreatic cancer care, not only for borderline resectable and locally advanced disease, but also in selected resectable, recurrent, oligometastatic, oligoprogressive, and palliative settings. Treatment should generally be integrated with systemic therapy, with modern image guidance, motion management, and adaptive techniques used when dose escalation is pursued.

The American Society for Radiation Oncology (ASTRO) has updated its 2019 pancreatic cancer guideline after several randomized trials and advances in radiation delivery reshaped the evidence base. The new recommendations cover invasive ductal pancreatic adenocarcinoma from potentially curable disease through recurrence, metastases, and symptom palliation.

For resectable disease, preoperative chemoradiation is now conditionally recommended; if preoperative radiation is not given, postoperative chemoradiation after multiagent chemotherapy is conditionally recommended for patients with pN0 disease. Postoperative chemoradiation is also considered reasonable with positive margins or pN+ disease.

For borderline resectable cancer, preoperative chemoradiation or RT is strongly recommended.

Locally advanced disease should generally receive chemoradiation or RT after multiagent chemotherapy, while medically inoperable patients may receive definitive chemoradiation or RT, including without induction chemotherapy when multiagent treatment is not appropriate.

Drug-related guidance favors concurrent single-agent chemotherapy with chemoradiation: infusional 5-FU, capecitabine, or gemcitabine. Capecitabine may be preferred over gemcitabine with conventionally fractionated chemoradiation because of lower toxicity in comparative data; caution is advised when combining gemcitabine with dose-escalated regimens, and concurrent chemotherapy should not be used with stereotactic body radiation therapy (SBRT).

What's changed

• New evidence supports a broader role for radiation therapy in resectable, borderline resectable, locally advanced, recurrent, and selected metastatic pancreatic cancer settings.
• Preoperative chemoradiation is now conditionally recommended for resectable disease and recommended for borderline resectable disease to improve local control and increase the likelihood of margin-negative surgery.
• For locally advanced pancreatic cancer, chemoradiation or radiation after multiagent chemotherapy is recommended to improve local control and reduce morbidity from uncontrolled local progression.
• New recommendations support definitive-intent radiation for isolated locoregional recurrence, selected oligometastatic and oligoprogressive disease, and reirradiation in carefully selected patients.
• Greater emphasis is placed on dose-escalated radiation, SBRT, elective nodal/microscopic disease coverage, image guidance, motion management, and adaptive radiation therapy.

“Indications for the use of radiation therapy in treating pancreatic cancer have changed notably in the last several years,” guideline chair Daniel Chang, MD, FASTRO, said, adding that newer evidence and technologies now allow clinicians to identify appropriate patients and deliver treatment with greater precision.

Source: Chuong MD, et al. (2026 Aug 11) Pract Radiat Oncol. Radiation Therapy for Pancreatic Cancer: An ASTRO Clinical Practice Guideline