NCCN Updates Guidelines for Pancreatic Adenocarcinoma

05/15/18

The National Comprehensive Cancer Network (NCCN) has issued updates to their clinical practice guidelines, drugs and biologics compendium, radiation therapy compendium, and imaging appropriate use criteria guidelines for pancreatic adenocarcinoma.

Along with the extensive revisions to the workup algorithms, “consider genetic counseling and germline testing if diagnosis confirmed” has been added as an option to the additional workup recommendations following a multidisciplinary consultation.

In the section for resectable disease, a treatment option has been added: “consider neoadjuvant therapy in high-risk patients, clinical trial preferred.”

A couple of revisions were made to the section for second-line therapy for patients with good performance status and disease progression. For locally advanced or metastatic disease, the pathways for those previously treated with gemcitabine-based or fluoropyrimidine-based therapy have been combined, with the recommended chemotherapy options based on prior therapy outlined in the principles of chemotherapy section. SBRT has been added as an option for locally advanced disease if not previously given and if the primary site is the sole site of disease progression.

Second-line therapy options have been added for patients with poor performance status and disease progression after first-line therapy for locally advanced or metastatic adenocarcinoma. The guideline clarifies that the systemic therapy options for a recurrence in the pancreatic bed are the same as those for recurrent metastatic disease, and the choice of regimen depends on the time to recurrence after completion of primary therapy.

“Consider induction chemotherapy followed by SBRT” has been removed from the options for a recurrence in the pancreatic bed.

The systemic therapy options have been clarified for patients with metastatic disease that recurred less than 6 months from completion of primary therapy: “Switch to gemcitabine-based systemic chemotherapy (if fluoropyrimidine-based therapy previously used) or switch to fluoropyrimidine-based systemic chemotherapy (if gemcitabine-based therapy previously used.”

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Various recommendations have been added to the principles of palliation and supportive care section for the treatment of bleeding from the primary tumor site.

Additionally, multiple changes have been made to the principles of chemotherapy section. The indications for the use of gemcitabine plus cisplatin have been revised in all settings to read “(Only for known BRCA1/2 mutations),” 5-FU/cisplatin plus concurrent radiation therapy has been removed from the chemoradiation options for all settings where chemoradiation is listed, second-line therapy options have been added for patients with locally advanced or metastatic disease and poor performance status, and FOLFIRI (5-FU plus leucovorin and irinotecan) has been added as a second-line therapy option for patients with locally advanced or metastatic disease and good performance status.—Zachary Bessette