August 20, 2026
5 min read
Key takeaways:
- The guideline includes evidence from several prospective trials conducted since 2019.
- It addresses radiation therapy’s role in the resectable, locally advanced, recurrent, metastatic and palliative settings.
An updated clinical guideline is designed to clarify the settings in which radiation therapy is appropriate for pancreatic cancer and outline how the modality can be integrated safely with other treatments.
The guideline — which updates recommendations that American Society for Radiation Oncology (ASTRO) issued in 2019 — address radiation therapy’s role in multiple settings.
“For many years, we haven’t had the prospective evidence necessary to fully demonstrate the impact of radiation therapy in pancreatic cancer,” Daniel Chang, MD, FASTRO, chair of the department of radiation oncology at University of Michigan and chair of the guideline task force, told Healio. “That was partly due to lack of advancements in systemic therapy, which resulted in patients having very poor prognosis. Now, in the modern era of systemic therapy, we’re seeing longer survival that opens the door for local treatments — including radiation — and the outcomes are starting to become more evident.”
The guidelines provide clinicians with “a practical framework” to identify patients who may benefit from radiation therapy and ensure it is delivered effectively and safely, Chang added.
“I’m hopeful these guidelines give radiation oncologists the ability to make stronger arguments for radiation and foster conversations among the entire multidisciplinary team that lead to them being more open-minded about using it,” he said.
Noteworthy updates
ASTRO — in collaboration with ASCO, the European Society for Radiotherapy and Oncology, and the Society of Surgical Oncology — convened a multidisciplinary taskforce that included radiation, medical and surgical oncologists, along with a medical physicist, radiation oncology resident and patient representative.
Task force members performed a systematic review of literature published through June of this year. A formal consensus process, peer review and a public comment period took place prior to formal approval.
The guideline incorporates high-quality evidence from several prospective randomized trials that authors say solidifies the role of radiation therapy for pancreatic cancer and highlights the potential of more modern radiotherapy techniques.
Recommendations address indications for nonmetastatic pancreatic cancer — including resectable, borderline resectable, locally advanced disease and resectable but medically inoperable disease — as well as the role for the modality in the recurrent, metastatic and palliative settings.
They provide insights about optimal dosing and target volumes for various stages of disease, including when shorter radiation courses may be appropriate. They also highlight best practices for treatment planning and delivery.
A few elements are particularly noteworthy, Chang said.
The updated guideline includes a strong recommendation — supported by two prospective randomized trials — for preoperative radiation for borderline resectable pancreatic cancer.
Another strong recommendation addresses radiation for locally advanced disease, including use of dose escalation when appropriate volumetric image guidance and motion management are available. The previous guideline did not routinely recommend dose escalation.
“This is clinically important because, historically, the radiation dose that could be safely delivered to pancreatic tumors was limited by the close proximity of the stomach and intestines,” Chang said. “Modern image guidance, motion management and adaptive radiation therapy can allow substantially higher doses to be delivered while respecting normal tissue constraints. The updated guideline, therefore, provides a framework for moving beyond conventional radiation doses in appropriately selected patients.”
The updated guideline includes a recommendation for elective targeting of anatomic regions at risk for microscopic disease, such as the peritumoral margin, extrapancreatic neural pathways and regional nodal basins.
“This is clinically meaningful because durable local control may depend not only on controlling the visible tumor but also on addressing microscopic disease immediately beyond it,” Chang said.
The guideline also includes a recommendation for the role of radiation — particularly stereotactic body radiation therapy — for patients with oligometastatic disease. A recent trial demonstrated a PFS advantage with this approach, Chang said.
An ‘exciting new era’
More research is necessary to address important unanswered questions, Chang said.
These include determining the optimal way to integrate radiation therapy with systemic treatments, as well as identifying which patients are likely to derive the greatest benefit from more intensive local treatment.
“Hopefully there will be more level one evidence for integrating radiation with chemotherapy,” Chang said. “Some prior trials have not used the best-of-the-best chemotherapy with the best-of-the-best radiation. That is partly because the field is moving quickly and it is hard to design trials that keep up with all of the advancements. We are trying to address that now with some trials that are opening, and hopefully we can find a way to get the best of both worlds with combined-modality therapy.”
Additional evidence also is needed to clarify the role of radiation in the metastatic setting.
“Historically, these patients have never been thought of for complex multidisciplinary therapy, but I think that is where a lot of the ‘bang for our buck’ can come from,” Chang said.
His enthusiasm is based on two recent trials.
The randomized phase 2 EXTEND trial included patients with pancreatic cancer who had limited metastatic disease, defined as up to five sites. Researchers assigned patients to standard systemic therapy alone or with metastases-directed therapy, primarily SBRT. The results showed a PFS benefit with metastases-directed therapy, demonstrating the benefit of local therapy.
Meanwhile, results of the randomized phase 3 RASolute-302 trial showed the oral pan-RAS inhibitor daraxonrasib (Revolution Medicines) doubled survival vs. standard chemotherapy for patients with previously treated metastatic disease.
Other research published over the past several months highlighted the potential of other oral regimens in later-line settings, as well as the possible role for vaccines among patients with relapsed disease.
“For so many years, we saw limited progress and very shallow improvements in survival curves,” Chang said. “It is incredibly exciting to see some significant advances, but that long interval of very little progress reminds us that we never want to take our foot off the pedal. Radiation therapy, alongside other local therapies — whether it’s ablation or even surgical resection, could unlock anexciting new era for management of pancreatic cancer.”
Historically, much of the discussion surrounding radiation therapy for pancreatic cancer has focused on local control and symptom palliation, Chang said.
“As systemic therapies improve and patients live longer, achieving durable control of the primary tumor may become increasingly important,” he said. “The possibility that more effective local therapy could ultimately contribute to longer survival for appropriately selected patients is exciting. If daraxonrasib or other agents in the pipeline are moved into the upfront setting, hopefully that will extend survival even further and the dream of making pancreatic cancer a chronic disease — previously thought to be impossible — may become reality.”
For more information:
Daniel Chang, MD, FASTRO, can be reached at dtchangd@med.umich.edu.
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