NICE summary
The recommendations in this Best Practice topic are based on authoritative international guidelines, supplemented by recent practice-changing evidence and expert opinion. For your added benefit, we summarise below the key recommendations from relevant NICE guidelines.
Key NICE recommendations on diagnosis
This summary covers pancreatic cancer in adults (aged 18 and over).
Refer people aged 40 and over with jaundice using a suspected cancer pathway referral for pancreatic cancer.[165]
Consider an urgent (i.e., to be done within 2 weeks), direct-access CT scan (or an urgent ultrasound scan if CT is not available) to assess for pancreatic cancer in people aged 60 and over with weight loss and any of the following:[165]
Diarrhoea or constipation
Back pain
Abdominal pain
Nausea or vomiting
New-onset diabetes.
Unexplained weight loss and unexplained appetite loss may be symptoms of pancreatic cancer. Assess people with either symptom for additional features of cancer and offer urgent investigation or a suspected cancer pathway referral.[165]
A pancreatic protocol CT scan should be offered to people with:[68]
Obstructive jaundice and suspected pancreatic cancer (the pancreatic protocol CT scan should be offered before draining the bile duct)
Pancreatic abnormalities on imaging but no jaundice.
If the diagnosis is still unclear, fluorodeoxyglucose-positron emission tomography/CT (FDG‑PET/CT) and/or endoscopic ultrasound (EUS) with EUS-guided tissue sampling should be offered.[68]
For people with pancreatic abnormalities on imaging but no jaundice, EUS with EUS-guided tissue sampling should be offered if cytology/histology is needed.[68]
For people with obstructive jaundice and suspected pancreatic cancer, a biliary brushing should be taken for cytology if endoscopic retrograde cholangiopancreatography is being used to relieve the biliary obstruction and there is no tissue diagnosis.[68]
For people with pancreatic cysts, a pancreatic protocol CT scan or magnetic resonance cholangiopancreatography should be offered. If more information is needed after one of these tests, the other should be offered.[68]
The person should be referred for resection if they have any of these high-risk features: obstructive jaundice with cystic lesions in the head of the pancreas, enhancing solid component in the cyst, a main pancreatic duct that is 10 mm diameter or larger.[68]
EUS +/- fine-needle aspiration should be offered after these tests if more information is needed (e.g., on the likelihood of malignancy, or the need for surgery).[68]
When fine-needle aspiration is used, a carcinoembryonic antigen assay should be performed in addition to cytology if there is sufficient sample.[68]
People with cysts that are thought to be malignant should undergo staging.[68]
For people with inherited high risk of pancreatic cancer, surveillance should be considered. See the NICE guideline for more information about pancreatic cancer surveillance.[68]
Staging
A pancreatic protocol CT (that includes the chest, abdomen and pelvis) should be offered to people with newly diagnosed pancreatic cancer who have not had one.[68]
People with localised disease on CT who will be having cancer treatment should be offered FDG‑PET/CT.[68]
If more information is needed to decide on management, other staging investigations should be considered (e.g., MRI, EUS, laparoscopy with laparoscopic ultrasound).[68]
Links to NICE guidance
Pancreatic cancer in adults: diagnosis and management (NG85) February 2018. https://www.nice.org.uk/guidance/ng85
Suspected cancer: recognition and referral (NG12) October 2023. https://www.nice.org.uk/guidance/ng12
Key NICE recommendations on management
Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is ‘off-label’). Refer to the full NICE guideline and your local drug formulary for further information when prescribing.
A specialist pancreatic cancer multidisciplinary team should decide (with the person) what care is needed for suspected or confirmed pancreatic cancer.
Venous thromboembolism prophylaxis should be considered for people with pancreatic cancer in line with the NICE guideline Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism (NG89).
For pain management, EUS-guided or image-guided percutaneous neurolytic coeliac plexus block should be considered for people with uncontrolled pancreatic pain or unacceptable opioid adverse effects or for people receiving escalating doses of analgesics.
Do not offer thoracic splanchnicectomy for pain management in pancreatic cancer.
Enteric-coated pancreatin should be offered to people with unresectable pancreatic cancer. It should also be considered before and after pancreatic cancer resection.
Do not use fish oils to manage weight loss in unresectable pancreatic cancer.
Early enteral nutrition (e.g., oral and tube feeding) should be offered, rather than parenteral nutrition, for people with a functioning gut who have had pancreatoduodenectomy.
Specifically assess the psychological impact of fatigue, pain, gastrointestinal symptoms (including changes to appetite), nutrition, anxiety and depression throughout the person’s care pathway, providing support as appropriate.
Relieving biliary and/or duodenal obstruction
Resection should be offered, rather than preoperative biliary drainage, to people with resectable cancer and obstructive jaundice (due to biliary obstruction) who are well enough for resection and not enrolled in a clinical trial requiring preoperative biliary drainage.
Other options for biliary drainage in selected people include surgical biliary bypass and endoscopically placed self-expanding metal stents.
If possible, symptomatic duodenal obstruction caused by unresectable cancer should be relieved. Gastrojejunostomy and duodenal stenting are options in selected people.
Resectable and borderline resectable pancreatic cancer
Neoadjuvant therapy should only be considered as part of a clinical trial.
For people having surgery for head of pancreas cancer, pylorus-preserving resection should be considered if the tumour can be adequately resected.
People should be given sufficient time to recover from surgery, before starting adjuvant therapy as soon as they are well enough to tolerate all 6 cycles.
Adjuvant gemcitabine plus capecitabine should be offered. If the person is not well enough to tolerate combination therapy, gemcitabine should be considered.
Ongoing specialist assessment and care should be offered after resection and should be provided if the person has new, unexplained or unresolved symptoms after treatment.
Unresectable pancreatic cancer: locally advanced
Systemic combination chemotherapy should be offered to people with locally advanced pancreatic cancer who are well enough to tolerate it. Gemcitabine should be considered for people who are not well enough to tolerate combination chemotherapy.
Capecitabine should be considered as the radiosensitiser when chemoradiotherapy is used.
Unresectable pancreatic cancer: metastatic
As first-line treatment, FOLFIRINOX should be offered to people with metastatic pancreatic cancer and an Eastern Cooperative Oncology Group performance status of 0 to 1.
Gemcitabine combination therapy should be considered for people not well enough to tolerate FOLFIRINOX. Nab-paclitaxel with gemcitabine is a recommended option in selected people. For more information, see the NICE guideline Paclitaxel as albumin-bound nanoparticles with gemcitabine for untreated metastatic pancreatic cancer (TA476).
Gemcitabine should be offered to people who are not well enough to tolerate combination chemotherapy.
As second-line treatment, the following should be considered:
Oxaliplatin-based chemotherapy: for people who have not had first-line oxaliplatin
Gemcitabine-based chemotherapy: for people whose cancer has progressed after first-line FOLFIRINOX.
© NICE (2018) (2023). All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Links to NICE guidance
Pancreatic cancer in adults: diagnosis and management (NG85) February 2018. https://www.nice.org.uk/guidance/ng85
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