New ASTRO guidelines optimize radiation therapy for pancreatic cancer

An updated clinical guideline from the American Society for Radiation Oncology (ASTRO) provides evidence-based recommendations on the use of radiation therapy to treat adult patients with pancreatic cancer. The guideline updates ASTRO's 2019 recommendations to reflect recent clinical trials that provide growing evidence for radiation therapy in the resectable, locally advanced and metastatic settings. It was published in Practical Radiation Oncology, ASTRO's clinical practice journal.

Pancreatic cancer is one of the deadliest cancers, and epidemiologic models estimate that by 2030 it will become the second leading cause of cancer-related death in the United States. In 2026, an estimated 67,500 U.S. adults will be diagnosed with pancreatic cancer and approximately 52,700 will die from the disease. Five-year survival is 13% across all stages.

Surgery is the only established potentially curative treatment for pancreatic cancer, but fewer than one in five patients are candidates at diagnosis because many tumors are already locally advanced or metastatic. Most patients receive chemotherapy, and emerging RAS-targeted therapies may expand options for those with metastatic disease. Radiation therapy plays an integral role in multidisciplinary care by improving local control, helping some patients become candidates for surgery and relieving symptoms such as pain or bleeding. As newer systemic treatments help patients live longer, controlling persistent or progressing disease at individual sites also becomes increasingly important and potentially expands the role of radiation therapy for appropriately selected patients.

Indications for the use of radiation therapy in treating pancreatic cancer have changed notably in the last several years. New clinical evidence helps clarify which patients can benefit from radiation therapy, while technological advances such as image guidance, motion management and adaptive radiation therapy allow us to deliver that care with greater precision."

Daniel Chang, MD, FASTRO, chair of the guideline task force and professor and chair of radiation oncology, University of Michigan

"Pancreatic cancer requires coordinated, multidisciplinary care because treatment decisions depend heavily on whether a tumor can be removed surgically and how the cancer responds to chemotherapy," said Michael D. Chuong, MD, vice chair of the guideline task force and vice chair and medical director of radiation oncology at the Baptist Health Herbert Wertheim Cancer Institute. "This guideline gives clinicians clearer direction about when radiation therapy is appropriate and how to integrate it safely with other treatments."

Key recommendations from the guideline are listed below. Multidisciplinary evaluation and decision-making are also recommended for all patients before and throughout treatment.

Indications for nonmetastatic pancreatic cancer

• For patients with resectable pancreatic cancer, chemoradiation prior to surgery is conditionally recommended. The guideline notes that preoperative therapy for resectable tumors remains an area of active investigation but may help reduce the risk of local recurrence and improve surgical outcomes. For patients with resectable disease who do not receive preoperative radiation therapy, postoperative chemoradiation following multiagent chemotherapy is conditionally recommended for patients with pathologically uninvolved (pN0) lymph nodes.

• For patients with borderline resectable disease, preoperative radiation therapy or chemoradiation is recommended to improve local control and increase the likelihood of a margin-negative resection.

• For patients with locally advanced pancreatic cancer, chemoradiation or radiation therapy after multiagent chemotherapy is recommended as definitive treatment to improve local control and reduce morbidity from uncontrolled local progression.

• For patients with resectable but medically inoperable disease, or those who decline surgery, chemoradiation or radiation therapy following multiagent chemotherapy is recommended. Chemoradiation or radiation therapy without initial chemotherapy is also reasonable for patients at higher risk for treatment-related complications or those who decline upfront multiagent chemotherapy.

Indications in the recurrent, metastatic and palliative settings

• For patients with isolated locoregional recurrence after surgery and no prior radiation therapy, definitive-intent radiation therapy or chemoradiation is recommended. For those who previously received radiation therapy, reirradiation is conditionally recommended, with careful consideration of prior treatment plans and radiation doses to nearby normal tissues.

• For patients with oligometastatic or oligoprogressive pancreatic cancer, meaning cancer that has spread to or is progressing in a limited number of sites, definitive-intent chemoradiation or radiation therapy is conditionally recommended to the metastatic lesions and to the primary tumor if it was not previously treated with definitive local therapy.

• Palliative radiation therapy is recommended for patients with pancreatic cancer-related symptoms such as bleeding, pain or obstruction. Dose-escalated approaches may be reasonable for pain relief in selected patients.

Treatment planning and delivery

• Recommendations address optimal dosing and target volumes for different stages of pancreatic cancer, including when shorter radiation courses such as stereotactic body radiation therapy (SBRT) may be appropriate. For patients with locally advanced pancreatic cancer, dose escalation is recommended when volumetric image guidance and motion management are available. For patients receiving radiation therapy before or after surgery, or as definitive treatment, the guideline recommends including nearby anatomic areas at risk for microscopic cancer spread in the treatment field.

• Best practices for treatment planning and delivery emphasize precision and safety, including the use of intensity modulated radiation therapy (IMRT), daily image guidance and patient-specific assessment of respiratory motion. Adaptive radiation therapy is recommended for dose-escalated SBRT to help protect nearby organs while maintaining effective tumor coverage.

The guideline also highlights important unanswered questions and areas where additional research is needed, particularly how best to integrate radiation therapy with evolving systemic treatments. Future research may help determine whether combinations such as radiation therapy and RAS inhibitors can improve outcomes, as well as better identifying which patients are most likely to benefit from more intensive local treatment.

About the guideline

"Radiation Therapy for Pancreatic Cancer: An ASTRO Clinical Practice Guideline" was developed by a multidisciplinary task force of radiation, medical and surgical oncologists, as well as a radiation oncology resident, medical physicist and patient representative. Recommendations were based on a systematic review of research published from 2010 through June 2026. The guideline was developed in collaboration with the American Society of Clinical Oncology, the European Society for Radiotherapy and Oncology and the Society of Surgical Oncology.

ASTRO's clinical guidelines are intended as tools to promote appropriately individualized, shared decision-making between physicians and patients. None should be construed as strict or superseding the appropriately informed and considered judgments of individual physicians and patients.