How I treat pancreatic cancer

Pancreatic adenocarcinoma (PA) represents 90% of solid pancreatic malignant tumours. With one of the worst prognoses in oncology (all stages 5-year overall survival (OS) of 9%), PA was the seventh-leading cause of cancer-related deaths worldwide in 2018, and during the last 20 years, there have been unexplained increases in its incidence and mortality. This article summarises how to manage, to our opinion, PA in everyday practice according to tumour staging into resectable, unresectable or metastatic disease. Surgery followed by consensual adjuvant chemotherapy is the first-intention treatment for resectable patients. Unresectable but non-metastatic PA should be treated with induction chemotherapy and optionally with chemoradiotherapy to enable when possible secondary surgical resection. First-line and second-line chemotherapy does improve quality of life and OS in the metastatic setting, FOLFIRINOX and gemcitabine + nab-paclitaxel being the two current standard first-line options. Molecular profiling of metastatic patients is emerging, as some personalised therapies are possible for rare subtypes such as MSI high, BRCA1-2 mutated and NRG1/NTRK fusion gene PA.