Q: What is the role of radiotherapy in the management of pancreatic cancer, and when should radiation therapy be used?

Alok Khorana, MD
Professor of Medicine 

Director, Gastrointestinal Malignancies Program 

Cleveland Clinic
Cleveland, Ohio

Although it is widely used in other cancers, including lung nodules and metastases to the liver and primary hepatocellular carcinoma among others, stereotactic body radiotherapy (SBRT) is a relatively new application in pancreatic cancer. Initially, the approach of SBRT to pancreatic cancer was confined to a few select situations. Recently, data from the National Cancer Database have been evaluated and have shown that SBRT is associated with significant outcomes, compared with chemotherapy alone or chemotherapy with traditional external beam radiation therapy. At our institution, we use SBRT either in select patients for whom a combination chemotherapy or a systemic therapy is not an option because of comorbidities or performance status issues or in patients for whom systemic therapy has done a great job controlling the disease but a primary pancreas is still in place. If patients are tired of being on systemic therapy, at the 6-month time point we evaluate to make sure there is no distant disease that is not controlled, and then we consider SBRT to the primary lesion in hopes of allowing time off from systemic therapy and extending disease control. That is supported by the recent treatment guidelines as well.

Thomas A. Abrams, MD
Assistant Professor of Medicine

Harvard Medical School

Senior Physician

Dana-Farber Cancer Institute
Boston, Massachusett

Radiation in general has become less of a true standard of care for locally advanced disease than it may have been in the past, but it still has a very important role. For patients with locally advanced disease, trying to downstage their disease to a point where it is resectable is really the goal. For those patients who are not rendered resectable through induction chemotherapy, trying chemoradiotherapy or SBRT, really makes sense not only for local control but for continued attempt to downstaging. Those types of patients are ideal candidates for thinking about radiation. Also, patients with poor performance status who are surgical candidates will benefit from palliative SBRT to exert some local control over the disease. Also, for patients who had surgical resections where there is a positive margin or positive lymph nodes, we should be considering radiation for those patients too in addition to adjuvant chemotherapy. There are a number of patients for whom pancreatic radiation should be considered. Not all of those patients will end up receiving radiation, but the consideration needs to be for those types of patients.

Michael Morse, MD, MHS, FACP
Professor of Medicine, Division of Medical Oncology 

Professor, Department of Surgery 

Duke University Medical Center
Durham, North Carolina

As a medical oncologist looking objectively at radiation, I think there are adequate data that say in locally advanced pancreatic cancer, conventional chemoradiation following standard chemotherapy probably does not offer a survival benefit. However, that is using conventional radiation, which can be fairly toxic. If you consider somebody who has a very good response to their induction chemotherapy, perhaps for 4 to 6 months, it is certainly reasonable as a consolidation. Also, now that we’re talking about doing SBRT, the tolerability of it is improved, and it certainly may improve local control and delay the need for resuming therapy in the future. To avoid a person with local advanced disease from having to stay on therapy indefinitely, a follow-up course of radiation after the induction chemotherapy could make sense in that subpopulation. In terms of the people with resected disease, we have moved away from radiation, and chemotherapy has become more of the backbone of treatment, but radiotherapy certainly can still be considered in patients who have had no evidence of recurrence but had positive margin or a very large tumor, where there is concern about local recurrence. I also think there is still probably a role in the adjuvant setting for some patients getting radiation.