Although the aetiology of pancreatic cancer is unknown, the current prevention strategies involve reducing risk factors. The two most effective prevention strategies include avoiding tobacco smoking and maintaining a normal body weight (American Cancer Society 2019; Xu et al. 2018). Some studies suggest a change in diet may decrease the risk of pancreatic cancer by decreasing soft drink and sugar consumption and increasing consumption of whole grains and vegetables (Lei et al. 2016; Pericleous et al. 2014).

The risk factors for developing pancreatic cancer include:

• tobacco smoking (most established risk factor; risk increases significantly with greater intensity and duration) (Arriaga et al. 2019)
• cystic lesions of the pancreas
• obesity
• increased consumption of red meat and processed meat
• a family history of pancreatic cancer
• older age
• chronic pancreatitis
• longstanding type 2 diabetes mellitus
• male gender
• Asian or Pacific Islander ethnicity
• chronic alcohol consumption
• liver cirrhosis
• stomach infections with the bacterium Helicobacter pylori, which causes stomach ulcers
• heavy occupational exposure to certain pesticides, dyes and chemicals used in metal refining (Cancer Australia 2017a).

Having certain hereditary conditions also increase a person’s risk of pancreatic cancer:

• hereditary pancreatitis syndrome
• hereditary nonpolyposis colon cancer (HNPCC – Lynch syndrome)
• Peutz-Jeghers syndrome
• hereditary BRACA2-related breast and ovarian cancer syndrome
• familial atypical multiple mole melanoma (FAMMM) syndrome
• ataxia-telangiectasia syndrome (ATM mutation)
• Li-Fraumeni syndrome (TP53 mutation).

Many cases present with non-specific symptoms or are asymptomatic until advanced stages of the disease. The following signs and symptoms should be investigated:

• acute pancreatitis where the cause is not alcohol ingestion and gallstones are not evident
• new-onset diabetes
• jaundice that is progressive, together with unexplained weight loss and abdominal pain that may radiate to the back (the jaundice may also be accompanied with dark urine, light-coloured stools and itchy skin)
• pain, which is often severe, unrelenting and of a short duration
• unexplained weight loss
• pale and greasy stools
• nausea and vomiting
• constipation
• fatigue
• enlargement of gall bladder
• blood clot in the leg without a clear risk factor
• incidental lesions found on radiology (Freelove & Walling 2006; Kamisawa et al. 2016).

The presence of multiple signs and symptoms, particularly in combination with other underlying risk factors, indicates an increased risk of pancreatic cancer.

Increasingly, incidental diagnosis may occur with pancreatic abnormalities detected on investigation for other complaints.

The incidence of pancreatic cancer in people below 40 years is extremely low. The cause of jaundice in people aged under 40 years is more likely to be caused by other conditions such as alcoholism or hepatitis. People aged under 40 years with jaundice should be referred to non–cancer related pathways.

Depending on the presenting symptoms and risk factors, the general practitioner examinations include the following.

Where there is suspicion of pancreatic cancer, consider:

• an abdominal CT scan with pancreatic protocol
• serum CA 19-9 and liver function tests
• early referral (strongly indicated), usually prior to a definitive diagnosis being made.

Where jaundice is present, the following should be performed urgently:

• liver function tests
• abdominal ultrasound
• CT where appropriate.

An abnormal result should be discussed face to face with the patient and information provided.

If the cancer diagnosis is confirmed or the results are inconsistent or indeterminate, the general practitioner must refer the patient to an appropriate specialist (gastroenterologist, oncologist or hepatopancreaticobiliary [HPB] surgeon with professional expertise in pancreatic cancer management and access to a multidisciplinary team) to make the diagnosis. In patients with locally advanced, non-metastatic disease, if resectability needs to be determined, referral should be to an HPB surgeon.

Patients should be enabled to make informed decisions about their choice of specialist and health service. General practitioners should make referrals in consultation with the patient after considering the clinical care needed, cost implications (see referral options and informed financial consent), waiting periods, location and facilities, including discussing the patient’s preference for health care through the public or the private system.

Referral for suspected or diagnosed pancreatic cancer should include the following essential information to accurately triage and categorise the level of clinical urgency:

• important psychosocial history and relevant medical history
• family history, current symptoms, medications and allergies
• results of current clinical investigations (imaging and pathology reports)
• results of all prior relevant investigations
• notification if an interpreter service is required.

Many services will reject incomplete referrals, so it is important that referrals comply with all relevant health service criteria.

If access is via online referral, a lack of a hard copy should not delay referral.

The specialist should provide timely communication to the general practitioner about the consultation and should notify the general practitioner if the patient does not attend appointments.

Aboriginal and Torres Strait Islander patients will need a culturally appropriate referral. To view the optimal care pathway for Aboriginal and Torres Strait Islander people and the corresponding quick reference guide, visit the Cancer Australia website. Download the consumer resources – Checking for cancer and Cancer from the Cancer Australia website.

The treatment team, after taking a thorough medical history and making a thorough medical examination of the patient, should undertake the following investigations under the guidance of a specialist.

Most diagnostic procedures should be completed prior to the MDM. Diagnosis of a mass is primarily by imaging. Biopsy is only required where there is diagnostic uncertainty, or where tissue is required for further management or clinical trials. Contrary to the situation with most cancers, definitive tissue diagnosis prior to the multidisciplinary planning is not recommended.

The following investigation is suggested (to be completed first if not already performed):

• contrast-enhanced CT scan.

If diagnostic uncertainty remains, the following investigations are recommended:

• endoscopic ultrasound with or without biopsy
• contrast-enhanced MRI of the pancreas or magnetic resonance cholangiopancreatography (MRCP) in patients who cannot tolerate contrast or where diagnostic uncertainty remains (Pietryga & Morgan 2015)
• diagnostic laparoscopy with or without laparoscopic ultrasound when resection is planned

Staging is a critical element in treatment planning and should be clearly documented in the patient’s medical record. Synoptic reporting is encouraged where operative resection has occurred and pathological staging is available. The most widely used staging tools for pancreatic cancer are the American Joint Committee on Cancer’s TNM staging system and stage grouping. The imaging modalities used for diagnosis also allow for simultaneous staging of pancreatic cancer. The pancreatic cancer can be diagnosed and staged as resectable or borderline resectable, locally advanced or metastatic.

Staging for pancreatic cancer involves these tests:

• CT chest/abdominal/pelvis and positron emission tomography (PET)
• MRI pancreatic and/or liver
• laparoscopy plus or minus laparoscopic ultrasound for high-risk patients.

Visit the Cancer Institute New South Wales website for information about understanding the stages of cancer.

Patient performance status is a central factor in cancer care and should be clearly documented in the patient’s medical record.

Performance status should be measured and recorded using an established scale such as the Karnofsky scale or the Eastern Cooperative Oncology Group (ECOG) scale.

Patients should be encouraged to participate in research or clinical trials where available and appropriate.

For more information visit the Cancer Australia website.

The intent of treatment can be defined as one of the following:

• curative
• anti-cancer therapy to improve quality of life and/or longevity without expectation of cure
• symptom palliation.

The treatment intent should be established in a multidisciplinary setting, documented in the patient’s medical record and conveyed to the patient and carer as appropriate.

The potential benefits need to be balanced against the morbidity and risks of treatment.

The lead clinician should discuss the advantages and disadvantages of each treatment and associated potential side effects with the patient and their carer or family before treatment consent is obtained and begins so the patient can make an informed decision. Supportive care services should also be considered during this decision-making process. Patients should be asked about their use of (current or intended) complementary therapies (see Appendix D).

Timeframes for starting treatment should be informed by evidence-based guidelines where they exist. The treatment team should recognise that shorter timeframes for appropriate consultations and treatment can promote a better experience for patients.

Initiate advance care planning discussions with patients before treatment begins (this could include appointing a substitute decision-maker and completing an advance care directive). Formally involving a palliative care team/service may benefit any patient, so it is important to know and respect each person’s preference (AHMAC 2011).

Early referral to palliative care can improve the quality of life for people with cancer (Haines 2011; Temel at al. 2010; Zimmermann et al. 2014). This is particularly true for cancers with poor prognosis.

In general, all patients with pancreatic cancer, given the poor prognosis, should be offered referral to palliative care assessment as an integrated aspect of their overall oncology care (Gaertner et al. 2011).

In particular, referral to palliative care services is required when:

• symptoms affect quality of life
• ECOG ≥ 2
• estimated likely survival is less than a year and/or the patient/carer has increasing difficulty managing care needs
• complex psychosocial needs, including those of carers
• patient/family wishes for palliative care support, especially in the community setting
• bereavement support for carers.

Emphasise the value of palliative care in improving symptom management and quality of life to patients and their carers.

The ‘Dying to Talk’ resource may help health professionals when initiating discussions with patients about future care needs (see ‘More information’). Ensure that carers and families receive information, support and guidance about their role in palliative care (Palliative Care Australia 2018).

Patients, with support from their family or carer and treating team, should be encouraged to consider appointing a substitute decision-maker and to complete an advance care directive.

Refer to Step 6 for a more detailed description of managing patients with recurrent, residual or metastatic disease.

These online resources are useful:

• Advance Care Planning Australia
• Care Search
• Dying to Talk
• the Palliative Care resource kit
• Palliative Care Australia (for patients and carers)

The team should support the patient to participate in research or clinical trials where available and appropriate. Many emerging treatments are only available on clinical trials that may require referral to certain trial centres.

For more information visit the Cancer Australia website.

The transition from active treatment to post-treatment care is critical to long-term health. In some cases, people will need ongoing, hospital-based care, and in other cases a shared follow-up care arrangement with their general practitioner may be appropriate. This will vary depending on the type and stage of cancer and needs to be planned.

Shared follow-up care involves the joint participation of specialists and general practitioners in the planned delivery of follow-up and survivorship care. A shared care plan is developed that outlines the responsibilities of members of the care team, the follow-up schedule, triggers for review, plans for rapid access into each setting and agreement regarding format, frequency and triggers for communication.

After completing initial treatment, a designated member of the multidisciplinary team (most commonly nursing or medical staff involved in the patient’s care) should provide the patient with a needs assessment and treatment summary and develop a survivorship care plan in conjunction with the patient. This should include a comprehensive list of issues identified by all members of the multidisciplinary team involved in the patient’s care and by the patient. These documents are key resources for the patient and their healthcare providers and can be used to improve communication and care coordination.

The treatment summary should cover, but is not limited to:

• the diagnostic tests performed and results
• diagnosis including stage, prognostic or severity score
• tumour characteristics
• treatment received (types and dates)
• current toxicities (severity, management and expected outcomes)
• interventions and treatment plans from other health providers
• potential long-term and late effects of treatment
• supportive care services provided
• follow-up schedule
• contact information for key healthcare providers

As most patients with pancreatic cancer are palliated, they should already have a palliative care physician/team that will oversee their palliation. If a patient is thought to have been cured after their treatment, then care in the post-treatment phase is driven by predicted risks (such as the risk of recurrence, developing late effects and psychological issues) as well as individual clinical and supportive care needs. It is important that post-treatment care is evidence-based and consistent with guidelines. Currently there is no established protocol for postoperative surveillance.

Follow-up care over the first two years should be based on institutional experience. Ideally, three–six-monthly tumour markers and radiological imaging should be carried out for patients at high risk of developing a new pancreatic cancer.

Responsibility for follow-up care should be agreed between the lead clinician, the general practitioner, relevant members of the multidisciplinary team and the patient. This is based on guideline recommendations for post-treatment care, as well as the patient’s current and anticipated physical and emotional needs and preferences.

Evidence comparing shared follow-up care and specialised care indicates equivalence in outcomes including recurrence rate, cancer survival and quality of life (Cancer Research in Primary Care 2016).

Ongoing communication between healthcare providers involved in care and a clear understanding of roles and responsibilities is key to effective survivorship care.

In particular circumstances, other models of post-treatment care can be safely and effectively provided such as nurse-led models of care (Monterosso et al. 2019). Other models of post-treatment care can be provided in these locations or by these health professionals:

• in a shared care setting
• in a general practice setting
• by non-medical staff
• by allied health or nurses
• in a non-face-to-face setting (e.g. by telehealth).

A designated member of the team should document the agreed survivorship care plan. The survivorship care plan should support wellness and have a strong emphasis on healthy lifestyle changes such as a balanced diet, a non-sedentary lifestyle, weight management and a mix of aerobic and resistance exercise (COSA 2018; Hayes et al. 2019).

This survivorship care plan should also cover, but is not limited to:

• what medical follow-up is required (surveillance for recurrence or secondary and metachronous cancers, screening and assessment for medical and psychosocial effects)
• model of post-treatment care, the health professional providing care and where it will be delivered
• care plans from other health providers to manage the consequences of cancer and cancer treatment
• wellbeing, primary and secondary prevention health recommendations that align with chronic disease management principles
• rehabilitation recommendations
• available support services
• a process for rapid re-entry to specialist medical services for suspected recurrence.

The survivorship care plan may need to be updated to reflect changes in the patient’s clinical and psychosocial status and needs.

Processes for rapid re-entry to hospital care should be documented and communicated to the patient and relevant stakeholders.

The lead clinician should discuss (and general practitioner reinforce) options for follow-up at the start and end of treatment. It is critical for optimal aftercare that the designated member of the treatment team educates the patient about the symptoms of recurrence.

General practitioners (including nurses) can:

• connect patients to local community services and programs
• manage long-term and late effects
• manage comorbidities
• provide wellbeing information and advice to promote self-management
• screen for cancer and non-cancerous conditions.

Templates and other resources to help with developing treatment summaries and survivorship care plans are available from these organisations:

• Australian Cancer Survivorship Centre
• Cancer Australia – Principles of Cancer Survivorship
• Cancer Council Australia and states and territories
• Clinical Oncology Society of Australia – Model of Survivorship Care
• eviQ – Cancer survivorship: introductory course
• MyCarePlan.org.au
• South Australian Cancer Service – Statewide Survivorship Framework resources
• American Society of Clinical Oncology – guidelines

Support cancer survivors to participate in research or clinical trials where they are available and appropriate. These might include studies to understand survivors’ issues, to better manage treatment side effects, or to improve models of care and quality of life.

For more information visit the Cancer Australia website.

With the low rates of curable pancreatic cancer and the majority of patients palliated, it is likely that their current symptoms will worsen progressively, and this should be managed following discussion by a multidisciplinary team in consultation with palliative care specialists.

Some patients will have metastatic disease on initial presentation. Others may present with symptoms of recurrent disease after a previous cancer diagnosis. Access to the best available therapies, including clinical trials, as well as treatment overseen by a multidisciplinary team, are crucial to achieving the best outcomes for anyone with metastatic disease.

Signs and symptoms will depend on the type of cancer initially diagnosed and the location of metastatic disease. They may be discovered by the patient or by surveillance in the post-treatment period. Symptoms can often present as weight loss, jaundice and abdominal pain.

Managing metastatic disease is complex and should therefore involve all the appropriate specialties in a multidisciplinary team including palliative care where appropriate. From the time of diagnosis, the team should offer patients appropriate psychosocial care, supportive care, advance care planning and symptom-related interventions as part of their routine care. The approach should be personalised to meet the patient’s individual needs, values and preferences. The full complement of supportive care measures as described throughout the optimal care pathway and in Appendices A and B, and in the special population groups section should be offered to assist patients and their families and carers to cope. These measures should be updated as the patient’s circumstances change.

Survivorship care should be considered and offered at an early stage. Some people live with advanced cancer for many months or years. As survival is improving in many patients, survivorship issues should be considered as part of routine care. Health professionals should therefore be ready to change and adapt treatment strategies according to disease status, prior treatment tolerance and toxicities and the patient’s quality of life, in addition to the patient’s priorities and life plans.

If there is an indication that a patient’s cancer has returned, care should be provided under the guidance of a treating specialist. Each patient should be evaluated to determine if referral to the original multidisciplinary team is necessary. Often referral back to the original multidisciplinary team will not be necessary unless there are obvious aspects of care involving different therapeutic and supportive care disciplines not otherwise accessible. The multidisciplinary team may include new members such as palliative care specialists.

Treatment will depend on the location, extent of recurrent or residual disease, previous management and the patient’s preferences.

In managing people with pancreatic cancer, treatment may include these options:

• surgery
• stenting
• chemotherapy
• radiation therapy
• intra-arterial therapies
• percutaneous ablation
• pain management
• palliative care.

The potential goals of treatment should be discussed, respecting the patient’s cultural values. Wherever possible, written information should be provided.

Encourage early referral to clinical trials or accepting an invitation to participate in research.

Advance care planning is important for all patients with a cancer diagnosis but especially those with advanced disease. Patients should be encouraged to think and talk about their healthcare values and preferences with family or carers, appoint a substitute decision-maker and consider developing an advance care directive to convey their preferences for future health care in the event they become unable to communicate their wishes (AHMAC 2011).

Refer to section 4.3 ‘More information’ for links to resources.

Refer patients and carers to Advance Care Planning Australia or to the Advance Care Planning National Phone Advisory Service on 1300 208 582.

Early referral to palliative care has been shown to improve the quality of life for people with cancer (Haines 2011; Temel et al. 2010; Zimmermann et al. 2014). In general, all patients with pancreatic cancer, given the poor prognosis, should be offered referral to palliative care assessment as an integrated aspect of their overall oncology care (Gaertner et al. 2011). The treatment team should emphasise the value of palliative care in improving symptom management and quality of life to patients and their carers. Refer to section 4.3 for more detailed information.

The lead clinician should ensure timely and appropriate referral to palliative care services.

Refer to the end of section 4.3 ‘Palliative care’ for links to resources.

The treatment team should support the patient to participate in research and clinical trials where available and appropriate.

For more information visit the Cancer Australia website.

If the treatment team does not include a palliative care member, the lead clinician should consider referring the patient to palliative care services, with the general practitioner’s engagement. This may include inpatient palliative unit access (as required).

The multidisciplinary team may consider seeking additional expertise from these professionals:

• clinical psychologist
• clinical nurse specialist or practitioner
• social worker
• palliative medicine specialist
• pain specialist
• pastoral or spiritual carer
• bereavement counsellor
• music therapist
• art therapist
• cultural expert
• Canteen for children of parents with cancer

The team might also recommend that patients access these services:

• home and community-based care
• specialist community palliative care workers
• community nursing.

If the patient does not already have an advance care directive in place, a designated member of the treatment team should encourage them to develop one in collaboration with their family or carer (AHMAC 2011).

It is essential for the treatment team to consider the appropriate place of care, the patient’s preferred place of death and the support needed for the patient, their family and carers.

The treatment team should also ensure that carers and families receive the information, support and guidance about their role according to their needs and wishes (Palliative Care Australia 2018).

The treatment team can refer patients and carers to these resources:

• Palliative Care Australia
• Advance Care Planning Australia or to Advance Care Planning Australia’s National Advisory Service on 1300 208 582.

Clinical trials may help improve palliative care and in managing a patient’s symptoms of advanced cancer (Cancer Council Victoria 2019). The treatment team should support the patient to participate in research and clinical trials where available and appropriate.

For more information visit the Cancer Australia website. See ’Resource list’ for additional clinical trial databases.

Cancer is the third leading cause of burden of disease for Aboriginal and Torres Strait Islander people. While Australia’s cancer survival rates are among the best in the world, Aboriginal and Torres Strait Islander people continue to experience a different pattern of cancer incidence and significant disparities in cancer outcomes compared with non-Indigenous Australians.

For Aboriginal and Torres Strait Islander people, health and connection to land, culture, community and identity are intrinsically linked. Health encompasses a whole-of-life view and includes a cyclical concept of life–death–life.

The distinct epidemiology of cancer among Aboriginal and Torres Strait Islander people, and unique connection to culture, highlight the need for a specific optimal care pathway for Aboriginal and Torres Strait Islander people with cancer. Ensuring this pathway is culturally safe and supportive is vital to tackling the disparities for Aboriginal and Torres Strait Islander people.

Published in 2018, the Optimal care pathway for Aboriginal and Torres Strait Islander people with cancer provides guidance to health practitioners and service planners on optimal care for Aboriginal and Torres Strait Islander people with cancer across the cancer continuum.

In addition to the key principles underpinning cancer-specific pathways, these are the key concepts that are fundamental to Aboriginal and Torres Strait Islander health:

• providing a holistic approach to health and wellbeing
• providing a culturally appropriate and culturally safe service
• acknowledging the diversity of Aboriginal and Torres Strait Islander peoples
• understanding the social determinants and cultural determinants of health (Cancer Australia 2015).

To view the Optimal care pathway for Aboriginal and Torres Strait Islander people with cancer, visit the Cancer Australia website. To view the consumer resources – Checking for cancer and Cancer, visit the Cancer Australia website.

For people from culturally diverse backgrounds in Australia, a cancer diagnosis can come with additional complexities, particularly when English proficiency is poor. In many languages there is not a direct translation of the word ‘cancer’, which can make communicating vital information difficult. Perceptions of cancer and related issues can differ greatly in people from culturally diverse backgrounds and this can affect their understanding and decision making after a cancer diagnosis. In addition to different cultural beliefs, when English language is limited there is potential for miscommunication of important information and advice, which can lead to increased stress and anxiety for patients.

A professionally trained interpreter (not a family member or friend) should be made available when communicating with people with limited English proficiency. Navigation of the Australian healthcare system can pose problems for those with a non-Anglo culture, and members of the treatment teams should pay particular attention to supporting these patients.

The Australian Cancer Survivorship Centre has developed a glossary of more than 700 cancer terms in nine different languages. The multilingual glossary has been designed as a resource for professional translators, interpreters and bilingual health professionals working in the cancer field. The glossary is a unique tool that enables language professionals with access to accurate, consistent and culturally appropriate terminology.

Visit the Peter Mac website to see the glossary.

Disability, which can be physical, intellectual or psychological, may have existed before the cancer diagnosis or may be new in onset (occurring due to the cancer treatment or incidentally). Adjusting to life with a disability adds another challenge to cancer care and survivorship.

Several barriers prevent people with disabilities from accessing timely and effective health care (AIHW 2017b):

• physical limitations
• competing health needs
• the trauma of undergoing invasive procedures
• potential barriers associated with obtaining informed consent
• failure to provide assistance with communication
• lack of information
• discriminatory attitudes among healthcare staff.

In caring for people with disabilities and a cancer diagnosis, the Australian Institute of Health and Welfare disability flag should be used at the point of admittance to correctly identify and meet the additional requirements of a person with disability. Facilities should actively consider access requirements, and health practitioners should make reasonable adjustments where required.

Patients aged between seven and 65 years who have a permanent or significant disability may be eligible for support or funding through the National Disability Insurance Scheme (National Disability Insurance Agency 2018). More information can be found on the NDIS website.

Patients aged 65 years or older (50 years or older for Aboriginal or Torres Strait Islander people) may be eligible for subsidised support and services through aged care services. An application to determine eligibility can be completed online over the phone. More information can be found at the My Aged Care website.

‘Talking End of Life’ is a resource that shows how to teach people with intellectual disability about end of life. It is designed for disability support workers but is also helpful for others including families, health professionals and educators.

To view the resource, visit the Talking End of Life website.

Given the average age at diagnosis of pancreatic cancer is 72.8 years (AIHW 2017a) , most people with pancreatic cancer are elderly and may therefore experience a rapid deterioration. Their ability to self-care may be impaired and therefore they may require early consideration of palliative care.

Planning and delivering appropriate cancer care for older people can present a number of challenges. This could also be true for frail people or those experiencing comorbidities. Effective communication between oncology and geriatrics departments will help facilitate best practice care, which takes into account physiological age, complex comorbidities, risk of adverse events and drug interactions, as well as the implications of cognitive impairment on suitability of treatment and consent (Steer et al. 2009).

At a national interdisciplinary workshop convened by the Clinical Oncology Society of Australia, it was recommended that people over the age of 70 undergo some form of geriatric assessment, in line with international guidelines (COSA 2013; palliAGED 2018). Screening tools can be used to identify those patients in need of a comprehensive geriatric assessment (Decoster et al. 2015). This assessment can be used to help determine life expectancy and treatment tolerance and guide appropriate referral for multidisciplinary intervention that may improve outcomes (Wildiers et al. 2014).

Frailty is not captured through traditional measures of performance status (e.g. ECOG) and includes assessment in the domains of:

• function
• comorbidity
• presence of geriatric syndromes
• nutrition
• polypharmacy
• cognition
• emotional status
• social supports.

Malignant pancreatic tumours are rare in children and adolescents, with an incidence of 0.46 cases per one million (younger than 30 years; NCI 2019b). In recent years, adolescent and young adult oncology has emerged as a distinct field due to lack of progress in survival and quality-of-life outcomes (Ferrari et al. 2010; Smith et al. 2013). The significant developmental change that occurs during this life stage complicates a diagnosis of cancer, often leading to unique physical, social and emotional effects for young people at the time of diagnosis and throughout the cancer journey (Smith et al. 2012).

In caring for young people with cancer, akin to the comorbidities that require specific care in the older cancer population, the treatment team needs to pay careful attention to promoting normal development (COSA 2014). This requires personalised assessments and management involving a multidisciplinary, disease-specific, developmentally targeted approach that adheres to the following principles:

• understanding the developmental stages of adolescence and supporting normal adolescent health and development alongside cancer management
• understanding and supporting the rights of young people
• communication skills and information delivery that are appropriate to the young person
• meeting the needs of all involved, including the young person, their carers and their family
• working with educational institutions and workplaces
• considering survivorship and palliative care needs.

An oncology team caring for an adolescent or young adult with cancer should be able to demonstrate these specific areas of expertise:

• be able to ensure access to expert adolescent and young adult health providers who have knowledge specific to the biomedical and psychosocial needs of the population
• understand the biology and current management of the disease in the adolescent and young adult age group
• consider participating in research and clinical trials for each patient
• engage in proactive discussion and management of fertility preservation, late effects of treatment, ongoing need for contraception, and psychosocial and psychosexual needs
• provide treatment in an environment that is friendly to adolescents and young adults.

In general, people from lower socioeconomic groups are at greater risk of poor health, have higher rates of illness, disability and death, and live shorter lives than those from higher socioeconomic groups (AIHW 2016). People experiencing socioeconomic disadvantage are less likely to participate in screening programs, more likely to be obese, less likely to exercise and much more likely to smoke, which are all risk factors for cancer. In 2010–2014 age-standardised cancer incidence rates were higher in the lowest socioeconomic areas compared with the highest socioeconomic areas for all cancers combined (Cancer Australia 2019c).

Socioeconomic status and low health literacy are closely correlated. Therefore, effective communication with patients and carers is particularly important given the prevalence of low health literacy in Australia (estimated at 60 per cent of Australian adults) (ACSQHC 2014).

Consideration should be taken for cancer patients experiencing socioeconomic disadvantage to reduce their risk of being underserved for health care.

A diagnosis of cancer may present additional challenges to people who have pre-existing chronic mental health or psychiatric concerns, resulting in exacerbation of their mental health symptoms. This may include heightened anxiety, worsening depression or thoughts of self-harm.

As poor adjustment and coping can affect treatment decisions, people who are known to have a mental health diagnosis need psychosocial assessment in the oncology setting to formulate a plan for ongoing support throughout treatment.

Psychosocial support can assist with challenges in communicating with health professionals, enhance understanding of the treatment journey, ensure capacity for consent to treatment options and improve compliance with treatment requests. A referral for psychosocial support from a health professional to the psycho-oncology team can ensure these patients are provided with targeted interventions or referrals to community-based services that may mitigate problems associated with the impacts of social isolation that frequently accompany chronic mental ill-health.

Many patients with chronic mental health problems may be well known to external service providers. Psycho-oncology health professionals can form meaningful partnerships with existing service providers to optimise patient care throughout treatment and beyond.

Drug use disorders fall within the area of mental health conditions. People who are opiate dependent may have specific and individual requirements regarding pain management and their own preference for type of opiate prescribed or used.

People who identify as sexually or gender diverse may have unique needs following a cancer diagnosis. Sexually or gender diverse identities include (but are not limited to) people who identify as lesbian, gay, bisexual or transgender, collectively ‘LGBT’. There is no universally agreed upon initialism to describe this community, with other terms such as queer/questioning (Q), intersex (I), asexual (A) and pansexual (P) often included, as well as a plus symbol (+) indicating inclusivity of other identities not explicitly mentioned.

Sexual orientation and gender identity are relevant across the entire spectrum of cancer care, from prevention to survivorship and end-of-life care. LGBT people are less likely to participate in cancer screening, and some segments of the LGBT community exhibit elevated rates of specific cancer risk factors – for example, higher rates of smoking and alcohol use. Regarding treatment, there may be unique factors relevant to LGBT people that may affect decision making. Additionally, the LGBT population experiences higher rates of anxiety, depression and stressful life circumstances, and may be at risk of inferior psychosocial outcomes following a cancer diagnosis. LGBT people are also more likely to be estranged from their families of origin, and for older people, less likely to have adult children who may provide support and care.

Barriers to care for LGBT people include past negative interactions with healthcare systems, experiences or fear of discrimination and harassment in healthcare settings, assumptions of cisgender/heterosexual identity, lack of recognition or exclusion of same-sex partners from care, and a lack of relevant supportive care and information resources.

To provide safe and appropriate care for LGBT people with cancer, healthcare providers should:

• display environmental cues to show an inclusive and safe setting for LGBT patients
• avoid assumptions about the sexual orientation or gender identity of patients and their partners
• facilitate positive disclosure of sexual orientation or gender identity
• include same-sex/gender partners and families of choice in care
• be aware of relevant supportive care and information resources
• provide non-judgemental, patient-centred care

Supportive care in cancer refers to the following five domains:

• the physical domain, which includes a wide range of physical symptoms that may be acute, relatively short lived or ongoing, requiring continuing interventions or rehabilitation
• the psychological domain, which includes a range of issues related to the patient’s mental health wellbeing and personal relationships
• the social domain, which includes a range of social and practical issues that will affect the patient, carer and family such as the need for emotional support, maintaining social networks and financial concerns
• the information domain, which includes access to information about cancer and its treatment, recovery and survivorship support services and the health system overall
• the spiritual domain, which focuses on the patient’s changing sense of self and challenges to their underlying beliefs and existential concerns (Palliative Care Victoria 2019).

Fitch’s (2000) model of supportive care recognises the variety and level of intervention required at each critical point as well as the need to be specific to the individual patient. The model targets the type and level of intervention required to meet patients’ supportive care needs.

Consider a referral to a psychologist, psychiatrist, pastoral/spiritual care practitioner, social worker, specialist nurse or a relevant community-based program if the patient has these issues:

• displaying emotional cues such as tearfulness, distress that requires specialist intervention, avoidance or withdrawal
• being preoccupied with or dwelling on thoughts about cancer and death
• displaying fears about the treatment process or the changed goals of their treatment
• displaying excessive fears about cancer progression or recurrence
• worrying about loss associated with their daily function, dependence on others and loss of dignity
• becoming isolated from family and friends and withdrawing from company and activities that they previously enjoyed
• feeling hopeless and helpless about the effect that cancer is having on their life and the disruption to their life plans
• struggling to communicate with family and loved ones about the implications of their cancer diagnosis and treatment
• experiencing changes in sexual intimacy, libido and function
• struggling with the diagnosis of metastatic or advanced disease
• having difficulties quitting smoking (refer to Quitline on 13 7848) or with other drug and alcohol use
• having difficulties transitioning to palliative care.

Additional considerations that may arise for the multidisciplinary team include:

• support for the carer – encourage referrals to psychosocial support from a social worker, psychologist or general practitioner
• referral to an exercise physiologist or physiotherapist as a therapeutic approach to prevent and manage psychological health
• referral to wellness-after-cancer programs to provide support, information and offer strategies.

Complementary therapies may be used together with conventional medical treatments to support and enhance quality of life and wellbeing. They do not aim to cure the patient’s cancer. Instead, they are used to help control symptoms such as pain and fatigue (Cancer Council Australia 2019).

The lead clinician or health professional involved in the patient’s care should discuss the patient’s use (or intended use) of complementary therapies not prescribed by the multidisciplinary team to assess safety and efficacy and to identify any potential toxicity or drug interactions.

The lead clinician should seek a comprehensive list of all complementary and alternative medicines being taken and explore the patient’s reason for using these therapies and the evidence base. A transparent and honest discussion that is free from judgement should be encouraged.

While some complementary therapies are supported by strong evidence, others are not. For such therapies, the lead clinician should discuss their potential benefits and use them alongside conventional therapies (NHMRC 2014).

If the patient expresses an interest in using complementary therapies, the lead clinician should consider referring patients to health providers within the multidisciplinary team who have expertise in the field of complementary and alternative therapies (e.g. a clinical pharmacist, dietitian or psychologist) to assist them to reach an informed decision. Costs of such approaches should be part of the discussion with the patient and considered in the context of evidence of benefit.

The lead clinician should assure patients who use complementary therapies that they can still access a multidisciplinary team review and encourage full disclosure about therapies being used.

• See Cancer Australia’s position statement on complementary and alternative therapies
• See the Clinical Oncological Society of Australia’s position statement Use of complementary and alternative medicine by cancer patients

Advance Care Planning Australia

Advance Care Planning Australia provides national advance care planning resources for individuals, families, health professional and service providers. Resources include a national advisory service, information resources, a legal forms hub and education modules.

• Telephone: 1300 208 582
• Website

Australian Cancer Survivorship Centre

The Australian Cancer Survivorship Centre has developed information resources and events to help people move from initial treatment to post treatment and beyond, including those receiving maintenance treatments. While they do not provide clinical advice, they connect with a range of providers to enable improved care.

• Telephone: (03) 8559 6220
• Website

Australian Commission on Safety and Quality in Health Care

The Australian Commission on Safety and Quality in Health Care has developed a resource for patients and carers explaining the coordination of care that patients should receive from their health service during cancer treatment. The resource is called What to expect when receiving medication for cancer care.

Beyond Blue

Beyond Blue provides information about depression, anxiety and related disorders, as well as about available treatment and support services.

• Telephone: 1300 22 4636
• Website

Cancer Australia

Cancer Australia provides information for consumers, carers and their families including printed resources and video content.

• Website

Cancer Council’s Cancer Information and Support Service

Cancer Council 13 11 20 is a confidential telephone support service available to anyone affected by cancer. This service acts as a gateway to evidence-based documented, practical and emotional support available through Cancer Council services and other community organisations. Calls will be answered by a nurse or other oncology professional who can provide information relevant to a patient’s or carer’s situation. Health professionals can also access this service.

• Telephone: 13 11 20 – Monday to Friday, 9.00am to 5.00pm (some states have extended hours)
• Website

Cancer Council’s Cancer Connect

Cancer Connect is a free and confidential telephone peer support service that connects someone who has cancer with a specially trained volunteer who has had a similar cancer experience.

A Connect volunteer can listen with understanding and share their experiences and ways of coping. They can provide practical information, emotional support and hope. Many people newly diagnosed with cancer find this one-to-one support very beneficial.

For more information on Cancer Connect call Cancer Council on 13 11 20.

Canteen

Canteen helps adolescents, young adults and parents to cope with cancer in their family. Canteen offers individual support services, peer support services and a youth cancer service, as well as books, resources and useful links.

• Telephone: 1800 835 932 to talk to a health professional about information and support for young people or 1800 226 833 for other enquiries
• Website

Clinical trial information

For a collection of clinical trials available in Australia see the following sources of information:

• Australian clinical trials
• Australian New Zealand Clinical Trials Registry
• ClinicalTrials.gov

CanEAT pathway

A guide to optimal cancer nutrition for people with cancer, carers and health professionals.

• Website
• Website

Guides to best cancer care

The short guides help patients, carers and families understand the optimal cancer care that should be provided at each step. They include optimal timeframes within which tests or procedures should be completed, prompt lists to support patients to understand what might happen at each step of their cancer journey and to consider what questions to ask, and provide information to help patients and carers communicate with health professionals.

The guides are located on an interactive web portal, with downloadable PDFs available in multiple languages.

• Website

Look Good, Feel Better

A free national community service program, run by the Cancer Patients Foundation, dedicated to teaching cancer patients how to manage the appearance-related side effects caused by treatment for any type of cancer.

• Telephone: 1800 650 960
• Website

National Comprehensive Cancer Network

The National Comprehensive Cancer Network’s Guideline for pancreatic cancer is based on the same treatment information doctors use and aim to help patients talk to their doctor about the best treatment options for them.

• Website

Pancare Foundation

A national non-for-profit organisation that aims to increase survival and supports patients with pancreatic and other gastrointestinal cancers.

• Phone: 1300 881 698
• Website

PanKind

A national organisation dedicated to doubling survival for pancreatic cancer patients through fundraising for research, advocacy, awareness and patient support.

• Phone: (02) 7207 6970
• Website

PanSupport

An online resource that focuses on patient care, advice on managing pancreatic cancer symptoms (such as with diet and fatigue) and activities that can strengthen mental health. There is information for carers and about organisations, support groups and tools that could assist patients.

• Website

Quitline

Quitline is a confidential, evidence-based telephone counselling service. Highly trained Quitline counsellors use behaviour change techniques and motivational interviewing over multiple calls to help people plan, make and sustain a quit attempt.

Quitline is a culturally inclusive service for all, and Aboriginal counsellors are also available. Health professionals can refer patients to Quitline online or via fax.

• Telephone: 13 7848
• Website or the relevant website in your state or territory.

Australian Cancer Survivorship Centre

The Australian Cancer Survivorship Centre provides expertise in survivorship care, information, support and education. Its purpose is to support and enable optimal survivorship care.

• Telephone: (03) 8559 6220
• Website

Australian Commission on Safety and Quality in Health Care

The Australian Commission on Safety and Quality in Health Care has developed a guide for clinicians containing evidence-based strategies to support clinicians to understand and fulfil their responsibilities to cancer patients. This guide is particularly relevant to steps 3 to 6 of the optimal care pathway. The guide is titled NSQHS Standards user guide for medication management in cancer care for clinicians.

Cancer Australia

Information for health providers including guidelines, cancer learnings, cancer guides, reports, resources, videos, posters and pamphlets.

• Website

Cancer Council Australia

Information on prevention, research, treatment and support provided by Australia’s peak independent cancer authority.

• Website

CanEAT pathway

A guide to optimal cancer nutrition for people with cancer, carers and health professionals.

• Website
• Website

Care Search: Palliative Care Knowledge Network

Information for patients and carers on living with illness, advice on how to care, and help finding services.

• Telephone: (08) 7221 8233
• Website

eviQ

A clinical information resource providing health professionals with current evidence-based, peer-maintained, best practice cancer treatment protocols and information relevant to the Australian clinical environment.

• Website

National Health and Medical Research Council

Information on clinical practice guidelines, cancer prevention and treatment.

• Website

We acknowledge the Traditional Owners of Country throughout Australia and their continuing connection to the land, sea and community. We pay our respects to them and their cultures and to Elders past, present and emerging.

This work is available from the Cancer Council website.

First published in May 2015. This edition published in June 2021.

ISBN: 978 1 76096 157 2

Cancer Council Victoria and Department of Health Victoria 2021 Optimal care pathway for people with pancreatic cancer, 2nd edn, Cancer Council Victoria, Melbourne.

Enquiries about this publication can be sent to optimalcare.pathways@cancervic.org.au.

Our thanks to the following health professionals, consumer representatives, stakeholders and organisations consulted in developing this optimal care pathway.

Professor Christopher Christophi (Chair), Surgeon, Austin Health and The University of Melbourne

Dr Richard Khor, Radiation Oncologist, Austin Health and Olivia Newton-John Cancer Centre

Professor Michael Michael, Medical Oncologist, Peter MacCallum Cancer Centre

Dr Krithika Murali, Clinical Geneticist Fellow, Victorian Clinical Genetics Services

Dr Mehrdad Nikfarjam, Surgeon, Austin Health

Ms Rose Rocca, Dietitian, Peter MacCallum Cancer Centre

Mr Jim Siderov, Pharmacist, Austin Health

Associate Professor Odette Spruijt, Palliative Care Consultant, Peter MacCallum Cancer Centre

Professor Robert Thomas, Special Advisor on Health, Professorial Fellow, The University of Melbourne

Ms Julia Brancato, Project Coordinator, Optimal Care Pathways, Cancer Council Victoria

Professor Chris Christophi, The University of Melbourne, Department of Surgery, Austin Health (Chair)

Professor Jon Emery, Herman Professor of Primary Care, The University of Melbourne, Western Health; Director of Primary Care Collaborative Cancer Trials Group

Mr Adrian Fox, Hepatobiliary Surgeon, Eastern Health

Associate Professor Sze Ting Lee, Nuclear Medicine Physician, Centre for PET, Austin Health

Ms Helen Mott, Cancer Support Nurse, Haematology Oncology, Alfred Health

Associate Professor Vijayaragavan Muralidharan, Hepatobiliary Surgeon, The University of Melbourne, Austin Health

Dr Mehrdad Nikfarjam, Pancreas Surgeon, The University of Melbourne, Austin Health

Ms Lucy Pollerd, Social Worker, Peter MacCallum Cancer Centre

Ms Meg Rogers, Nurse Coordinator, Upper Gastrointestinal Cancer Service, Peter MacCallum Cancer Centre

Ms Amy Sutherland, Dietitian, Northern Health

Professor Robert Thomas, Chief Cancer Advisor, Department of Health and Human Services

Ms Kathryn Whitfield, Acting Manager, Cancer Strategy and Development, Department of Health and Human Services

Alexandra Viner, Project Manager –Optimal Care Pathways

Advance Care Planning Australia

Allied Health Professions Australia

Australasian Association of Nuclear Medicine Specialists

Australasian Chapter of Palliative Medicine, Royal Australia College of Physicians

Australasian Pancreatic Club

Australia and New Zealand Hepatic, Pancreatic and Biliary Association

Australian and New Zealand Gastric and Oesophageal Surgery Association

Australian and New Zealand Society of Neuroradiology

Australian and New Zealand Society of Palliative Care

Australian Cancer Survivorship Centre

Australian College of Nursing

Australian Medical Association

Australian Society of Medical Imaging and Radiation Therapy

PanKind

Cancer Nurses Society of Australia

Clinical Oncology Society of Australia

Interventional Radiology Society of Australasia

Medical Oncology Group of Australia

Oncology Social Workers Australia and New Zealand

Royal Australasian College of Physicians

Royal Australasian College of Surgeons

Royal Australian and New Zealand College of Radiologists

Royal Australian College of General Practitioners

Royal College of Pathologists of Australasia
Upper Gastrointestinal Cancer Registry

Alfred Health

Cancer Australia

Cancer Council Victoria, Strategy and Support Division

Cancer Institute New South Wales

Concord Repatriation General Hospital New South Wales

Consumer representative

Department of Health Victoria, Commissioning and System Improvement Division, Cancer Unit

National Cancer Expert Reference Group

Olivia Newton-John Cancer Wellness and Research Centre

St Vincent’s Hospital Melbourne

Other stakeholders consulted to provide feedback include relevant Cancer Council committees and networks, Integrated Cancer Services, Primary Health Networks and several health services.

The multidisciplinary team may include the following members:

• care coordinator (as determined by multidisciplinary team members)*
• dietitian*
• gastroenterologist (with expertise in endoscopic retrograde cholangiopancreatography (ERCP) and/or endoscopic ultrasound)*
• hepato-pancreato biliary surgeon*
• interventional/ hepato-pancreato biliary radiologist*
• nurse (with appropriate expertise)*
• medical oncologist*
• radiation oncologist*
• palliative care specialist*
• pathologist*
• Aboriginal health practitioner, Indigenous liaison officer or remote general practitioner
• clinical trials coordinator
• exercise physiologist
• fertility specialist
• general practitioner
• nuclear medicine physician
• occupational therapist
• pharmacist
• physiotherapist
• psychiatrist
• psychologist
• social worker
• spiritual/pastoral care.

* Denotes core members. Core members of the multidisciplinary team are expected to attend most multidisciplinary team meetings either in person or remotely.