The potential for curative surgery depends on the staging of the tumour, and only 10–20 per cent of patients have clearly resectable disease after careful pretherapeutic staging. This potential is assessed by the multidisciplinary team.

Patients who undergo surgical resection for localised pancreatic cancer have a median survival of 15–20 months and a five-year survival of 8–15 per cent (Lambert et al. 2019). Unfortunately, 80 per cent of patients present with metastatic or locally advanced disease, by which time the tumour is unresectable (Lambert et al. 2019).

Unresectable tumours are defined based on the presence of metastases including non-regional lymph node involvement, more than 180 degrees of contact with the major vessels, or tumoural invasion of the major vessels (Elbanna et al. 2020).

Curative surgery includes the following options with or without chemotherapy (adjuvant or neoadjuvant chemotherapy or neoadjuvant chemoradiation):

• Whipple procedure (pancreaticoduodenal resection)
• distal pancreatectomy
• total pancreatectomy.

Timeframe for starting treatment

Surgery should be undertaken within four weeks of the initial diagnosis, depending on urgency and modality.

Training and experience required of the surgeon

Surgeon (FRACS or equivalent) with adequate training and experience in hepatobiliary surgery with institutional credentialing and agreed scope of practice within this area.

There is strong evidence to suggest that surgeons who undertake a high volume of resections have better clinical outcomes for complex cancer surgery such as pancreatic resections (Toomey et al. 2016).

Documented evidence of the surgeon’s training and experience, including their specific (sub-specialty) experience with pancreatic cancer and procedures to be undertaken, should be available.

Health service characteristics

To provide safe and quality care for patients having surgery, health services should have these features:

• critical care support
• 24-hour medical staff availability
• 24-hour operating room access and intensive care unit
• diagnostic imaging
• endoscopic retrograde cholangiopancreatography (ERCP)
• 24-hour access to interventional radiology
• access to endoscopic ultrasound
• nuclear medicine imaging
• pathology
• full support from other surgical specialties.

There is strong evidence to suggest that high-volume hospitals have better clinical outcomes for complex cancer surgery such as pancreatic resections (Hata et al. 2016). Centres that do not have sufficient caseloads should establish processes to routinely refer surgical cases to high-volume centres.

Even if the cancer is deemed surgically curable the following should be considered (NCI 2019a):

• neoadjuvant chemotherapy for all high-risk patients
• neoadjuvant chemotherapy or chemoradiation therapy, especially in patients with borderline resectable disease or delay in surgery
• adjuvant chemotherapy in the postoperative setting
• chemoradiation therapy (or SBRT on a trial) for borderline resectable or locally advanced patients who are still potentially operable
• adjuvant chemotherapy within 12 weeks following resection.

Timeframes for starting treatment

Neoadjuvant chemotherapy should begin within four weeks of the initial diagnosis, depending on urgency and modality.

Adjuvant chemotherapy in the postoperative setting should begin within 12 weeks of surgery.

Training and experience required of the appropriate specialists

Medical oncologists must have training and experience of this standard:

• Fellow of the Royal Australian College of Physicians (or equivalent)
• adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015).

Cancer nurses should have accredited training in these areas:

• anti-cancer treatment administration
• specialised nursing care for patients undergoing cancer treatments, including side effects and symptom management
• the handling and disposal of cytotoxic waste (ACSQHC 2020).

Systemic therapy should be prepared by a pharmacist whose background includes this experience:

• adequate training in systemic therapy medication, including dosing calculations according to protocols, formulations and/or preparation.

In a setting where no medical oncologist is locally available (e.g. regional or remote areas), some components of less complex therapies may be delivered by a general practitioner or nurse with training and experience that enables credentialing and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required.

The training and experience of the appropriate specialist should be documented.

Health service characteristics (systemic therapy)

To provide safe and quality care for patients having systemic therapy, health services should have these features:

• a clearly defined path to emergency care and advice after hours
• access to diagnostic pathology including basic haematology and biochemistry, and imaging
• cytotoxic medicines prepared in a pharmacy with appropriate facilities or externally sourced from Therapeutics Goods Association–licensed manufacturers
• occupational health and safety guidelines regarding handling of cytotoxic drugs, including preparation, waste procedures and spill kits (eviQ 2019;)
• guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs)
• coordination for combined therapy with radiation therapy, especially where facilities are not co-located
• appropriate molecular pathology access.

Training and experience required of radiation oncologists

Radiation oncologists must have training and experience of this standard:

• Fellowship of the Royal Australian and New Zealand College of Radiologists (or equivalent)
• adequate training and experience, institutional credentialing and agreed scope of practice in pancreatic cancer (ACSQHC 2015).

The training and experience of the radiation oncologist should be documented.

Health service unit characteristics (radiation therapy)

To provide safe and quality care for patients having radiation therapy, health services should have these features:

• linear accelerator (LINAC) capable of image-guided radiation therapy (IGRT)
• dedicated CT planning
• access to MRI and PET imaging
• automatic record-verify of all radiation treatments delivered
• a treatment planning system
• trained medical physicists, radiation therapists and nurses with radiation therapy experience
• coordination for combined therapy with systemic therapy, especially where facilities are not co-located
• participation in Australian Clinical Dosimetry Service audits
• an incident management system linked with a quality management system.

If the cancer is deemed unresectable, any other treatment is almost certainly palliative because pancreatic cancer is unlikely to be cured by chemotherapy and radiation therapy. Palliative therapy may be indicated for:

• nutritional assessment and support (including enzyme support therapy)
• surgical or radiological biliary decompression
• relief of gastric outlet obstruction
• pain control
• psychological care to address the potentially disabling psychological events associated with the diagnosis and treatment of pancreatic cancer.

The most commonly used therapies in unresectable pancreatic cancer include:

• endoscopic or radiological intervention
• surgical interventions – endoscopic biliary stent placement, percutaneous radiological biliary stent placement, palliative surgical biliary and/or gastric bypass
• chemotherapy
• chemotherapy followed by chemoradiation therapy for those without metastatic disease
• chemotherapy, followed by radiotherapy in selected cases
• coeliac plexus or intrapleural block.

For patients who are too unwell to undergo curative therapy, radiotherapy has been shown to improve survival, pain control and hospital admissions compared with the best supportive care.

Endoscopic stenting is recommended as initial palliation for biliary obstruction. Percutaneous transhepatic biliary stenting may be required for failed endoscopic stenting. For patients with gastric outlet obstruction, either surgical bypass or endoscopic stenting would be appropriate.

It is important to weigh up the risks versus benefits of any palliative therapy if the patient’s prognosis is not changed with implementation.

Timeframes for starting treatment

Treatment should begin within four weeks of initial diagnosis, depending on urgency and modality.

There is currently one approved targeted therapy available to treat patients with locally advanced, unresectable or metastatic pancreatic cancer.

Maintenance therapy with the PARP inhibitor olaparib (Lynparza) has been shown to significantly delay the progression of metastatic pancreatic cancer in patients with BRCA gene mutations compared with placebo (ASCO 2019).

A number of emerging therapies are being investigated for pancreatic cancer. Areas of interest for emerging therapies include identifying molecular targets, targeting cancer stem cells and stromal modulation, immunotherapies such as cancer vaccines, adoptive cell therapy and stemness inhibitors (Amanam & Chung 2018; Lambert et al. 2019).

The key principle for precision medicine is prompt and clinically oriented communication and coordination with an accredited laboratory and pathologist. Tissue analysis is integral for access to emerging therapies and, as such, tissue specimens should be treated carefully to enable additional histopathological or molecular diagnostic tests in certain scenarios.