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.