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Pancreatic Cancer Health Center

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Pancreatic Cancer Treatment (PDQ®): Treatment - Health Professional Information [NCI] - Stage III Pancreatic Cancer Treatment

Treatment Options for Stage III Pancreatic Cancer

While stage III and stage IV pancreatic cancer are both incurable, the natural history of stage III (locally advanced) disease may be different than it is for stage IV disease. An autopsy series demonstrated that 30% of patients presenting with stage III disease died without evidence of distant metastases.[1][Level of evidence: 1iiA] Therefore, investigators have struggled with the question of whether chemoradiation for patients presenting with stage III disease is warranted.

Treatment options for stage III pancreatic cancer include the following:

  1. Palliative surgery: palliative surgical biliary and/or gastric bypass, percutaneous radiologic biliary stent placement, or endoscopic biliary stent placement.[2,3]
  2. Chemoradiation therapy:
    • Chemoradiation followed by chemotherapy.
    • Chemotherapy followed by chemoradiation, for patients without metastatic disease.
  3. Chemotherapy: gemcitabine; gemcitabine and erlotinib; gemcitabine and nab-paclitaxel; or 5-fluorouracil (5-FU), leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX).

Palliative surgery

A significant proportion (approximately one-third) of patients with pancreatic cancer will present with stage III or locally advanced disease. Patients with stage III pancreatic cancer have tumors that are technically unresectable because of local vessel impingement or invasion by tumor. These patients may benefit from palliation of biliary obstruction by endoscopic, surgical, or radiological means.[4]

Chemoradiation therapy

The role of chemoradiation in locally advanced pancreatic cancer remains controversial. Table 8 summarizes phase III randomized studies of chemoradiation for stage III pancreatic cancer.

Table 8. Randomized Studies in Stage III Pancreatic Cancer: Median Survival

TrialRegimenChemoradiationRadiation AloneChemotherapy AloneP Value
5-FU = 5-fluorouracil; ECOG = Eastern Cooperative Oncology Group; FFCD = Fédération Francophone de Cancérologie Digestive; GEM = gemcitabine; GITSG = Gastrointestinal Tumor Study Group; Gy = gray (unit of absorbed radiation of ionizing radiation);P value = probability value; XRT = x-ray or radiation therapy.
GITSG[5]Radiation alone vs. 5-FU/60 Gy XRT40 weeks20 weeks<.01
ECOG[6]Radiation vs. 5-FU, mitomycin C/59 Gy XRT8.4 months7.1 months.16
FFCD[7]GEM vs. GEM, cisplatin, 60 Gy XRT8.6 months13 months.03
ECOG[8]GEM vs. GEM/50.4 Gy XRT11.1 months9.2 months.017
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