ASTRO Updates Guideline on Radiation Therapy for Pancreatic Cancer

The American Society for Radiation Oncology (ASTRO) has published an updated clinical practice guideline on the use of radiation therapy (RT) for adult patients with pancreatic cancer, according to a news release from the society.¹ The guideline updates ASTRO's 2019 recommendations to reflect randomized trial evidence published since then. This includes results from the CONKO-007 (NCT01827553), PREOPANC (EudraCT 2012-003181-40), PREOPANC-2 (EudraCT 2017-002036-17), Alliance A021501 (NCT02839343), and the NRG Oncology/RTOG 0848 (NCT01013649) trials.² The guideline was developed with the American Society of Clinical Oncology, the European Society for Radiotherapy and Oncology, and the Society of Surgical Oncology.

“Indications for the use of radiation therapy in treating pancreatic cancer have changed notably in the last several years,” stated Daniel Chang, MD, FASTRO, chair of the guideline task force and professor and chair of radiation oncology at the University of Michigan, in the press release.¹ “New clinical evidence helps clarify which patients can benefit from radiation therapy, while technological advances such as image guidance, motion management and adaptive radiation therapy allow us to deliver that care with greater precision.”

What does the guideline recommend for nonmetastatic pancreatic cancer?

For resectable disease, preoperative chemoradiation is conditionally recommended. For those with resectable disease who do not receive preoperative chemoradiotherapy, postoperative chemoradiation following multiagent chemotherapy is conditionally recommended for patients with pathologically uninvolved (pN0) lymph nodes. For borderline resectable disease, preoperative RT or chemoradiation is recommended to improve local control and increase the likelihood of a margin-negative resection.

For locally advanced pancreatic cancer, chemoradiation or RT after multiagent chemotherapy is recommended as definitive treatment to improve local control and reduce morbidity from uncontrolled local progression. Although randomized trials including LAP07 (NCT00634725) and CONKO-007 did not show an overall survival benefit with conventional-dose RT, they did demonstrate significantly improved local control.^1,2 For patients with resectable but medically inoperable disease, or those who decline surgery, chemoradiation or RT following multiagent chemotherapy is recommended.

How should radiation be used in recurrent, metastatic, and palliative settings?

For isolated locoregional recurrence after surgery with no prior RT, definitive-intent RT or chemoradiation is recommended; reirradiation is conditionally recommended for patients who previously received RT, with careful attention to prior treatment plans and cumulative dose to nearby organs. For oligometastatic or oligoprogressive pancreatic cancer, definitive-intent chemoradiation or RT is conditionally recommended to the metastatic lesions and to the primary tumor if it was not previously treated with definitive local therapy. Palliative RT is recommended for symptoms such as bleeding, pain, or obstruction, with dose-escalated approaches reasonable for pain relief in select patients.¹

What are the preferred treatment planning and delivery techniques?

The guideline recommends dose escalation for locally advanced disease when volumetric image guidance and motion management are available, along with inclusion of nearby anatomic areas at risk for microscopic spread, such as the “triangle volume,” in preoperative, postoperative, and definitive RT fields. The guideline emphasizes best practices including intensity-modulated radiation therapy, daily image guidance, and patient-specific respiratory motion assessment. Adaptive RT is recommended for dose-escalated stereotactic body radiation therapy to protect nearby organs while maintaining tumor coverage.¹

Recommendations were based on a systematic review of research published from 2010 through June 2026. The task force noted continued uncertainty around integrating RT with evolving systemic therapy, including whether combining RT with RAS inhibitors could improve outcomes.

“Pancreatic cancer requires coordinated, multidisciplinary care because treatment decisions depend heavily on whether a tumor can be removed surgically and how the cancer responds to chemotherapy,” said Michael D. Chuong, MD, vice chair of the guideline task force and vice chair and medical director of radiation oncology at the Baptist Health Herbert Wertheim Cancer Institute, in the press release.¹ “This guideline gives clinicians clearer direction about when radiation therapy is appropriate and how to integrate it safely with other treatments.”

References

1. American Society for Radiation Oncology. ASTRO updates guideline on radiation therapy for pancreatic cancer. News release. American Society for Radiation Oncology. August 13, 2026. Accessed August 17, 2026. https://tinyurl.com/4nnuufuf
2. Chuong MD, Jethwa KR, Ludmir E, et al. Radiation therapy for pancreatic cancer: an ASTRO clinical practice guideline. Pract Radiat Oncol. 2026. doi:10.1016/j.prro.2026.07.002