ASTRO Updates Pancreatic Cancer Radiation Therapy Guidelines

The American Society for Radiation Oncology (ASTRO) has updated its clinical practice guideline for radiation therapy in adult patients with pancreatic cancer. The disease is among the most deadly malignancies, with 67,500 U.S. adults expected to be diagnosed in 2026, more than 50,000 instances of which will likely be fatal. The five-year survival rate across all stages is about 13%, and surgery remains the only potentially curative treatment, with fewer than 20% of patients seen as viable candidates.

Published in Practical Radiation Oncology, the guidelines replace ASTRO's 2019 recommendations. Incorporating evidence from recent clinical trials and advances in radiation technology, the update provides guidance on radiation therapy across resectable, locally advanced, recurrent, metastatic and palliative disease.

The guidelines emphasize multidisciplinary decision-making and recognize the growing role of radiation therapy in controlling local disease. For patients with resectable pancreatic cancer, preoperative chemoradiation is conditionally recommended, while postoperative chemoradiation may be considered for certain patients who did not receive radiation before surgery. For borderline resectable disease, preoperative radiation therapy or chemoradiation is recommended to improve local control and the likelihood of achieving a margin-negative surgical resection. For locally advanced disease, radiation therapy or chemoradiation following multiagent chemotherapy is recommended as definitive treatment to improve local control.

Definitive radiation therapy or chemoradiation is recommended for isolated locoregional recurrence in patients who have not previously received radiation, while reirradiation should be considered for selected patients who have previously undergone radiation therapy. Radiation therapy also may be appropriate for patients with oligometastatic or oligoprogressive disease involving a limited number of metastatic or progressing sites. Palliative radiation is still recommended for symptoms such as pain, bleeding and obstruction.

Advances in treatment planning and delivery also are featured in the updated recommendations. The guidelines support the use of intensity-modulated radiation therapy, daily image guidance and patient-specific respiratory motion assessment. The updated recommendations were developed by a multidisciplinary task force and are based on a review of research published between 2010 and June 2026.