Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Diagnosis

People with obstructive jaundice

1.1.1 For people with obstructive jaundice and suspected pancreatic cancer, offer a pancreatic protocol CT scan before draining the bile duct.

1.1.2 If the diagnosis is still unclear, offer fluorodeoxyglucose-positron emission tomography/CT (FDG‑PET/CT) and/or endoscopic ultrasound (EUS) with EUS‑guided tissue sampling.

1.1.3 Take a biliary brushing for cytology if:

  • endoscopic retrograde cholangiopancreatography (ERCP) is being used to relieve the biliary obstruction and

  • there is no tissue diagnosis.

People without jaundice who have pancreatic abnormalities on imaging

1.1.4 Offer a pancreatic protocol CT scan to people with pancreatic abnormalities but no jaundice.

1.1.5 If the diagnosis is still unclear, offer FDG‑PET/CT and/or EUS with EUS‑guided tissue sampling.

1.1.6 If cytological or histological samples are needed, offer EUS with EUS‑guided tissue sampling.

People with pancreatic cysts

1.1.7 Offer a pancreatic protocol CT scan or magnetic resonance cholangiopancreatography (MRI/MRCP) to people with pancreatic cysts. If more information is needed after one of these tests, offer the other one.

1.1.8 Refer people with any of these high-risk features for resection:

  • obstructive jaundice with cystic lesions in the head of the pancreas

  • enhancing solid component in the cyst

  • a main pancreatic duct that is 10 mm diameter or larger.

1.1.9 Offer EUS after CT and MRI/MRCP if more information on the likelihood of malignancy is needed, or if it is not clear whether surgery is needed.

1.1.10 Consider fine-needle aspiration during EUS if more information on the likelihood of malignancy is needed.

1.1.11 When using fine-needle aspiration, perform carcinoembryonic antigen (CEA) assay in addition to cytology if there is sufficient sample.

1.1.12 For people with cysts that are thought to be malignant, follow the recommendations on staging.

People with inherited high risk of pancreatic cancer

1.1.13 Ask people with pancreatic cancer if any of their first-degree relatives has had it. Address any concerns the person has about inherited risk.

1.1.14 Offer surveillance for pancreatic cancer to people with:

  • hereditary pancreatitis and a PRSS1 mutation

  • BRCA1, BRCA2, PALB2 or CDKN2A (p16) mutations, and one or more first-degree relatives with pancreatic cancer

  • Peutz–Jeghers syndrome.

1.1.15 Consider surveillance for pancreatic cancer for people with:

  • 2 or more first-degree relatives with pancreatic cancer, across 2 or more generations

  • Lynch syndrome (mismatch repair gene [MLH1, MSH2, MSH6 or PMS2] mutations) and any first-degree relatives with pancreatic cancer.

1.1.16 Consider an MRI/MRCP or EUS for pancreatic cancer surveillance in people without hereditary pancreatitis.

1.1.17 Consider a pancreatic protocol CT scan for pancreatic cancer surveillance in people with hereditary pancreatitis and a PRSS1 mutation.

1.1.18 Do not offer EUS to detect pancreatic cancer in people with hereditary pancreatitis.

1.2 Specialist pancreatic multidisciplinary teams

1.2.1 A specialist pancreatic cancer multidisciplinary team should decide what care is needed, and involve the person with suspected or confirmed pancreatic cancer in the decision. Care should be delivered in partnership with local cancer units.

1.3 Staging

1.3.1 For people with newly diagnosed pancreatic cancer who have not had a pancreatic protocol CT scan, offer a pancreatic protocol CT scan that includes the chest, abdomen and pelvis.

1.3.2 Offer fluorodeoxyglucose-positron emission tomography/CT (FDG-PET/CT) to people with localised disease on CT who will be having cancer treatment (surgery, radiotherapy or systemic therapy).

1.3.3 If more information is needed to decide the person's clinical management, consider one or more of the following:

  • MRI, for suspected liver metastases

  • endoscopic ultrasound, if more information is needed for tumour and node staging

  • laparoscopy with laparoscopic ultrasound, for suspected small-volume peritoneal and/or liver metastases if resectional surgery is a possibility.

    See recommendation 1.2.1 on how care should be agreed and delivered.

1.4 Psychological support

1.4.1 Throughout the person's pancreatic cancer care pathway, specifically assess the psychological impact of:

  • fatigue

  • pain

  • gastrointestinal symptoms (including changes to appetite)

  • nutrition

  • anxiety

  • depression.

1.4.2 Provide people and their family members or carers (as appropriate) with information and support to help them manage the psychological impact of pancreatic cancer on their lives and daily activities. This should be:

  • available on an ongoing basis

  • relevant to the stage of the person's condition

  • tailored to the person's needs.

1.4.3 For more guidance on providing information and support, see the NICE guideline on patient experience in adult NHS services.

1.5 Pain management

1.5.1 Consider EUS-guided or image-guided percutaneous neurolytic coeliac plexus block to manage pain for people with pancreatic cancer who:

  • have uncontrolled pancreatic pain or

  • are experiencing unacceptable opioid adverse effects or

  • are receiving escalating doses of analgesics.

1.5.2 Do not offer thoracic splanchnicectomy to people with pancreatic cancer.

1.6 Nutritional management

1.6.1 Offer enteric-coated pancreatin for people with unresectable pancreatic cancer.

1.6.2 Consider enteric-coated pancreatin before and after pancreatic cancer resection.

1.6.3 Do not use fish oils as a nutritional intervention to manage weight loss in people with unresectable pancreatic cancer.

1.6.4 For people who have had pancreatoduodenectomy and who have a functioning gut, offer early enteral nutrition (including oral and tube feeding) rather than parenteral nutrition.

1.6.5 For more guidance on nutrition support, see the NICE guideline on nutrition support in adults.

1.7 Relieving biliary and duodenal obstruction

Biliary obstruction

1.7.1 Offer resectional surgery rather than preoperative biliary drainage to people who:

  • have resectable pancreatic cancer and obstructive jaundice and

  • are well enough for the procedure and

  • are not enrolled in a clinical trial that requires preoperative biliary drainage.

1.7.2 During attempted resection for pancreatic cancer, consider surgical biliary bypass if the cancer is found to be unresectable.

1.7.3 If biliary drainage is needed in a person who has resectable pancreatic cancer and obstructive jaundice and is not yet fit enough for resectional surgery, offer endoscopically placed self-expanding metal stents.

1.7.4 For people with suspected pancreatic cancer who may need their stent removed later on, consider endoscopically placed self-expanding fully covered metal stents.

1.7.5 Offer endoscopically placed self-expanding metal stents rather than surgical biliary bypass to people with unresectable pancreatic cancer.

Duodenal obstruction

1.7.6 During attempted resection for head of pancreas cancer, consider prophylactic gastrojejunostomy if the cancer is found to be unresectable.

1.7.7 If possible, relieve symptomatic duodenal obstruction caused by unresectable pancreatic cancer.

1.7.8 When deciding between gastrojejunostomy and duodenal stent placement, consider gastrojejunostomy for people with a more favourable prognosis.

1.8 Managing resectable and borderline resectable pancreatic cancer

Neoadjuvant therapy

1.8.1 Only consider neoadjuvant therapy for people with borderline resectable pancreatic cancer as part of a clinical trial.

1.8.2 Only consider neoadjuvant therapy for people with resectable pancreatic cancer as part of a clinical trial.

Surgery

1.8.3 For people having surgery for head of pancreas cancer, consider pylorus-preserving resection if the tumour can be adequately resected.

1.8.4 Consider standard lymphadenectomy[1] rather than extended lymphadenectomy for people having head of pancreas resection.

Adjuvant treatment

1.8.5 Give people time to recover from surgery before starting adjuvant therapy. Start adjuvant therapy as soon as they are well enough to tolerate all 6 cycles.

1.8.6 Offer adjuvant gemcitabine plus capecitabine[2] to people who have had sufficient time to recover after pancreatic cancer resection.

1.8.7 Consider adjuvant gemcitabine[3] for people who are not well enough to tolerate combination chemotherapy.

Follow-up for resected pancreatic cancer

1.8.8 For people who have had resection, offer ongoing specialist assessment and care to identify and manage any problems resulting from surgery.

1.8.9 For people who have new, unexplained or unresolved symptoms after treatment, provide access to specialist investigation and support services.

1.9 Managing unresectable pancreatic cancer

Locally advanced pancreatic cancer

1.9.1 Offer systemic combination chemotherapy to people with locally advanced pancreatic cancer who are well enough to tolerate it.

1.9.2 Consider gemcitabine for people with locally advanced pancreatic cancer who are not well enough to tolerate combination chemotherapy.

1.9.3 When using chemoradiotherapy, consider capecitabine as the radiosensitiser.

Metastatic pancreatic cancer

First-line treatment

1.9.4 Offer FOLFIRINOX[4] to people with metastatic pancreatic cancer and an Eastern Cooperative Oncology Group (ECOG) performance status of 0–1.

1.9.5 Consider gemcitabine combination therapy[5] for people who are not well enough to tolerate FOLFIRINOX. For guidance on combination therapy with gemcitabine and nab–paclitaxel, see the NICE technology appraisal guidance on paclitaxel as albumin-bound nanoparticles with gemcitabine for untreated metastatic pancreatic cancer.

1.9.6 Offer gemcitabine to people who are not well enough to tolerate combination chemotherapy.

Second-line treatment

1.9.7 Consider oxaliplatin-based chemotherapy[6] as second-line treatment for people who have not had first-line oxaliplatin.

1.9.8 Consider gemcitabine-based chemotherapy[7] as second-line treatment for people whose cancer has progressed after first-line FOLFIRINOX.

Venous thromboembolism prophylaxis

The updated NICE guideline on venous thromboembolism will cover venous thromboembolism prophylaxis for people with pancreatic cancer. This guideline is due to be published in March 2018, and the draft recommendations are available now.



[2] Although this use is common in UK clinical practice, at the time of publication (February 2018) gemcitabine plus capecitabine did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[3] Although this use is common in UK clinical practice, at the time of publication (February 2018) gemcitabine did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[4] Although this use is common in UK clinical practice, at the time of publication (February 2018) FOLFIRINOX did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[5] Although this use is common in UK clinical practice, at the time of publication (February 2018) many gemcitabine combination therapies did not have a UK marketing authorisation covering the first-line treatment of adults with metastatic pancreatic cancer. The prescriber should follow relevant professional guidance, taking full responsibility for the decision to prescribe. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[6] Although this use is common in UK clinical practice, at the time of publication (February 2018) oxaliplatin-based chemotherapy did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[7] Although this use is common in UK clinical practice, at the time of publication (February 2018) gemcitabine-based chemotherapy did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

  • National Institute for Health and Care Excellence (NICE)