To assist the oncologists in making major clinical decisions encountered while managing their pancreatic cancer patients, the Indian Council of Medical Research (ICMR) has issued a consensus document on pancreatic cancers.

This consensus document may be used as framework for more focused and planned research programmes to carry forward the process. The aim of this ICMR guidelines is to assist oncologists in making major clinical decisions encountered while managing their patients, while realizing the fact that some patients may require treatment strategies other than those suggested in these guidelines.

This consensus statement represents the current thinking of the ICMR on the topic, based on available evidence. This document has been developed by national experts in the field and does not in any way bind a clinician to follow this guideline verbatim. Doctors can use an alternative mode of therapy on the basis of their discussions with the patient and institution and national or international guidelines. The mention of pharmaceutical drugs for therapy does not constitute endorsement or recommendation for use but serves as a guide for clinicians in complex decision-making processes.

Pancreatic cancer is the 12th most common cancer and the 4th leading cause of cancer-related deaths in the world. The age-standardized incidence rates of the cancer vary considerably in different parts of the world from as low as 0.6/100,000 persons per year in regions of Asia to as high as 12.6/100,000 in the West. The age-standardised incidence rates for pancreatic cancer on an average are 8.2 and 2.7/100,000 amongst males in the developed and developing countries, respectively and 5.4 and 2.1/100,000 amongst females in the developed and developing countries, respectively.

In India, the incidence rates of pancreatic cancer are low compared to western countries. In India, the incidence of pancreatic cancer is 0.5-2.4/100,000 persons per year in women - 0.2- 1.8/100,000 persons per year in men. However, irrespective of the incidence of the disease, survival in patients with pancreatic cancer is generally low with the 1-year and 5- year relative survival rates for all stages being 26% and 6%, respectively. The cause for such poor long-term outcomes is possibly related to the fact that the disease is largely asymptomatic in the early stages and by the time symptoms do develop, the disease is locally advanced or metastatic. Only 10-20% of patients have resectable pancreatic cancer at presentation. In the midst of all the dismal statistics for pancreatic cancer, there are some aspects that need to be appreciated, viz. the 5-year survival rates for patients with localised disease who are amenable to curative resection is 22% as compared to 2% for those with distant disease.

As per the document, histological confirmation is mandatory prior to the commencement of definitive treatment. All patients should be staged according to the TNM staging system and risk should be assessed at diagnosis. A baseline contrast-enhanced computed tomography (CECT) scan of the chest, abdomen, and pelvis should be considered. Patients should receive multidisciplinary care under the care of a surgical, medical, and radiation oncologist. Patients should be classified as resectable, borderline resectable or locally advanced based on radiologic criteria at diagnosis and treatment plan discussed accordingly. Resectable Pancreatic Cancer - Primary Surgery remains the standard of care. Neoadjuvant therapy (chemotherapy +/- radiotherapy) should be considered in locally advanced and borderline resectable tumours to downstage the disease followed by reassessment for surgery in those with stable or partial regression radiological criteria.

This may be followed by adjuvant chemotherapy. Patients with metastatic pancreatic cancer beyond the regional lymph nodes, should be assessed for chemotherapy versus best supportive care on an individual basis. Preferred first-line regimens for chemotherapy include –Gemcitabine-Nab Paclitaxel, Folfirinox. Patients should be offered regular surveillance after completion of curative resection or treatment of advanced disease. Encourage participation in institutional and ethical review board-approved, registered controlled clinical trials. Refer for early palliative care, if indicated, the ICMR's consensus document on pancreatic cancers further states.