Management of locally advanced/metastatic disease: Radiation oncology

Patients with locally advanced pancreatic cancer (LAPC) have a dismal prognosis. Such tumors are unresectable, and optimal treatment with chemotherapy and/or radiation therapy is still not established. Radiation therapy is often used to improve local control which can potentially improve overall survival and most importantly quality of life. Many radiation regimens can be considered, and no standard treatment has demonstrated a clear improvement in clinical outcomes. We advise that the modality of choice be dependent on the availability of equipment, the dose and fractionation of treatment, and the dose received by normal tissue. A thorough discussion with the patient concerning treatment goals is equally as essential. Three notable strategies for LAPC are IMRT, VMAT, and proton. These radiation modalities tend to have improved dose distribution to the target volumes while minimizing the radiation dose to surrounding normal tissues. SBRT can also be considered in cases where the tumor does not invade the duodenum or other neighboring structures. Despite improved clinical outcomes with modern radiation modalities, future studies remain essential to optimize the role of radiation therapy in patients with LAPC.