Pancreatic cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up

Key guideline recommendations

1. Patients with a family history and high-risk individuals should receive genetic counselling.

   III, A

2. Discussion in a multidisciplinary tumour board at specialist centres is mandatory to determine the recommended treatment strategy for patients with pancreatic cancer.

   III, A

3. Because of limited phase III evidence, neoadjuvant therapy is not recommended for resectable pancreatic cancer, except within a clinical trial.

   II, E

4. After resection of pancreatic cancer, completion of 6 months of adjuvant chemotherapy is strongly recommended.

   I, A

5. Adjuvant mFOLFIRINOX is recommended for patients with resected pancreatic cancer and ECOG 0 to 1 (ESMO-MCBS v1.1: A).

   I, A

6. Adjuvant chemoradiotherapy is not recommended and should not be given to patients after surgery outside a clinical trial.

   I, E

7. Patients with borderline resectable pancreatic cancer have a high probability of R1 resection and should be considered for induction therapy; if trial entry is not possible, induction therapy is preferred over upfront surgery [II, A].

   III, A

8. For patients with ECOG 2, KPS of at least 70 and bilirubin no more than 1.5 times the upper limit of normal, gemcitabine–nab-paclitaxel can be considered (ESMO-MCBS v1.1: 3).

   II, A

9. For patients with ECOG 3 to 4, symptom-directed care should be considered, as the risks of any chemotherapy in this setting probably outweigh its benefits.

   IV, A

10. Patients with a BRCA mutation should receive platinum-based chemotherapy.

    III, A

11. BRCA genetic testing should be offered to all patients with metastatic pancreatic cancer to determine eligibility for platinum-based chemotherapy followed by olaparib maintenance. Olaparib maintenance is an option for patients with a germline BRCA1/2 variant whose disease is stable or responding on platinum chemotherapy (ESMO-MCBS v1.1: 2; ESCAT: I-A).

    I, B

12. In patients with MSI-H/dMMR pancreatic tumours, pembrolizumab can be offered as second-line or later treatment (ESMO-MCBS v1.1: 3; ESCAT: I-C).

    II, B

13. 2025 update — first line: in patients with ECOG 0 to 1, bilirubin below 1.5 times the upper limit of normal and no major comorbidity, two regimens are recommended as first-line chemotherapy: FOLFIRINOX (ESMO-MCBS v1.1: 5 versus gemcitabine) or NALIRIFOX (ESMO-MCBS v1.1: 2 versus gemcitabine–nab-paclitaxel).

    I, A (Express Update 2025)

14. 2025 update — gemcitabine–nab-paclitaxel can also be used in the same patients (ESMO-MCBS v1.1: 3 versus gemcitabine).

    I, B (Express Update 2025)

15. 2025 update — second line: after FOLFIRINOX, gemcitabine–paclitaxel can be offered to patients with ECOG 0 to 2 and a favourable comorbidity profile [I, B]. Other options are gemcitabine–nab-paclitaxel [III, C; not EMA-‎ or FDA-approved as second line] or gemcitabine alone [III, C].

    I, B (Express Update 2025)

16. 2025 update — after NALIRIFOX, a gemcitabine-based regimen can be offered to patients with ECOG 0 to 2 and a favourable comorbidity profile.

    V, C (Express Update 2025)

Study population

Clinical significance and place in guidelines

Limitations