What is your approach to localized pancreatic cancer that would otherwise be resectable, except for poor patient characteristics?

Tough question—since there is no prospectively validated phase III data to guide us in such situations, we've adopted an approach that utilizes bi-modality treatment sequencing, punctuated with aggressive supportive care and frequent multidisciplinary evaluation (q 2 months) to re-assess eligibility for curative intent surgery.

We typically start with induction chemotherapy (usually a doublet, rarely single agent) with close attention to clinical (MD visit q 2 weeks), biochemical (CA 19-9 q monthly in CA 19-9 producers) and radiographic (pancreas protocol CT scan q 2 months) response. We continue induction chemotherapy for 4-6 months and fold in concurrent chemo-radiotherapy/SBRT (after careful multidisciplinary discussion) followed by anot...