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<h1>(1) Potentially curable pancreatic cancer: American Society of Clinical Oncology clinical practice guideline. (2) Potentially curable pancreatic cancer: American Society of Clinical Oncology clinical practice guideline update.</h1>
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<table><tr><td>Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MHG. Potentially curable pancreatic cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2017 Jul 10;35(20):2324-8. [3 references] <a href="https://web.archive.org/web/20180713032048/http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=28398845 " target="_blank">PubMed</a> <img alt="External Web Site Policy" src="/web/20180713032048im_/https://www.guideline.gov/UI/images/icon_externallink.gif"/></td></tr></table><table><tr><td>Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MHG. Potentially curable pancreatic cancer: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2016 Jul 20;34(21):2541-56. [86 references] <a href="https://web.archive.org/web/20180713032048/http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=27247221" target="_blank">PubMed</a> <img alt="External Web Site Policy" src="/web/20180713032048im_/https://www.guideline.gov/UI/images/icon_externallink.gif"/></td></tr></table> <p><a href="/web/20180713032048/https://www.guideline.gov/Home/Disclaimer?id=51051&contentType=fulltextlink&redirect=http%253a%252f%252fascopubs.org%252fdoi%252fpdf%252f10.1200%252fJCO.2017.72.4948">View the original guideline documentation</a> <img alt="External Web Site Policy" src="/web/20180713032048im_/https://www.guideline.gov/UI/images/icon_externallink.gif"/></p>
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<div id="status-tab" class="content-tab-panel">
<p><div class="content_para"><p>This is the current release of the guideline.</p>
<p>This guideline meets NGC's 2013 (revised) inclusion criteria.</p></div></p>
</div>
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<div id="classification-tab" class="content-tab-panel">
<h4>UMLS Concepts <a href="/web/20180713032048/https://www.guideline.gov/help-and-about/search-browse/umls-concepts" class="what-is">(what is this?)</a></h4>
<div class="field">
<h5 class="field-label">ICD9CM</h5>
<div class="field-content">
<a href="/web/20180713032048/https://www.guideline.gov/search?f_ICD9CM_CUI=C0031150&fLockTerm=Laparoscopy">Laparoscopy</a>
(54.21), <a href="/web/20180713032048/https://www.guideline.gov/search?f_ICD9CM_CUI=C0346647&fLockTerm=Malignant+neoplasm+of+pancreas%2c+part+unspecified">Malignant neoplasm of pancreas, part unspecified</a>
(157.9) </div>
<!-- /.field-content -->
</div>
<!-- /.field -->
<div class="field">
<h5 class="field-label">MSH</h5>
<div class="field-content">
<a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0001683&fLockTerm=Advance+Directives">Advance Directives</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0005516&fLockTerm=Biomarkers">Biomarkers</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0436307&fLockTerm=Chemoradiotherapy">Chemoradiotherapy</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0085533&fLockTerm=Chemotherapy%2c+Adjuvant">Chemotherapy, Adjuvant</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0376583&fLockTerm=Clinical+Laboratory+Techniques">Clinical Laboratory Techniques</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0008976&fLockTerm=Clinical+Trials+as+Topic">Clinical Trials as Topic</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0376636&fLockTerm=Disease+Management">Disease Management</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0014243&fLockTerm=Endoscopes">Endoscopes</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0376444&fLockTerm=Endosonography">Endosonography</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0018017&fLockTerm=Goals">Goals</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0023036&fLockTerm=Laparoscopes">Laparoscopes</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0031150&fLockTerm=Laparoscopy">Laparoscopy</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0024203&fLockTerm=Lymph+Node+Excision">Lymph Node Excision</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0024485&fLockTerm=Magnetic+Resonance+Imaging">Magnetic Resonance Imaging</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0027646&fLockTerm=Neoplasm+Staging">Neoplasm Staging</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C3658316&fLockTerm=Observational+Studies+as+Topic">Observational Studies as Topic</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0030231&fLockTerm=Palliative+Care">Palliative Care</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0030279&fLockTerm=Pancreatectomy">Pancreatectomy</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0030297&fLockTerm=Pancreatic+Neoplasms">Pancreatic Neoplasms</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0030678&fLockTerm=Patient+Care+Planning">Patient Care Planning</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0030679&fLockTerm=Patient+Care+Team">Patient Care Team</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0376409&fLockTerm=Patient+Preference">Patient Preference</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0033061&fLockTerm=Preoperative+Care">Preoperative Care</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C3665494&fLockTerm=Radiography%2c+Thoracic">Radiography, Thoracic</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0037438&fLockTerm=Social+Support">Social Support</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0040278&fLockTerm=Tissue+Banks">Tissue Banks</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0936234&fLockTerm=Tomography+Scanners%2c+X-Ray+Computed">Tomography Scanners, X-Ray Computed</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MSH_CUI=C0040405&fLockTerm=Tomography%2c+X-Ray+Computed">Tomography, X-Ray Computed</a>
</div>
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</div>
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<div class="field">
<h5 class="field-label">MTH</h5>
<div class="field-content">
<a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0001683&fLockTerm=Advance+Directives">Advance Directives</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0005516&fLockTerm=Biological+Markers">Biological Markers</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0201551&fLockTerm=CA+19-9+measurement">CA 19-9 measurement</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0436307&fLockTerm=Chemoradiotherapy">Chemoradiotherapy</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0008976&fLockTerm=Clinical+Trials">Clinical Trials</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0936234&fLockTerm=Computed+Tomography+Scanning+Systems">Computed Tomography Scanning Systems</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C1276305&fLockTerm=Curative+-+procedure+intent">Curative - procedure intent</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0027646&fLockTerm=Diagnostic+Neoplasm+Staging">Diagnostic Neoplasm Staging</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0376636&fLockTerm=Disease+Management">Disease Management</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0376444&fLockTerm=Echo+Endoscopy">Echo Endoscopy</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0014243&fLockTerm=Endoscopes">Endoscopes</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C1522577&fLockTerm=follow-up">follow-up</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0031150&fLockTerm=Laparoscopy">Laparoscopy</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0024203&fLockTerm=Lymph+node+excision">Lymph node excision</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0024485&fLockTerm=Magnetic+Resonance+Imaging">Magnetic Resonance Imaging</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0346647&fLockTerm=Malignant+neoplasm+of+pancreas">Malignant neoplasm of pancreas</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0018017&fLockTerm=objective+(goal)">objective (goal)</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0030231&fLockTerm=Palliative+Care">Palliative Care</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0030279&fLockTerm=Pancreatectomy">Pancreatectomy</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0030297&fLockTerm=Pancreatic+Neoplasm">Pancreatic Neoplasm</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0037438&fLockTerm=Social+support">Social support</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0344211&fLockTerm=Supportive+care">Supportive care</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C3665494&fLockTerm=Thoracic+Radiography">Thoracic Radiography</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_MTH_CUI=C0040405&fLockTerm=X-Ray+Computed+Tomography">X-Ray Computed Tomography</a>
</div>
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</div>
<!-- /.field -->
<div class="field">
<h5 class="field-label">PDQ</h5>
<div class="field-content">
<a href="/web/20180713032048/https://www.guideline.gov/search?f_PDQ_CUI=C0281361&fLockTerm=adenocarcinoma+of+the+pancreas">adenocarcinoma of the pancreas</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_PDQ_CUI=C0005516&fLockTerm=biological+markers">biological markers</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_PDQ_CUI=C0040405&fLockTerm=computed+tomography">computed tomography</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_PDQ_CUI=C0031150&fLockTerm=laparoscopy">laparoscopy</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_PDQ_CUI=C0024203&fLockTerm=lymphadenectomy">lymphadenectomy</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_PDQ_CUI=C0024485&fLockTerm=magnetic+resonance+imaging">magnetic resonance imaging</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_PDQ_CUI=C0344211&fLockTerm=supportive+care%2ftherapy">supportive care/therapy</a>
</div>
<!-- /.field-content -->
</div>
<!-- /.field -->
<div class="field">
<h5 class="field-label">SNOMEDCT_US</h5>
<div class="field-content">
<a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0281361&fLockTerm=Adenocarcinoma+of+pancreas">Adenocarcinoma of pancreas</a>
(700423003), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0201551&fLockTerm=Cancer+antigen+19-9+measurement">Cancer antigen 19-9 measurement</a>
(40939009), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0027646&fLockTerm=Cancer+staging">Cancer staging</a>
(258232002), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0008976&fLockTerm=Clinical+trial">Clinical trial</a>
(110465008), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0040405&fLockTerm=Computerized+axial+tomography">Computerized axial tomography</a>
(77477000), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C1276305&fLockTerm=Curative+-+procedure+intent">Curative - procedure intent</a>
(373808002), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0014243&fLockTerm=Endoscope">Endoscope</a>
(37270008), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0024203&fLockTerm=Excision+of+lymph+node">Excision of lymph node</a>
(234253006), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0024203&fLockTerm=Excision+of+lymph+node">Excision of lymph node</a>
(58347006), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0018017&fLockTerm=Goal">Goal</a>
(410518001), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0023036&fLockTerm=Laparoscope">Laparoscope</a>
(86174004), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0031150&fLockTerm=Laparoscopy">Laparoscopy</a>
(108191006), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0031150&fLockTerm=Laparoscopy">Laparoscopy</a>
(73632009), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0024485&fLockTerm=Magnetic+resonance+imaging">Magnetic resonance imaging</a>
(113091000), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0024485&fLockTerm=Magnetic+resonance+imaging">Magnetic resonance imaging</a>
(312250003), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0336660&fLockTerm=Magnetic+resonance+imaging+unit">Magnetic resonance imaging unit</a>
(90003000), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0346647&fLockTerm=Malignant+tumor+of+pancreas">Malignant tumor of pancreas</a>
(363418001), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0030297&fLockTerm=Neoplasm+of+pancreas">Neoplasm of pancreas</a>
(126859007), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0030231&fLockTerm=Palliative+care">Palliative care</a>
(103735009), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0030279&fLockTerm=Pancreatectomy">Pancreatectomy</a>
(33149006), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0033061&fLockTerm=Preoperative+care">Preoperative care</a>
(133898004), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0204452&fLockTerm=Psychological+assessment">Psychological assessment</a>
(405783006), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0204452&fLockTerm=Psychological+assessment">Psychological assessment</a>
(45392008), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C0344211&fLockTerm=Support">Support</a>
(243114000), <a href="/web/20180713032048/https://www.guideline.gov/search?f_SNOMEDCT_US_CUI=C3665494&fLockTerm=Thoracic+cage+X-ray">Thoracic cage X-ray</a>
(303932001) </div>
<!-- /.field-content -->
</div>
<!-- /.field -->
<div class="field">
<h5 class="field-label">SPN</h5>
<div class="field-content">
<a href="/web/20180713032048/https://www.guideline.gov/search?f_SPN_CUI=C0014243&fLockTerm=ENDOSCOPE+AND%2fOR+ACCESSORIES">ENDOSCOPE AND/OR ACCESSORIES</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_SPN_CUI=C0023036&fLockTerm=PERITONEOSCOPE">PERITONEOSCOPE</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_SPN_CUI=C0336660&fLockTerm=SYSTEM%2c+NUCLEAR+MAGNETIC+RESONANCE+IMAGING">SYSTEM, NUCLEAR MAGNETIC RESONANCE IMAGING</a>
, <a href="/web/20180713032048/https://www.guideline.gov/search?f_SPN_CUI=C0936234&fLockTerm=SYSTEM%2c+X-RAY%2c+TOMOGRAPHY%2c+COMPUTED">SYSTEM, X-RAY, TOMOGRAPHY, COMPUTED</a>
</div>
<!-- /.field-content -->
</div>
<!-- /.field -->
<div class="field">
<h5 class="field-label">UMD</h5>
<div class="field-content">
<a href="/web/20180713032048/https://www.guideline.gov/search?f_UMD_CUI=C0014243&fLockTerm=Endoscopes">Endoscopes</a>
(20-475), <a href="/web/20180713032048/https://www.guideline.gov/search?f_UMD_CUI=C0023036&fLockTerm=Laparoscopes">Laparoscopes</a>
(12-291), <a href="/web/20180713032048/https://www.guideline.gov/search?f_UMD_CUI=C0182606&fLockTerm=Radiographic+Units%2c+Chest">Radiographic Units, Chest</a>
(10-822), <a href="/web/20180713032048/https://www.guideline.gov/search?f_UMD_CUI=C0936234&fLockTerm=Scanning+Systems%2c+Computed+Tomography">Scanning Systems, Computed Tomography</a>
(13-469), <a href="/web/20180713032048/https://www.guideline.gov/search?f_UMD_CUI=C0336660&fLockTerm=Scanning+Systems%2c+Magnetic+Resonance+Imaging">Scanning Systems, Magnetic Resonance Imaging</a>
(16-260) </div>
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</div>
<!-- /.field -->
</div>
<!-- /.content-tab-panel -->
<div id="neats-tab" class="content-tab-panel">
<p id="NeatsDescription">
National Guideline Clearinghouse (NGC) has assessed this guideline's adherence to standards of trustworthiness, derived from the Institute of Medicine's report
<a href="/web/20180713032048/https://www.guideline.gov/disclaimer?id=51051&contentType=summary&redirect=http%3A%2F%2Fnationalacademies.org%2Fhmd%2FReports%2F2011%2FClinical-Practice-Guidelines-We-Can-Trust.aspx"><i>Clinical Practice Guidelines We Can Trust</i></a> <img alt="External Web Site Policy" src="/web/20180713032048im_/https://www.guideline.gov/UI/images/icon_externallink.gif">.
</p>
<div class="ratings" aria-hidden="true">
<span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-1.png" alt="Poor"/> = Poor</span>
<span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-2.png" alt="Fair"/> = Fair</span>
<span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-3.png" alt="Good"/> = Good</span>
<span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-4.png" alt="Very Good"/> = Very Good</span>
<span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-5.png" alt="Excellent"/> = Excellent</span>
</div>
<table aria-describedby="NeatsDescription">
<thead>
<tr>
<th id="section">NEATS Assessment <a class="icon-info" href="/web/20180713032048/https://www.guideline.gov/help-and-about/summaries/determining-extent-adherence-to-the-iom-standards-in-ngc"><span class="screen-reader-text">More about NGC's appraisal</span></a></th>
<th id="standard">Standard of Trustworthiness</th>
</tr>
</thead>
<tbody>
<tr>
<td class="topborderme" headers="section">Yes</td>
<td class="greenboldme topborderme" headers="standard">Disclosure of Guideline Funding Source</td>
</tr>
<tr>
<td class="topborderme" headers="section"> <span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-5.png" alt="Excellent"/></span>
</td>
<td class="greenboldme topborderme" headers="standard">Disclosure and Management of Financial Conflict of Interests</td>
</tr>
<tr>
<td class="topborderme" id="blank"></td>
<th class="greenboldme topborderme" id="185" headers="standard">Guideline Development Group Composition</th>
</tr>
<tr>
<td headers="section">
Yes
</td>
<td class="leftpadme" headers="185">Multidisciplinary Group</td>
</tr>
<tr>
<td headers="section">
Yes
</td>
<td class="leftpadme" headers="186">Methodologist Involvement</td>
</tr>
<tr>
<td headers="section">
<span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-4.png" alt="Very Good"/></span>
</td>
<td class="leftpadme" headers="187">Patient and Public Perspectives</td>
</tr>
<tr>
<td class="topborderme" id="blank"></td>
<th class="greenboldme topborderme" id="188" headers="standard">Use of a Systematic Review of Evidence</th>
</tr>
<tr>
<td headers="section">
<span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-5.png" alt="Excellent"/></span>
</td>
<td class="leftpadme" headers="188">Search Strategy</td>
</tr>
<tr>
<td headers="section">
<span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-5.png" alt="Excellent"/></span>
</td>
<td class="leftpadme" headers="189">Study Selection</td>
</tr>
<tr>
<td headers="section">
<span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-5.png" alt="Excellent"/></span>
</td>
<td class="leftpadme" headers="190">Synthesis of Evidence</td>
</tr>
<tr>
<td class="topborderme" id="blank"></td>
<th class="greenboldme topborderme" id="191" headers="standard">Evidence Foundations for and Rating Strength of Recommendations</th>
</tr>
<tr>
<td headers="section">
<span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-5.png" alt="Excellent"/></span>
</td>
<td class="leftpadme" headers="191">Grading the Quality or Strength of Evidence</td>
</tr>
<tr>
<td headers="section">
<span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-5.png" alt="Excellent"/></span>
</td>
<td class="leftpadme" headers="192">Benefits and Harms of Recommendations</td>
</tr>
<tr>
<td headers="section">
<span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-5.png" alt="Excellent"/></span>
</td>
<td class="leftpadme" headers="193">Evidence Summary Supporting Recommendations</td>
</tr>
<tr>
<td headers="section">
<span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-5.png" alt="Excellent"/></span>
</td>
<td class="leftpadme" headers="194">Rating the Strength of Recommendations</td>
</tr>
<tr>
<td class="topborderme" headers="section"> <span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-5.png" alt="Excellent"/></span>
</td>
<td class="greenboldme topborderme" headers="standard">Specific and Unambiguous Articulation of Recommendations</td>
</tr>
<tr>
<td class="topborderme" headers="section"> <span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-3.png" alt="Good"/></span>
</td>
<td class="greenboldme topborderme" headers="standard">External Review</td>
</tr>
<tr>
<td class="topborderme" headers="section"> <span class="rating"><img src="/web/20180713032048im_/https://www.guideline.gov/UI/images/rating-5.png" alt="Excellent"/></span>
</td>
<td class="greenboldme topborderme" headers="standard">Updating</td>
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<textarea id="citation">National Guideline Clearinghouse (NGC). Guideline summary: (1) Potentially curable pancreatic cancer: American Society of Clinical Oncology clinical practice guideline. (2) Potentially curable pancreatic cancer: American Society of Clinical Oncology clinical practice guideline update. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2017 Jul 10. [cited 2018 Jul 13]. Available: https://www.guideline.gov</textarea>
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<h2 id="420" class="accordion-title section-420 is-active" role="tab" aria-expanded="true"><a href="#">Recommendations</a></h2>
<div class="accordion-panel is-active" role="tabpanel">
<h3><a href="#">Major Recommendations</a></h3>
<p><div class="content_para"><p>Definitions for the rating of evidence (<strong>High</strong>, <strong>Intermediate</strong>, <strong>Low</strong>, <strong>Insufficient</strong>); types of recommendations (<strong>Evidence based</strong>, <strong>Formal consensus</strong>, <strong>Informal consensus</strong>, <strong>No recommendation</strong>); and strength of recommendations (<strong>Strong</strong>, <strong>Moderate</strong>, <strong>Weak</strong>) are provided at the end of the "Major Recommendations" field.</p>
<p><strong><span style="text-decoration: underline;">Clinical Question 1</span></strong></p>
<p><strong>After a histopathologic confirmation of pancreatic adenocarcinoma diagnosis, what initial assessment is recommended before initiating any therapy for potentially curable pancreatic cancer?</strong></p>
<p><em>Recommendation 1.1</em>: A multiphase computed tomography (CT) scan of the abdomen and pelvis using a pancreatic protocol or magnetic resonance imaging (MRI) should be performed for all patients with pancreatic cancer to assess the anatomic relationships of the primary tumor and to assess for the presence of intra-abdominal metastases. Endoscopic ultrasonography and/or diagnostic laparoscopy may be used as supplemental studies and to facilitate acquisition of a biopsy specimen. A chest x-ray may be performed to stage the thorax. Other staging studies should be performed only as dictated by symptom burden. A serum level of cancer antigen (CA) 19-9 and baseline standard laboratory studies should be assayed (Type: evidence based, benefits outweigh harms; Evidence quality: high; Strength of recommendation: strong).</p>
<p><em>Recommendation 1.2</em>: The baseline performance status, symptom burden, and comorbidity profile of a patient diagnosed with potentially curable pancreatic cancer should be evaluated carefully (Type: evidence based, benefits outweigh harms; Evidence quality: high; Strength of recommendation: strong).</p>
<p><em>Recommendation 1.3</em>: The goals of care (including a discussion of advance directives), patient preferences, and support systems should be discussed with every patient diagnosed with potentially curable pancreatic cancer and his or her caregivers (Type: evidence based, benefits outweigh harms; Evidence quality: intermediate; Strength of recommendation: strong).</p>
<p><em>Recommendation 1.4</em>: Multidisciplinary collaboration to formulate treatment and care plans and disease management for patients with potentially curable pancreatic cancer should be the standard of care (Type: evidence based, benefits outweigh harms; Evidence quality: intermediate; Strength of recommendation: strong).</p>
<p><em>Recommendation 1.5</em>: Every person with pancreatic cancer should be offered information about clinical trials, including therapeutic trials in all lines of treatment, as well as palliative care, biorepository/biomarker, and observational studies (Type: informal consensus, benefits outweigh harms; Evidence quality: intermediate; Strength of recommendation: strong).</p>
<p><strong><span style="text-decoration: underline;">Clinical Question 2</span></strong></p>
<p><strong>Which patients with potentially curable pancreatic cancer should be offered a potentially curative strategy with primary tumor resection?</strong></p>
<p><em>Recommendation 2.1</em>: Primary surgical resection of the primary tumor and regional lymph nodes is recommended for patients with potentially curable pancreatic cancer who meet all of the following criteria: no clinical evidence for metastatic disease, a performance status and comorbidity profile appropriate for a major abdominal operation, no radiographic interface between primary tumor and mesenteric vasculature on high-definition cross-sectional imaging, and an acceptable CA 19-9 level (in absence of jaundice) suggestive of localized disease (Type: evidence based, benefits outweigh harms; Evidence quality: intermediate; Strength of recommendation: strong).</p>
<p><strong><span style="text-decoration: underline;">Clinical Question 3</span></strong></p>
<p><strong>Which patients with potentially curable pancreatic cancer should be offered a potentially curative strategy with preoperative therapy, followed by planned primary tumor resection?</strong></p>
<p><em>Recommendation 3.1</em>: Preoperative therapy is recommended for patients with pancreatic cancer who meet any of the following criteria: radiographic findings suspicious but not diagnostic for extrapancreatic disease, a performance status or comorbidity profile not currently appropriate (but potentially reversible) for a major abdominal operation, a radiographic interface between primary tumor and mesenteric vasculature on cross-sectional imaging that does not meet the criteria in Clinical Question 2, or a CA 19-9 level (in absence of jaundice) suggestive of disseminated disease (Type: evidence based, benefits outweigh harms; Evidence quality: low; Strength of recommendation: strong).</p>
<p><em>Recommendation 3.2</em>: Preoperative therapy should be offered as an alternative treatment strategy for any patient who meets all criteria in Recommendation 2.1 (Type: evidence based, benefits outweigh harms; Evidence quality: low; Strength of recommendation: strong).</p>
<p><em>Recommendation 3.3</em>: If preoperative therapy is administered, a complete restaging evaluation (see Clinical Question 1) is recommended after completion of treatment and before final surgical planning (Type: informal consensus, benefits outweigh harms; Evidence quality: intermediate; Strength of recommendation: strong).</p>
<p><strong><span style="text-decoration: underline;">Clinical Question 4</span></strong></p>
<p><strong>What is the appropriate adjuvant regimen for patients with pancreatic cancer who have undergone an R0 or R1 resection of their primary tumor?</strong></p>
<p><em>Updated Recommendation 4.1</em>: All patients with resected pancreatic cancer who did not receive preoperative therapy should be offered 6 months of adjuvant chemotherapy in the absence of medical or surgical contraindications. The doublet regimen of gemcitabine and capecitabine is a new option; alternatively, monotherapy with gemcitabine alone or fluorouracil plus folinic acid can be offered if there are concerns about toxicity or tolerance. Adjuvant treatment should be initiated within 8 weeks of surgical resection, assuming complete recovery (Type: evidence based, benefits outweigh harms; Evidence quality: high; Strength of recommendation: strong).</p>
<p><em>Recommendation 4.2</em>: Adjuvant chemoradiation may be offered to patients who did not receive preoperative therapy and present after resection with microscopically positive margins (R1) and/or node-positive disease after completion of 4 to 6 months of systemic adjuvant chemotherapy as outlined in Recommendation 4.1. There is clinical equipoise regarding the benefit of adjuvant radiation therapy in this setting pending results of an ongoing international randomized controlled trial (RCT) (Type: Informal consensus, benefits outweigh harms; Evidence quality: intermediate; Strength of recommendation: moderate).</p>
<p><em>Recommendation 4.3</em>: For patients with pancreatic cancer who received preoperative therapy, there are no RCT data to guide the administration of postoperative therapy. The panel recommends that a total of 6 months of adjuvant therapy (including preoperative regimen) be offered based on extrapolation from adjuvant therapy trials (Type: informal consensus, benefits outweigh harms; Evidence quality: low; Strength of recommendation: strong).</p>
<p><strong><span style="text-decoration: underline;">Clinical Question 5</span></strong></p>
<p><strong>When should palliative care services be initiated for patients with pancreatic cancer that is potentially curable by surgery?</strong></p>
<p><em>Recommendation 5.1</em>: Patients with potentially curable pancreatic cancer should have a full assessment of symptom burden, psychological status, and social supports as early as possible, preferably at the first visit. In some instances, this may indicate a need for a formal palliative care consult and services (Type: informal consensus, benefits outweigh harms; Evidence quality: intermediate; Strength of recommendation: strong).</p>
<p><em>Recommendation 5.2</em>: Patients who have undergone pancreatectomy for potentially curable pancreatic cancer should receive ongoing supportive care for symptom burden that may result from the surgery and (preoperative and/or adjuvant) chemotherapy (Type: informal consensus, benefits outweigh harms; Evidence quality: intermediate; Strength of recommendation: strong).</p>
<p><strong><span style="text-decoration: underline;">Clinical Question 6</span></strong></p>
<p><strong>What is the recommended frequency of follow-up care or surveillance for patients with potentially curable pancreatic cancer after the administration of potentially curative multimodality therapy that includes resection?</strong></p>
<p><em>Recommendation 6.1</em>: In the absence of RCT evidence, the panel recommends that patients who have completed treatment of potentially curable pancreatic cancer and have no evidence of disease be monitored for recovery of treatment-related toxicities and recurrence. Visits may be offered at 3- to 6-month intervals; the role of serial cross-sectional imaging, the extent to which surveillance intervals should be prolonged over time, and the duration of recommended surveillance are all undefined (Type: informal consensus, benefits outweigh harms; Evidence quality: low; Strength of recommendation: moderate).</p>
<p><span style="text-decoration: underline;"><strong>Definitions</strong></span></p>
<p><strong>Guide for Rating Quality of Evidence</strong></p>
<table border="1" cellspacing="1" cellpadding="3" summary="Table: Guide for Rating Strength of Evidence">
<thead>
<tr>
<th class="Center" valign="top" scope="col">Rating for Strength of Evidence</th>
<th class="Center" valign="top" scope="col">Definition</th>
</tr>
</thead>
<tbody>
<tr>
<th class="Center" valign="top" scope="row">High</th>
<td valign="top">High confidence that the available evidence reflects the true magnitude and direction of the net effect (i.e., balance of benefits versus harms) and that further research is very unlikely to change either the magnitude or direction of this net effect.</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">Intermediate</th>
<td valign="top">Moderate confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research is unlikely to alter the direction of the net effect; however, it might alter the magnitude of the net effect.</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">Low</th>
<td valign="top">Low confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research may change either the magnitude and/or direction of this net effect.</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">Insufficient</th>
<td valign="top">Evidence is insufficient to discern the true magnitude and direction of the net effect. Further research may better inform the topic. The use of the consensus opinion of experts is reasonable to inform outcomes related to the topic.</td>
</tr>
</tbody>
</table>
<p><strong>Guide for Types of Recommendations</strong></p>
<table border="1" cellspacing="1" cellpadding="3" summary="Table: Guide for Types of Recommendations">
<thead>
<tr>
<th class="Center" valign="top" scope="col">Type of Recommendation</th>
<th class="Center" valign="top" scope="col">Definition</th>
</tr>
</thead>
<tbody>
<tr>
<th class="Center" valign="top" scope="row">Evidence based</th>
<td valign="top">There was sufficient evidence from published studies to inform a recommendation to guide clinical practice.</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">Formal consensus</th>
<td valign="top">The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. Therefore, the Expert Panel used a formal consensus process to reach this recommendation, which is considered the best current guidance for practice. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak"). The results of the formal consensus process are summarized in the guideline and reported in the Data Supplement (see the "Availability of Companion Documents" field).</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">Informal consensus</th>
<td valign="top">The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. The recommendation is considered the best current guidance for practice, based on informal consensus of the Expert Panel. The Panel agreed that a formal consensus process was not necessary for reasons described in the literature review and discussion. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak").</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">No recommendation</th>
<td valign="top">There is insufficient evidence, confidence, or agreement to provide a recommendation to guide clinical practice at this time. The Panel deemed the available evidence as insufficient and concluded it was unlikely that a formal consensus process would achieve the level of agreement needed for a recommendation.</td>
</tr>
</tbody>
</table>
<p><strong>Guide for Strength of Recommendations</strong></p>
<table border="1" cellspacing="1" cellpadding="3" summary="Table: Guide for Strength of Recommendations">
<thead>
<tr>
<th class="Center" valign="top" scope="col">Rating for Strength of Recommendation</th>
<th class="Center" valign="top" scope="col">Definition</th>
</tr>
</thead>
<tbody>
<tr>
<th class="Center" valign="top" scope="row">Strong</th>
<td valign="top">There is high confidence that the recommendation reflects best practice. This is based on (1) strong evidence for a true net effect (e.g., benefits exceed harms); (2) consistent results, with no or minor exceptions; (3) minor or no concerns about study quality; and/or (4) the extent of panelists' agreement. Other compelling considerations (discussed in the guideline's literature review and analyses) may also warrant a strong recommendation.</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">Moderate</th>
<td valign="top">There is moderate confidence that the recommendation reflects best practice. This is based on (1) good evidence for a true net effect (e.g., benefits exceed harms); (2) consistent results, with minor and/or few exceptions; (3) minor and/or few concerns about study quality; and/or (4) the extent of panelists' agreement. Other compelling considerations (discussed in the guideline's literature review and analyses) may also warrant a moderate recommendation.</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">Weak</th>
<td valign="top">There is some confidence that the recommendation offers the best current guidance for practice. This is based on (1) limited evidence for a true net effect (e.g., benefits exceed harms); (2) consistent results, but with important exceptions; (3) concerns about study quality; and/or (4) the extent of panelists' agreement. Other considerations (discussed in the guideline's literature review and analyses) may also warrant a weak recommendation.</td>
</tr>
</tbody>
</table></div></p>
<h3><a href="#">Clinical Algorithm(s)</a></h3>
<p><div class="content_para"><p>None provided</p></div></p>
</div>
<h2 id="396" class="accordion-title section-396 is-active" role="tab" aria-expanded="true"><a href="#">Scope</a></h2>
<div class="accordion-panel is-active" role="tabpanel">
<h3><a href="#">Disease/Condition(s)</a></h3>
<p><div class="content_para"><p>Potentially curable pancreatic cancer</p></div></p>
<h3><a href="#">Guideline Category</a></h3>
<p>Evaluation</p>
<p>Management</p>
<p>Treatment</p>
<h3><a href="#">Clinical Specialty</a></h3>
<p>Gastroenterology</p>
<p>Geriatrics</p>
<p>Oncology</p>
<p>Radiation Oncology</p>
<p>Surgery</p>
<h3><a href="#">Intended Users</a></h3>
<p>Advanced Practice Nurses</p>
<p>Nurses</p>
<p>Physician Assistants</p>
<p>Physicians</p>
<h3><a href="#">Guideline Objective(s)</a></h3>
<p><div class="content_para"><p><strong><span style="text-decoration: underline;">2016 Guideline</span></strong></p>
<ul style="list-style-type: disc;">
<li>To provide evidence-based recommendations to oncologists and others on potentially curative therapy for patients with localized pancreatic cancer </li>
<li>To help with clinical decision making and specifically to address the identification of patients with pancreatic cancer who should be offered potentially curative therapy, the identification of patients who should receive preoperative and/or adjuvant treatment, the use of palliative care services both before and after treatment, and optimal oncologic surveillance </li>
</ul>
<p><strong><span style="text-decoration: underline;">2017 Addendum</span></strong></p>
<p>To update the Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline by providing oncologists and other clinicians with current evidence </p></div></p>
<h3><a href="#">Target Population</a></h3>
<p><div class="content_para"><p>Patients diagnosed with potentially curable pancreatic cancer</p></div></p>
<h3><a href="#">Interventions and Practices Considered</a></h3>
<p><div class="content_para"><p><strong><span style="text-decoration: underline;">Evaluation</span></strong></p>
<ol style="list-style-type: decimal;" start="1">
<li>Multiphase computed tomography (CT) scan of the abdomen and pelvis </li>
<li>Magnetic resonance imaging (MRI)</li>
<li>Endoscopic ultrasonography and/or diagnostic laparoscopy as supplemental studies </li>
<li>Chest X-ray </li>
<li>Measurement of serum level of cancer antigen (CA) 19-9 </li>
<li>Baseline standard laboratory studies </li>
<li>Baseline performance status, symptom burden, and comorbidity profile </li>
</ol>
<p><strong><span style="text-decoration: underline;">Treatment/Management</span></strong></p>
<ol style="list-style-type: decimal;" start="1">
<li>Discussions of goals of care (including a discussion of advance directives), patient preferences, and support systems </li>
<li>Multidisciplinary collaboration to formulate treatment and care plans and disease management </li>
<li>Offering patients information about clinical trials, including therapeutic trials in all lines of treatment, as well as palliative care, biorepository/biomarker, and observational studies </li>
<li>Primary surgical resection of the primary tumor and regional lymph nodes </li>
<li>Preoperative therapy </li>
<li>Complete restaging evaluation after completion of preoperative treatment </li>
<li>Adjuvant chemotherapy or adjuvant chemoradiation after resection </li>
<li>Early full assessment of symptom burden, psychological status, and social supports </li>
<li>Palliative care services </li>
<li>Ongoing supportive care </li>
<li>Monitoring for recovery of treatment-related toxicities and recurrence (frequency of follow-up) </li>
</ol></div></p>
<h3><a href="#">Major Outcomes Considered</a></h3>
<p><ul style="list-style-type: disc;">
<li>Response rate(s) </li>
<li>Overall survival </li>
<li>Disease-free survival </li>
<li>Progression-free survival </li>
<li>Adverse events </li>
</ul></p>
</div>
<h2 id="405" class="accordion-title section-405 is-active" role="tab" aria-expanded="true"><a href="#">Methodology</a></h2>
<div class="accordion-panel is-active" role="tabpanel">
<h3><a href="#">Methods Used to Collect/Select the Evidence</a></h3>
<p>Hand-searches of Published Literature (Primary Sources)</p>
<p>Hand-searches of Published Literature (Secondary Sources)</p>
<p>Searches of Electronic Databases</p>
<h3><a href="#">Description of Methods Used to Collect/Select the Evidence</a></h3>
<p><div class="content_para"><p><strong><span style="text-decoration: underline;">2016 Guideline</span></strong></p>
<p>The recommendations were developed by the multidisciplinary Expert Panel using a systematic review of articles (April 2002 to June 2015) of phase III randomized controlled trials (RCTs). Other peer-reviewed articles were used to inform the recommendations on patient and clinician communication, health disparities, and multiple chronic conditions (MCCs), as well as the section on cost implication. Articles were selected for inclusion in the systematic review of the evidence on the basis of the following criteria: included patients with potentially curable (resectable or borderline resectable) pancreatic cancer; involved phase III RCTs of preoperative (neoadjuvant) or adjuvant chemotherapy alone and/or with chemoradiotherapy and/or compared with a control arm; and written in English, with human patients.</p>
<p>Articles were excluded from the systematic review if they were meeting abstracts not subsequently published in peer-reviewed journals; editorials, commentaries, letters, news articles, case reports, or narrative reviews; or published in a non-English language.</p>
<p><strong>Literature Search Strategy</strong></p>
<p>Computerized literature searches of MEDLINE and the Cochrane Collaboration Library were performed. The searches of the English-language literature published from January 2000 to June 2015 combined pancreatic neoplasm terms and follow-up-related terms and MeSH headings. Results of the databases searches were supplemented with hand searching of the bibliographies of systematic reviews and selected seminal articles, and contributions from Expert Panel members' personal files.</p>
<p>Details of the literature search strategy are provided in Data Supplement 3 (see the "Availability of Companion Documents" field). A Quality of Reporting of Meta-analyses (QUOROM) Diagram that reports the results of the literature search is available in Data Supplement 4 (see the "Availability of Companion Documents" field).</p>
<p><strong><span style="text-decoration: underline;">2017 Addendum</span></strong></p>
<p><strong>Guideline Update Process</strong></p>
<p>The American Society of Clinical Oncology (ASCO) uses a signals approach to facilitate guideline updating. This approach is intended to identify new, potentially practice-changing data—signals—that might translate into revised practice recommendations. The approach relies on routine literature searching and the expertise of ASCO guideline panel members to identify signals. The methodology supplement (see the "Availability of Companion Documents" field) provides additional information about the signals approach.</p>
<p>The recently published results of a randomized phase III study prompted an update of this guideline. The high quality of the reported evidence and the potential for its clinical impact prompted the Expert Panel to revise one of the guideline recommendations.</p></div></p>
<h3><a href="#">Number of Source Documents</a></h3>
<p><div class="content_para"><p><strong><span style="text-decoration: underline;">2016 Guideline</span></strong></p>
<p>There were only nine randomized controlled trials (RCTs) that met eligibility criteria and form the evidentiary basis for some of the guideline recommendations. Twelve systematic reviews or meta-analyses of various rigor and quality were obtained, but none were deemed suitable as the basis for recommendations.</p>
<p>See the Quality of Reporting of Meta-analyses (QUOROM) Diagram (Data Supplement 4) in the Data Supplement (see the "Availability of Companion Documents" field) for an outline of the study selection process.</p>
<p><strong><span style="text-decoration: underline;">2017 Addendum</span></strong></p>
<p>One randomized phase III study</p></div></p>
<h3><a href="#">Methods Used to Assess the Quality and Strength of the Evidence</a></h3>
<p>Weighting According to a Rating Scheme (Scheme Given)</p>
<h3><a href="#">Rating Scheme for the Strength of the Evidence</a></h3>
<p><div class="content_para"><p><strong><span style="text-decoration: underline;">Guide for Rating Quality of Evidence</span></strong></p>
<table border="1" cellspacing="1" cellpadding="3" summary="Table: Guide for Rating Strength of Evidence">
<thead>
<tr>
<th class="Center" valign="top" scope="col">Rating for Strength of Evidence</th>
<th class="Center" valign="top" scope="col">Definition</th>
</tr>
</thead>
<tbody>
<tr>
<th class="Center" valign="top" scope="row">High</th>
<td valign="top">High confidence that the available evidence reflects the true magnitude and direction of the net effect (i.e., balance of benefits versus harms) and that further research is very unlikely to change either the magnitude or direction of this net effect.</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">Intermediate</th>
<td valign="top">Moderate confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research is unlikely to alter the direction of the net effect; however, it might alter the magnitude of the net effect.</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">Low</th>
<td valign="top">Low confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research may change either the magnitude and/or direction of this net effect.</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">Insufficient</th>
<td valign="top">Evidence is insufficient to discern the true magnitude and direction of the net effect. Further research may better inform the topic. The use of the consensus opinion of experts is reasonable to inform outcomes related to the topic.</td>
</tr>
</tbody>
</table>
<p><strong><span style="text-decoration: underline;">Guide for Rating of Potential for Bias</span></strong></p>
<table border="1" cellspacing="1" cellpadding="3" summary="Table: Guide for Rating of Potential for Bias">
<thead>
<tr>
<th class="Center" valign="top" scope="col">Rating of Potential for Bias</th>
<th class="Center" valign="top" scope="col">Definitions for Rating Potential for Risk of Bias in Randomized Controlled Trials</th>
</tr>
</thead>
<tbody>
<tr>
<th class="Center" valign="top" scope="row">Low risk</th>
<td valign="top">No major features in the study that risk biased results, and none of the limitations are thought to decrease the validity of the conclusions. The study avoids problems such as failure to apply true randomization, selection of a population unrepresentative of the target patients, high dropout rates, and no intention-to-treat analysis; and key study features are described clearly (including the population, setting, interventions, comparison groups, measurement of outcomes, and reasons for dropouts).</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">Intermediate</th>
<td valign="top">The study is susceptible to some bias, but flaws are not sufficient to invalidate the results. Enough of the items introduce some uncertainty about the validity of the conclusions. The study does not meet all the criteria required for a rating of good quality, but no flaw is likely to cause major bias. The study may be missing information, making it difficult to assess limitations and potential problems.</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">High risk</th>
<td valign="top">There are significant flaws that imply biases of various types that may invalidate the results. Several of the items introduce serious uncertainty about the validity of the conclusions. The study has serious errors in design, analysis, or reporting; large amounts of missing information; or discrepancies in reporting.</td>
</tr>
</tbody>
</table></div></p>
<h3><a href="#">Methods Used to Analyze the Evidence</a></h3>
<p>Review of Published Meta-Analyses</p>
<p>Systematic Review with Evidence Tables</p>
<h3><a href="#">Description of the Methods Used to Analyze the Evidence</a></h3>
<p><div class="content_para"><p><strong><span style="text-decoration: underline;">2016 Guideline</span></strong></p>
<p><strong>Data Extraction</strong></p>
<p>Literature search results were reviewed and deemed appropriate for full text review by two American Society of Clinical Oncology (ASCO) staff reviewers in consultation with the Expert Panel Co-Chairs. Data were extracted by two staff reviewers and subsequently checked for accuracy through an audit of the data by another ASCO staff member. Disagreements were resolved through discussion and consultation with the Co-Chairs if necessary. Evidence tables are provided in Data Supplements 1 and 2 (see the "Availability of Companion Documents" field).</p>
<p><strong>Study Quality Assessment</strong></p>
<p>Study design aspects related to individual study quality, strength of evidence, strength of recommendations, and risk of bias were assessed and are provided in the Data Supplement (see the "Availability of Companion Documents" field). The study quality was particularly high for this group of randomized controlled trials (RCTs). Design aspects related to the individual study quality were assessed with factors such as blinding, allocation concealment, placebo control, intention to treat, funding sources, and so on, generally indicating a low potential risk of bias for most of the identified evidence. Follow-up times varied between studies, decreasing the comparability of the results. Refer to the "Rating Scheme for the Strength of the Evidence" and Rating Scheme for the Strength of the Recommendations" fields for more extensive definitions of ratings of evidence quality, strength of recommendations, and overall potential risk of bias.</p>
<p><strong><span style="text-decoration: underline;">2017 Addendum</span></strong></p>
<p>Not stated</p></div></p>
<h3><a href="#">Methods Used to Formulate the Recommendations</a></h3>
<p>Expert Consensus</p>
<p>Informal Consensus</p>
<h3><a href="#">Description of Methods Used to Formulate the Recommendations</a></h3>
<p><div class="content_para"><p><strong><span style="text-decoration: underline;">2016 Guideline</span></strong></p>
<p><strong>Panel Composition</strong></p>
<p>The American Society of Clinical Oncology (ASCO) Clinical Practice Guidelines Committee (CPGC) convened an Expert Panel with multidisciplinary representation in medical oncology, radiation oncology, surgical oncology, pathology, community oncology, patient/advocacy representation, and guideline implementation. The Expert Panel was led by two Co-Chairs who had primary responsibility for the development and timely completion of the guideline.</p>
<p><strong>Guideline Development Process</strong></p>
<p>The Expert Panel met via webinar on several occasions and corresponded frequently through e-mail; progress on guideline development was driven primarily by the Co-Chairs along with ASCO staff. The purpose of the meetings was for members to contribute content, provide critical review, interpret evidence, and finalize the guideline recommendations based upon the consideration of the evidence. All members of the Expert Panel participated in the preparation of the draft guideline document.</p>
<p><strong>Development of Recommendations</strong></p>
<p>The guideline recommendations were crafted, in part, using the GuideLines Into DEcision Support (GLIDES) methodology and accompanying BRIDGE-Wiz software™. This method helps guideline panels systematically develop clear, translatable, and implementable recommendations using natural language, based on the evidence and assessment of its quality to increase usability for end users. The process incorporates distilling the actions involved, identifying who will carry them out, to whom, under what circumstances, and clarifying if and how end users can carry out the actions consistently. This process helps the Panel focus the discussion, avoid using unnecessary and/or ambiguous language, and clearly state its intentions.</p>
<p>Some recommendations are based on informal consensus by the panel because there was no randomized controlled trial (RCT) evidence.</p>
<p><strong><span style="text-decoration: underline;">2017 Addendum</span></strong></p>
<p>The Expert Panel used e-mail to consider the new evidence published in the October 2016 update (Appendix Table A1, online only).</p></div></p>
<h3><a href="#">Rating Scheme for the Strength of the Recommendations</a></h3>
<p><div class="content_para"><p><strong><span style="text-decoration: underline;">Guide for Types of Recommendations</span></strong></p>
<table border="1" cellspacing="1" cellpadding="3" summary="Table: Guide for Types of Recommendations">
<thead>
<tr>
<th class="Center" valign="top" scope="col">Type of Recommendation</th>
<th class="Center" valign="top" scope="col">Definition</th>
</tr>
</thead>
<tbody>
<tr>
<th class="Center" valign="top" scope="row">Evidence based</th>
<td valign="top">There was sufficient evidence from published studies to inform a recommendation to guide clinical practice.</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">Formal consensus</th>
<td valign="top">The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. Therefore, the Expert Panel used a formal consensus process to reach this recommendation, which is considered the best current guidance for practice. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak"). The results of the formal consensus process are summarized in the guideline and reported in the Data Supplement (see the "Availability of Companion Documents" field).</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">Informal consensus</th>
<td valign="top">The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. The recommendation is considered the best current guidance for practice, based on informal consensus of the Expert Panel. The Panel agreed that a formal consensus process was not necessary for reasons described in the literature review and discussion. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak").</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">No recommendation</th>
<td valign="top">There is insufficient evidence, confidence, or agreement to provide a recommendation to guide clinical practice at this time. The Panel deemed the available evidence as insufficient and concluded it was unlikely that a formal consensus process would achieve the level of agreement needed for a recommendation.</td>
</tr>
</tbody>
</table>
<p><strong><span style="text-decoration: underline;">Guide for Strength of Recommendations</span></strong></p>
<table border="1" cellspacing="1" cellpadding="3" summary="Table: Guide for Strength of Recommendations">
<thead>
<tr>
<th class="Center" valign="top" scope="col">Rating for Strength of Recommendation</th>
<th class="Center" valign="top" scope="col">Definition</th>
</tr>
</thead>
<tbody>
<tr>
<th class="Center" valign="top" scope="row">Strong</th>
<td valign="top">There is high confidence that the recommendation reflects best practice. This is based on (1) strong evidence for a true net effect (e.g., benefits exceed harms); (2) consistent results, with no or minor exceptions; (3) minor or no concerns about study quality; and/or (4) the extent of panelists' agreement. Other compelling considerations (discussed in the guideline's literature review and analyses) may also warrant a strong recommendation.</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">Moderate</th>
<td valign="top">There is moderate confidence that the recommendation reflects best practice. This is based on (1) good evidence for a true net effect (e.g., benefits exceed harms); (2) consistent results, with minor and/or few exceptions; (3) minor and/or few concerns about study quality; and/or (4) the extent of panelists' agreement. Other compelling considerations (discussed in the guideline's literature review and analyses) may also warrant a moderate recommendation.</td>
</tr>
<tr>
<th class="Center" valign="top" scope="row">Weak</th>
<td valign="top">There is some confidence that the recommendation offers the best current guidance for practice. This is based on (1) limited evidence for a true net effect (e.g., benefits exceed harms); (2) consistent results, but with important exceptions; (3) concerns about study quality; and/or (4) the extent of panelists' agreement. Other considerations (discussed in the guideline's literature review and analyses) may also warrant a weak recommendation.</td>
</tr>
</tbody>
</table></div></p>
<h3><a href="#">Cost Analysis</a></h3>
<p><div class="content_para"><p><strong><span style="text-decoration: underline;">Cost Implications</span></strong></p>
<p>There are limited cost-effectiveness analyses regarding the various treatment modalities used in the multidisciplinary management of potentially curable pancreatic cancer. However, the available data seem to support the recommendations outlined in the guideline. A study from the United Kingdom evaluated the cost-effectiveness of diagnostic laparoscopy for assessing resectability in pancreatic and periampullary cancer and found that diagnostic laparoscopy before laparotomy in patients with potentially curable pancreatic cancer seems to be cost effective in pancreatic cancer (but not in periampullary cancer). A similar United States (U.S.) analysis found that routine diagnostic laparoscopy was the preferred strategy, allowing for cost reductions of $10,695 per quality-adjusted life-month (QALM) in patients receiving primary surgery and $4,158 per QALM in patients receiving preoperative therapy. A recent article evaluated a decision analytic model to compare neoadjuvant therapy with primary surgery in this population, estimating costs using Medicare payment (2011 U.S. dollars). Survival was reported in QALMs. The authors found that the surgery-first approach cost $46,830 and yielded survival of 8.7 QALMs, whereas the neoadjuvant chemoradiation approach cost $36,583 and yielded survival of 18.8 QALMs. Cost-effectiveness was driven primarily because the neoadjuvant approach identified patients with early metastases or poor performance status, who were spared an ineffective or prohibitively morbid operation. A similar prior analysis by the same group also found that incremental cost-effectiveness ratios were significantly lower for high-performing centers ($5,991 per QALM) than for low-performing centers ($9,144 per QALM), supporting the recommendation for multidisciplinary approach in high-volume centers. Finally, a Markov model evaluated various surveillance approaches in the postoperative setting. Not receiving scheduled surveillance was associated with a postoperative overall survival (OS) of 24.6 months and a cost of $3,837 per patient. Clinical evaluation and cancer antigen (CA) 19-9 assay every 6 months until recurrence was associated with an OS of 32.8 months and a cost of $7,496 per patient. Additional routine imaging every 6 months incrementally increased total cost by $3,465 without increasing OS. The authors concluded that increasing the frequency and intensity of postoperative surveillance of patients after curative therapy for pancreatic cancer beyond clinical evaluation and CA 19-9 testing every 6 months increases cost but confers no clinically significant survival benefit.</p></div></p>
<h3><a href="#">Method of Guideline Validation</a></h3>
<p>External Peer Review</p>
<p>Internal Peer Review</p>
<h3><a href="#">Description of Method of Guideline Validation</a></h3>
<p><div class="content_para"><p><strong><span style="text-decoration: underline;">2016 Guideline</span></strong></p>
<p>Members of the Expert Panel are responsible for reviewing and approving the penultimate version of the guideline, which is then circulated for external review and submitted to <em>Journal of Clinical Oncology</em> for editorial review and consideration for publication (see online Appendix, Table A1 in the original guideline document). All American Society of Clinical Oncology (ASCO) guidelines are ultimately reviewed and approved by the Expert Panel and the ASCO Clinical Practice Guideline Committee before publication.</p>
<p><strong><span style="text-decoration: underline;">2017 Addendum</span></strong></p>
<p>The revised guideline was circulated in draft form to the Expert Panel and approved. ASCO's Clinical Practice Guidelines Committee leadership reviewed and approved the final document.</p></div></p>
</div>
<h2 id="424" class="accordion-title section-424 is-active" role="tab" aria-expanded="true"><a href="#">Evidence Supporting the Recommendations</a></h2>
<div class="accordion-panel is-active" role="tabpanel">
<h3><a href="#">Type of Evidence Supporting the Recommendations</a></h3>
<p><div class="content_para"><p>The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).</p></div></p>
</div>
<h2 id="427" class="accordion-title section-427 is-active" role="tab" aria-expanded="true"><a href="#">Benefits/Harms of Implementing the Guideline Recommendations</a></h2>
<div class="accordion-panel is-active" role="tabpanel">
<h3><a href="#">Potential Benefits</a></h3>
<p><ul style="list-style-type: disc;">
<li>Improved identification of patients with pancreatic cancer who should be offered potentially curative therapy or should receive preoperative and/or adjuvant treatment </li>
<li>Adjuvant therapy improves survival and decreases recurrence compared with surgery alone, and the administration of chemotherapy in the postoperative setting is supported by randomized phase III data. </li>
<li>Among patients with potentially curable pancreatic cancer, baseline performance status and a comorbidity profile should be evaluated carefully because both have implications with regard to a patient's ability to tolerate therapy. Performance status has been consistently identified as a prognostic factor for patients with pancreatic cancer. Measurement of constructs such as frailty and performance status is important, and such measurements may be used to predict chemotherapy toxicity and surgical risk. Geriatric assessment can identify underlying issues that increase the risk of adverse outcomes of older patients undergoing major abdominal surgery. </li>
</ul>
<p>Refer to the "Literature review and analysis" and "Clinical interpretation" sections of the original guideline document for detailed discussions of the potential benefits and harms of each recommendation.</p></p>
<h3><a href="#">Potential Harms</a></h3>
<p><ul style="list-style-type: disc;">
<li>Operative mortality of patients age ≥80 years is higher than in younger patients (age 65 to 69 years), and many are transferred to extended care facilities after surgery. </li>
<li>Even on clinical trials, which enroll highly selected people with potentially curable pancreatic cancer, tolerance and completion of adjuvant therapy is challenging as a result of adverse events and toxicities. In patients undergoing surgery with curative intent, a high Charlson age-comorbidity index increased the risk of death significantly (score of ≥6 increased by threefold the odds of death) within the first year after surgery. In another study of resected pancreatic adenocarcinoma that involved multivariable analysis of 326 patients, elevated blood urea nitrogen (hazard ratio [HR], 4.34; P<.001) and a Khorana score ≥3 (HR, 2.31; <em>P</em>=.039) were associated with early mortality. </li>
<li>Cancer antigen (CA) 19-9 can be falsely elevated in the presence of obstructive jaundice, a common presentation for pancreatic cancer. Therefore, levels should be repeated after resolution of hyperbilirubinemia. </li>
<li>Treatment-related toxicity. A recent systematic review showed that chemoradiation plus gemcitabine was ranked the most toxic, with significantly higher hematologic toxic effects than chemoradiation plus fluorouracil (odds ratio [OR], 13.33; 95% confidence interval [CI], 1.01 to 169.36). The authors concluded that adjuvant chemotherapy with fluorouracil or gemcitabine is optimal; adjuvant chemoradiation is less effective and more toxic. </li>
</ul>
<p>Refer to the "Literature review and analysis" and "Clinical interpretation" sections of the original guideline document for detailed discussions of the potential benefits and harms of each recommendation.</p></p>
</div>
<h2 id="430" class="accordion-title section-430 is-active" role="tab" aria-expanded="true"><a href="#">Contraindications</a></h2>
<div class="accordion-panel is-active" role="tabpanel">
<h3><a href="#">Contraindications</a></h3>
<p><div class="content_para"><p>Resection of synchronous metastatic disease, even low-volume disease, is contraindicated because survival is low.</p></div></p>
</div>
<h2 id="432" class="accordion-title section-432 is-active" role="tab" aria-expanded="true"><a href="#">Qualifying Statements</a></h2>
<div class="accordion-panel is-active" role="tabpanel">
<h3><a href="#">Qualifying Statements</a></h3>
<p><ul style="list-style-type: disc;">
<li>The clinical practice guidelines and other guidance published herein are provided by the American Society of Clinical Oncology, Inc. (ASCO) to assist providers in clinical decision making. The information herein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating provider, as the information does not account for individual variation among patients. Recommendations reflect high, moderate, or low confidence that the recommendation reflects the net effect of a given course of action. The use of words like "must," "must not," "should," and "should not" indicates that a course of action is recommended or not recommended for either most or many cases, but there is latitude for the treating physician to select other courses of action in individual patients. In all cases, the selected course of action should be considered by the treating provider in the context of treating the individual patient. Use of the information is voluntary. ASCO provides this information on an as-is basis and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information, or for any errors or omissions. </li>
<li>Refer to the "Health Disparities," "MCCs" and "Limitation of the Research and Future Directions" sections in the original guideline document for additional qualifying information. </li>
</ul></p>
</div>
<h2 id="434" class="accordion-title section-434 is-active" role="tab" aria-expanded="true"><a href="#">Implementation of the Guideline</a></h2>
<div class="accordion-panel is-active" role="tabpanel">
<h3><a href="#">Description of Implementation Strategy</a></h3>
<p><div class="content_para"><p><strong><span style="text-decoration: underline;">Guideline Implementation</span></strong></p>
<p>American Society of Clinical Oncology (ASCO) guidelines are developed for implementation across health settings. Barriers to implementation include the need to increase awareness of the guideline recommendations among front-line practitioners and survivors of cancer and caregivers and also to provide adequate services in the face of limited resources. The guideline Bottom Line Box was designed to facilitate implementation of recommendations. This guideline will be distributed widely through the ASCO Practice Guideline Implementation Network. ASCO guidelines are posted on the <a href="/web/20180713032048/https://www.guideline.gov/Home/Disclaimer?id=51051&contentType=summary&redirect=http%3a%2f%2fwww.asco.org%2f" title="ASCO Web site">ASCO Web site</a> <img alt="External Web Site Policy" src="/web/20180713032048im_/https://www.guideline.gov/UI/images/icon_externallink.gif"/> and most often published in <em>Journal of Clinical Oncology</em> (<em>JCO</em>) and <em>Journal of Oncology Practice</em>.</p>
<p>For additional information on the ASCO implementation strategy, please see the <a href="/web/20180713032048/https://www.guideline.gov/Home/Disclaimer?id=51051&contentType=summary&redirect=https%3a%2f%2fwww.asco.org%2fpractice-guidelines%2fquality-guidelines%2fimplementation-strategy" title="ASCO Web site">ASCO Web site</a> <img alt="External Web Site Policy" src="/web/20180713032048im_/https://www.guideline.gov/UI/images/icon_externallink.gif"/>.</p></div></p>
<h3><a href="#">Implementation Tools</a></h3>
<p>Patient Resources</p>
<p>Quick Reference Guides/Physician Guides</p>
<p>Slide Presentation</p>
<p><div class="general-block">For information about availability, see the <i>Availability of Companion Documents</i> and <i>Patient Resources</i> fields below.</div></p>
</div>
<h2 id="439" class="accordion-title section-439 is-active" role="tab" aria-expanded="true"><a href="#">Institute of Medicine (IOM) National Healthcare Quality Report Categories</a></h2>
<div class="accordion-panel is-active" role="tabpanel">
<h3><a href="#">IOM Care Need</a></h3>
<p>End of Life Care</p>
<p>Getting Better</p>
<p>Living with Illness</p>
<h3><a href="#">IOM Domain</a></h3>
<p>Effectiveness</p>
<p>Patient-centeredness</p>