Palliation in LAPC has a significant role in
determining quality of life and ensuring patient’s goals of care have been meet. Studies
have suggested that pancreatic cancer is second
only to lung cancer in terms of the number of
emergency department visits in the later stages
of disease.120 Additionally, aggressive care in the
setting of incurable diseases such as LAPC has
been associated with poor quality of life.121 More
recently it has been shown that involvement of
palliative care in patients with advanced pancreatic is associated with less aggressive care near
death.122 Therefore, the incorporation of palliative or supportive care teams in the treatment
of patients with progressive LAPC can improve
quality of life and alleviate suffering associated
with increasing symptom burden.
LAPC is a difficult disease for both provider
and patient. There is a paucity of robust clinical
trials in the neoadjuvant setting for LAPC. Current research is complicated by varying consensus definitions of resectability and the varying
treatment configurations across studies. The
optimal type, timing, and sequence of treatment
and whether to add radiation therapy in LAPC
have not been clearly defined. However, based
on the available studies and consensus guidelines, patients who are deemed to have LAPC
should have neoadjuvant therapy. FOLFIRINOX or gemcitabine with nab-paclitaxel should
be considered first-line treatments. Patients with
LAPC who respond to chemotherapy or are
ineligible for multi-drug chemotherapy may
benefit from chemoradiotherapy. In patients
with unresectable disease, chemoradiotherapy
has been shown to enhance survival as compared to best supportive care or radiation alone.
For borderline resectable disease, it is reasonable to treat patients with either chemoradiotherapy, chemotherapy alone, or chemotherapy
followed by chemoradiotherapy.
Considering the invasive nature of LAPC and
the controversy around neoadjuvant treatment
protocols, enrollment of patients with LAPC
into clinical trials is important and will help
determine the optimal treatment regimen for
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