Understanding the diagnosis
Pancreatic cancer is not a single treatment pathway. The first priorities are to define the diagnosis, determine whether disease is localised or has spread, assess the relationship of the tumour to major blood vessels, and establish whether surgery should form part of treatment.1,2
A coordinated HPB pathway
Assessment may involve pancreas-protocol CT or MRI, EUS with tissue acquisition when indicated, biliary drainage for selected patients with obstruction, oncology input and multidisciplinary review before a treatment sequence is chosen.
Choosing the right cancer team from the outset
Pancreatic cancer treatment is best planned early by a multidisciplinary team with specific experience in pancreatic disease. Specialist HPB surgeons, medical oncologists, radiologists, pathologists, advanced endoscopists and other professionals assess staging, tumour biology, fitness for treatment and the optimal sequence of care. The right expertise at the right time can preserve treatment options and help patients avoid unnecessary procedures.
Resectable pancreatic cancer
For clearly resectable pancreatic cancer, surgery followed by adjuvant chemotherapy remains an established approach. Neoadjuvant therapy is not routinely recommended for every anatomically resectable tumour under the ESMO 2023 guideline; selected high-risk circumstances and clinical trials may warrant a different sequence.
Borderline resectable pancreatic cancer and neoadjuvant chemotherapy
When a pancreatic tumour abuts or involves important blood vessels, an operation may be technically possible but carries a higher risk of an incomplete cancer resection. This is called borderline resectable disease. International guidance favours induction systemic chemotherapy before surgery in suitable patients rather than immediate resection. Regimens may include modified FOLFIRINOX or gemcitabine plus nab-paclitaxel, selected according to patient fitness and oncology assessment.
After treatment, the multidisciplinary team reassesses pancreas-protocol imaging, clinical condition, CA 19-9 trends and disease progression. Lack of dramatic radiological shrinkage does not necessarily rule out surgery, because post-treatment changes around vessels can include fibrosis. Selected patients without progression may still benefit from surgical exploration.
Locally advanced disease and conversion surgery
Some patients initially considered unresectable can be reconsidered for surgery after a period of effective systemic treatment. This requires careful multidisciplinary review and does not mean that surgery will be appropriate for every patient.
Resectability is central to pancreatic cancer planning. For localised disease, surgery may include pancreaticoduodenectomy (Whipple procedure), distal pancreatectomy or, less commonly, total pancreatectomy. Systemic therapy is an important component of treatment and may be given before or after surgery depending on the clinical setting.1,2
The role of EUS and ERCP
EUS can provide high-resolution assessment and tissue acquisition. ERCP is primarily therapeutic and may be used to relieve biliary obstruction in selected patients. These procedures should be used to answer a defined clinical question rather than as routine tests for every patient.
Major pancreatic surgery
Prof Noel performs an estimated >30 major pancreatic resections per year. The figure represents approximate current annual clinical activity and varies from year to year.
Common questions
Does every pancreatic cancer need a biopsy before surgery?
No. Whether tissue confirmation is required depends on the imaging, proposed treatment sequence and diagnostic uncertainty. It is particularly important when systemic treatment is planned before surgery.
Can jaundice be treated before cancer treatment?
When biliary drainage is clinically indicated, ERCP and stent placement are commonly considered. The timing and need for drainage are individualised.
References & clinical guidance
- National Cancer Institute — Pancreatic Cancer Treatment (PDQ), patient version
- National Cancer Institute — Pancreatic Cancer Treatment (PDQ), health professional version
- ESGE — Endoscopic tissue sampling, upper GI and HPB tracts
- ESMO 2023 pancreatic cancer clinical practice guideline
- 2025 Pan-Asian adapted ESMO guideline — borderline resectable and locally advanced pancreatic cancer
Clinical content on this page is original patient-facing writing informed by the cited sources; it is not reproduced from them.
This information is educational and does not replace individual medical assessment. Diagnosis and treatment recommendations depend on the patient, imaging, pathology, disease stage and multidisciplinary assessment.