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Pancreatic cancer

About

What is covered

This interactive flowchart covers diagnosing and managing pancreatic cancer in adults aged 18 and over. It aims to improve care by ensuring quicker and more accurate diagnosis, and by specifying the most effective treatments for people depending on how advanced their cancer is.

Updates

Updates to this interactive flowchart

19 December 2018 Pancreatic cancer (NICE quality standard 177) added.
22 May 2018 Endoscopic bipolar radiofrequency ablation for treating biliary obstruction caused by cancer (NICE interventional procedures guidance 614) added to relieving biliary and duodenal obstruction.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on pancreatic cancer in adults in an interactive flowchart

What is covered

This interactive flowchart covers diagnosing and managing pancreatic cancer in adults aged 18 and over. It aims to improve care by ensuring quicker and more accurate diagnosis, and by specifying the most effective treatments for people depending on how advanced their cancer is.

Updates

Updates to this interactive flowchart

19 December 2018 Pancreatic cancer (NICE quality standard 177) added.
22 May 2018 Endoscopic bipolar radiofrequency ablation for treating biliary obstruction caused by cancer (NICE interventional procedures guidance 614) added to relieving biliary and duodenal obstruction.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Irreversible electroporation for treating pancreatic cancer (2017) NICE interventional procedures guidance 579
Laparoscopic distal pancreatectomy (2007) NICE interventional procedures guidance 204
Pancreatic cancer (2018) NICE quality standard 177

Quality standards

Pancreatic cancer

These quality statements are taken from the pancreatic cancer quality standard. The quality standard defines clinical best practice for pancreatic cancer and should be read in full.

Quality statements

Specialist pancreatic cancer multidisciplinary teams

This quality statement is taken from the pancreatic cancer quality standard. The quality standard defines clinical best practice for pancreatic cancer and should be read in full.

Quality statement

Adults with suspected pancreatic cancer have their diagnosis and care agreed by a specialist pancreatic cancer multidisciplinary team (MDT).

Rationale

Early input from a specialist pancreatic cancer MDT can minimise delays to diagnosis, optimise staging strategy and ensure that all management options are considered. A specialist MDT can also provide specific expertise, including knowledge of novel treatments and ongoing clinical trials, which may not be available within a local MDT. The care agreed by specialist pancreatic cancer MDTs should be delivered in partnership with local MDTs. This should ensure that people with pancreatic cancer have access to support for a broad range of needs associated with pancreatic cancer such as nutrition, pain management, and coping with anxiety and depression.

Quality measures

Structure
a) Evidence of specialist pancreatic cancer MDTs in the area.
Data source: Local data collection, for example service protocols, or local or regional network arrangements.
b) Evidence of clear care pathways between local cancer units and specialist pancreatic cancer MDTs.
Data source: Local data collection, for example local or regional network arrangements, documented local referral policies or agreed patient pathways.
Process
Proportion of adults with suspected pancreatic cancer who have their diagnosis and care agreed by a specialist pancreatic cancer MDT.
Numerator – the number in the denominator who have their diagnosis and care agreed by a specialist pancreatic cancer MDT.
Denominator – the number of adults with suspected pancreatic cancer.
Data source: Local data collection, for example patient records or local cancer unit reports.
Outcome
a) Proportion of adults with a pancreatic cancer diagnosis confirmed by a specialist pancreatic cancer MDT.
b) Proportion of adults with pancreatic cancer receiving pancreatic cancer treatment.
c) Proportion of adults with pancreatic cancer who agree they were given enough care and support from healthcare services.
Data source: Local data collection, for example surveys carried out with people with pancreatic cancer or their families.

What the quality statement means for different audiences

Service providers (local cancer networks, secondary care services, community imaging services and specialist cancer centres) ensure that pathways and systems are in place for specialist pancreatic cancer MDTs to review all cases of suspected pancreatic cancer. They also ensure that care agreed by the specialist pancreatic cancer MDTs is delivered in partnership with local MDTs, and that people have access to support for a broad range of needs associated with pancreatic cancer such as nutrition, pain management and coping with anxiety and depression.
Healthcare professionals (such as members of the local cancer network, clinical oncologists and radiologists) are aware of local pathways for pancreatic cancer and work in partnership with specialist pancreatic cancer MDTs to ensure accurate diagnosis. They also work with the specialist pancreatic cancer MDTs to plan treatment and provide care and support to meet a broad range of needs associated with pancreatic cancer such as nutrition, pain management and coping with anxiety and depression.
Commissioners (NHS England and clinical commissioning groups) ensure that they commission standardised pancreatic cancer care in which adults with suspected pancreatic cancer have their diagnosis and care agreed by a specialist pancreatic cancer MDT.
Adults who may have pancreatic cancer have their condition reviewed by a team of specialists called a pancreatic cancer multidisciplinary team. This team has special expertise in diagnosing and treating pancreatic cancer. They can also make sure that adults who are diagnosed with pancreatic cancer get pain relief, help with nutrition, and advice on where to find support for other problems such as anxiety or depression.

Source guidance

Pancreatic cancer in adults: diagnosis and management (2018) NICE guideline NG85, recommendation 1.2.1

Definitions of terms used in this quality statement

Suspected pancreatic cancer
Pancreatic cancer is suspected based on findings from a standard CT and/or a pancreatic protocol CT. Pancreatic cysts with high-risk features of pancreatic cancer are included.
[Expert opinion]

Staging using FDG-PET/CT

This quality statement is taken from the pancreatic cancer quality standard. The quality standard defines clinical best practice for pancreatic cancer and should be read in full.

Quality statement

Adults with localised pancreatic cancer on CT have staging using fluorodeoxyglucose positron emission tomography/CT (FDG-PET/CT) before they have surgery, radiotherapy or systemic therapy.

Rationale

Undergoing cancer treatment when the pancreatic cancer has already spread can reduce the person’s quality of life without increasing their life expectancy. FDG-PET/CT adds information to CT imaging and allows for more accurate staging, particularly with respect to detecting metastatic disease. Confirmation of localised disease ensures that treatment continues as planned, but if the cancer has spread, the treatment can be reviewed based on the new information. This can prevent ineffective surgeries or unnecessary radical local treatments.

Quality measures

Structure
Evidence of local arrangements to ensure that FDG-PET/CT is used for staging in adults with localised pancreatic cancer on CT before they have surgery, radiotherapy or systemic therapy.
Data source: Local data collection, for example service protocols.
Process
Proportion of adults with localised pancreatic cancer on CT having surgery, radiotherapy or systemic therapy who had FDG-PET/CT before receiving cancer treatment.
Numerator – the number in the denominator who had FDG-PET/CT staging before receiving treatment.
Denominator – the number of adults with localised pancreatic cancer on CT who had surgery, radiotherapy or systemic therapy.
Data source: Local data collection, for example patient records.
Outcome
a) Proportion of adults with pancreatic cancer who have staging recorded at diagnosis.
b) Proportion of adults with localised pancreatic cancer on CT who were found to have metastatic disease on FDG-PET/CT.

What the quality statement means for different audiences

Service providers (specialist regional centres) have processes in place to ensure that adults with localised pancreatic cancer on CT who will be having cancer treatment (surgery, radiotherapy or systemic therapy) have staging using FDG-PET/CT before cancer treatment starts to verify that the disease has not spread.
Healthcare professionals (surgeons and oncologists) use FDG-PET/CT to ensure accurate staging in adults with localised pancreatic cancer on CT before they start cancer treatment (surgery, radiotherapy or systemic therapy).
Commissioners (NHS England and clinical commissioning groups) commission services in which adults with localised pancreatic cancer on CT who will be having cancer treatment (surgery, radiotherapy or systemic therapy) have FDG-PET/CT to ensure more accurate staging before cancer treatment starts.
Adults with localised pancreatic cancer have a special scan called an FDG-PET/CT scan. This scan gives doctors information that helps them decide the best treatment. It shows exactly where the cancer is, and how far advanced it is (the stage of the cancer).

Source guidance

Pancreatic cancer in adults: diagnosis and management (2018) NICE guideline NG85, recommendation 1.3.2

Definitions of terms used in this quality statement

Localised pancreatic cancer
Cancer limited to the place where it started, that is, the pancreas, with no sign that it has spread to distant sites.
[Expert opinion] 

Resectional surgery

This quality statement is taken from the pancreatic cancer quality standard. The quality standard defines clinical best practice for pancreatic cancer and should be read in full.

Quality statement

Adults with resectable pancreatic cancer and obstructive jaundice have resectional surgery rather than preoperative biliary drainage unless the drainage is specifically indicated.

Rationale

Prompt resectional surgery has the potential to increase positive outcomes for adults with resectable pancreatic cancer. For those who are well enough for resectional surgery and not enrolled in a clinical trial that requires biliary drainage, performing preoperative biliary drainage can delay surgery, increase complications and hospitalisations, and raise the risk of pre surgery pancreatitis compared with surgery alone. Carrying out the resection without performing biliary drainage also reduces costs.

Quality measures

Structure
Evidence of local care protocols, which ensure that adults with resectable pancreatic cancer and obstructive jaundice have resectional surgery without preoperative biliary drainage unless the drainage is specifically indicated.
Data source: Local data collection, for example service protocols, regional network arrangements, documented local referral policies or agreed patient pathways.
Process
Proportion of adults with resectable pancreatic cancer and obstructive jaundice with no indication for preoperative biliary drainage who had resectional surgery without the drainage.
Numerator – the number in the denominator who had resectional surgery without preoperative biliary drainage.
Denominator – the number of adults with resectable pancreatic cancer and obstructive jaundice with no indication for preoperative biliary drainage.
Data source: Local data collection, for example patient records.
Outcome
a) Time to resectional surgery for adults with resectable pancreatic cancer and obstructive jaundice.
Data source: NHS England’s cancer waiting times.
b) Disease-free survival in adults with resectable pancreatic cancer and obstructive jaundice who had resectable surgery without preoperative biliary drainage.
Data source: Local data collection, for example patient records.
c) Overall survival in adults with resectable pancreatic cancer.
Data source: Local data collection, for example patient records.
d) Health-related quality of life in adults with pancreatic cancer.
Data source: Local data collection, for example surveys carried out with people with pancreatic cancer or their families.

What the quality statement means for different audiences

Service providers (secondary and tertiary services and specialist regional centres) ensure that systems are in place for adults with resectable pancreatic cancer to have resectional surgery as soon as possible. This includes ensuring that adults with resectable pancreatic cancer and obstructive jaundice have resectional surgery rather than preoperative biliary drainage if they are well enough for surgery and if they are not enrolled in a clinical trial that requires preoperative biliary drainage.
Healthcare professionals (such as gastroenterologists, surgeons and interventional radiologists) are aware of the local pathways for pancreatic cancer and understand that adults with resectable pancreatic cancer should have resectional surgery as soon as possible. They ensure that all adults with resectable pancreatic cancer and obstructive jaundice have resectional surgery without unnecessary delays such as performing preoperative biliary drainage, if they are well enough for surgery and are not enrolled in a clinical trial that requires preoperative biliary drainage.
Commissioners (NHS England and clinical commissioning groups) ensure that they commission services that carry out resectional surgery in adults who have resectable pancreatic cancer without unnecessary delays. They ensure that preoperative biliary drainage is not carried out unnecessarily in adults with resectable pancreatic cancer and obstructive jaundice who are well enough for surgery and are not enrolled in a clinical trial that requires this procedure.
Adults with pancreatic cancer and jaundice who are well enough to have an operation to remove their tumour can have the operation without needing to have their jaundice treated first, unless they are in a clinical trial that requires the jaundice to be treated.

Source guidance

Pancreatic cancer in adults: diagnosis and management (2018) NICE guideline NG85, recommendation 1.7.1

Definitions of terms used in this quality statement

Specific indications for biliary drainage in adults with resectable pancreatic cancer and obstructive jaundice
  • Not being well enough for resectional surgery.
  • Being enrolled in a clinical trial that requires preoperative biliary drainage.
[NICE’s guideline on pancreatic cancer in adults, recommendation 1.7.1]

Pancreatic enzyme replacement therapy

This quality statement is taken from the pancreatic cancer quality standard. The quality standard defines clinical best practice for pancreatic cancer and should be read in full.

Quality statement

Adults with unresectable pancreatic cancer are prescribed enteric-coated pancreatin.

Rationale

Pancreatic cancer inhibits the ability of the pancreas to deliver pancreatic enzymes, which assist digestion and absorption of fat, carbohydrates and proteins. Enteric-coated pancreatin can improve the nutritional status and wellbeing of people with pancreatic cancer and, as a result, their ability to tolerate treatment.

Quality measures

Structure
a) Evidence of local arrangements to ensure that adults with unresectable pancreatic cancer are prescribed enteric-coated pancreatin.
Data source: Local data collection, for example service specification or local protocols.
b) Evidence of local arrangements to ensure that adults with unresectable pancreatic cancer prescribed enteric-coated pancreatin receive advice on how to take it.
Data source: Local data collection, for example service specification or local protocols.
Process
Proportion of adults with unresectable pancreatic cancer prescribed enteric-coated pancreatin.
Numerator – the number in the denominator prescribed enteric-coated pancreatin.
Denominator – the number of adults with unresectable pancreatic cancer.
Data source: Local data collection, for example patient records.
Outcome
a) Malnutrition Universal Screening Tool (MUST) score in adults with unresectable pancreatic cancer.
Data source: Local data collection, for example patient records.
b) Health-related quality of life in people with pancreatic cancer.

What the quality statement means for different audiences

Service providers (secondary and tertiary services, dietetics services and specialist regional centres) ensure that adults with unresectable pancreatic cancer are prescribed enteric-coated pancreatin and given advice on how to use it effectively.
Healthcare professionals (such as GPs, dieticians, pancreatic cancer nurse specialists and members of the local cancer network) prescribe enteric-coated pancreatin to adults with unresectable pancreatic cancer and explain how to use it effectively.
Commissioners (clinical commissioning groups) ensure that they commission services in which adults with unresectable pancreatic cancer are prescribed enteric-coated pancreatin and given advice on how to use it effectively.
Adults with pancreatic cancer that cannot be treated with surgery are given a medicine called pancreatin, which makes it easier to digest food and absorb nutrients. They are given information about how to take the pancreatin tablets to make sure they work as well as possible. Pancreatin can help them to keep their weight stable, feel better, have more energy for normal daily activities and cope with their cancer treatment.

Source guidance

Pancreatic cancer in adults: diagnosis and management (2018) NICE guideline NG85, recommendation 1.6.1

Equality and diversity considerations.

Currently, pancreatic enzyme supplements are made from pork products that may be unacceptable for some people because of their religion or beliefs. People with pancreatic cancer need to be made aware of the ingredients to make an informed decision.

Effective interventions to address psychological needs (placeholder)

This quality statement is taken from the pancreatic cancer quality standard. The quality standard defines clinical best practice for pancreatic cancer and should be read in full.

What is a placeholder statement?

A placeholder statement is an area of care that has been prioritised by the quality standards advisory committee but for which no source guidance is currently available. A placeholder statement indicates the need for evidence-based guidance to be developed in this area.

Rationale

People and their families or carers are often left devastated by a diagnosis of cancer, particularly when they learn that the treatment options are limited and the prognosis is poor. As a result, they often have significant needs for psychological support to help them and their families cope with the diagnosis of a life-limiting disease.
Cancer and cancer treatment can also leave people feeling very unwell. They may experience a range of symptoms that can reduce their quality of life and ability to take part in normal daily activities. Symptoms of pancreatic cancer can include pain, anxiety, depression, fatigue, bowel or digestive problems, loss of appetite, weight loss, itchiness and nausea. People with pancreatic cancer and their families and carers need timely access to information and psychological support to help them cope with these symptoms and side effects, and maintain as good a quality of life as possible for as long as possible.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Why we made the recommendations on nab-paclitaxel

NICE reviewed its technology appraisal guidance on paclitaxel as albumin-bound nanoparticles (nab-paclitaxel) in combination with gemcitabine for previously untreated metastatic pancreatic cancer because the company submitted more evidence and proposed a patient access scheme that would make nab-paclitaxel available with a confidential price discount.
Nab-paclitaxel plus gemcitabine would normally be considered for people with metastatic adenocarcinoma of the pancreas who would otherwise have gemcitabine.
Evidence shows that nab-paclitaxel plus gemcitabine is more effective in increasing survival than gemcitabine monotherapy, but is less effective than FOLFIRINOX (a combination of fluorouracil, leucovorin, irinotecan and oxaliplatin) and similarly effective to gemcitabine plus capecitabine (although the results were uncertain).
Nab-paclitaxel plus gemcitabine met NICE's end-of-life criteria when compared with gemcitabine monotherapy, but not when compared with gemcitabine plus capecitabine or FOLFIRINOX because it did not improve survival.
The most likely estimate of cost effectiveness compared with gemcitabine monotherapy is £41,000 to £46,000 per quality-adjusted life year (QALY) gained. Nab-paclitaxel plus gemcitabine is not cost effective compared with gemcitabine plus capecitabine or FOLFIRINOX.
Nab-paclitaxel plus gemcitabine can therefore be recommended for people with metastatic pancreatic cancer only if other combination chemotherapies are not suitable, and they would otherwise have gemcitabine monotherapy.
For more information see the committee discussion in the NICE technology appraisal on paclitaxel as albumin-bound nanoparticles with gemcitabine for untreated metastatic pancreatic cancer.

Glossary

carcinoembryonic antigen
Eastern Cooperative Oncology Group
endoscopic retrograde cholangiopancreatography
endoscopic ultrasound
fluorodeoxyglucose-positron emission tomography/CT
magnetic resonance cholangiopancreatography

Paths in this pathway

Pathway created: February 2018 Last updated: May 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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