Advances in the management of pancreatic ductal adenocarcinoma

CMAJ | JUNE 7, 2021 | VOLUME 193 | ISSUE 23 © 2021 CMA Joule Inc. or its licensors T he incidence of pancreatic ductal adenocarcinoma (PDAC) is rising and PDAC is projected to become the third leading cause of cancer death in Canada.1 Although risk factors for PDAC are known, the reason for its rising incidence is not. Overall survival for this disease at 5 years has improved recently; however, survival for other malignant diseases has improved more.2 A 2018 retrospective study of patients in Alberta found that more than 40% of patients with advanced PDAC were not referred for specialist care.3 Surgical resection remains the only opportunity to cure PDAC, and only 15%–20% of patients present with resectable disease.4 However, PDAC is a heterogenous disease and several useful genomic classifiers5,6 and RNA-based subtypes7–9 have been identified that are beginning to inform treatment strategies for patients with nonresectable disease, with some showing survival benefit. We build on a previous review of the clinical presentation and surgical management of PDAC10 to discuss evidence supporting the most recent clinical advances in treatment (Box 1). An approach to the treatment of PDAC by stage is presented in Figure 1.