ASTRO updated its guidelines for radiation therapy for pancreatic cancer.

The American Society for Radiation Oncology has released significantly updated clinical guidelines for the use of radiation therapy for pancreatic cancer. The document, published in Practical Radiation Oncology on August 11, 2026, replaces the 2019 guidelines. This is not a new clinical trial, but a clinical guideline in which an expert panel systematized studies published from 2010 to June 2026 and redefined the placement of radiation at different stages of the disease. [1]

The major change is that radiation therapy is no longer considered solely as a means of local control in inoperable patients or as palliative pain treatment. In the updated system, it can be used preoperatively for resectable and borderline resectable cancer, postoperatively in selected patients, as definitive local treatment for locally advanced tumors, for isolated recurrence, and even in carefully selected patients with a small number of metastases or foci of progression. [2]

At the same time, the guidelines place much greater emphasis on the technological aspects of treatment. For locally advanced disease, ASTRO allows for dose escalation using stereotactic radiotherapy or moderately hypofractionated regimens if the clinic has volumetric imaging, tumor motion control during respiration, and the ability to precisely protect the stomach and intestines. For dose-escalated stereotactic therapy, adaptive planning is now explicitly recommended. [3]

But the document's message isn't that "radiotherapy is now necessary for everyone." Pancreatic cancer remains, first and foremost, a systemic and multidisciplinary disease: the decision depends on tumor resectability, response to chemotherapy, vascular invasion, the presence of metastases, the patient's overall condition, and the capabilities of the specific radiotherapy center. This is why ASTRO recommends discussing each patient in a multidisciplinary manner throughout treatment. [4]

What has changed in the 2026 recommendations?	ASTRO's position
Resectable tumor	Preoperative chemoradiation therapy may be considered conditionally
Borderline resectable tumor	Preoperative radiation/chemoradiation therapy is recommended
Locally advanced disease	Radiation or chemoradiation therapy after systemic treatment
Dose escalation	Supported with modern visualization and motion control
SBRT	A more prominent role, especially in definitive treatment
Adaptive RT	Recommended for dose-escalated SBRT
Postoperative irradiation	Conditionally for individual patients
Isolated local recurrence	Radical radiation therapy is possible
Re-irradiation	Possibly in carefully selected patients
Oligometastatic disease	Local irradiation of foci is conditionally recommended
Palliative care	Pain, bleeding, obstruction
The basic principle	Multidisciplinary team decision

[5]

What is the new publication?

The document is titled “Radiation Therapy for Pancreatic Cancer: An ASTRO Clinical Practice Guideline.” It was prepared by a multidisciplinary group including radiation, medical, and surgical oncologists, a medical physicist, a resident physician, and a patient representative. The principal authors were Michael D. Chuong, Krishan R. Jethwa, and Ethan Ludmir; Daniel Chang served as the working group chair. [6]

The experts faced four major questions: who needs radiotherapy for non-metastatic disease and when; what dose and fractionation to use; how to design the irradiation volumes and technically deliver the dose; and what role radiotherapy should play in local recurrence, metastatic disease, re-irradiation, and palliative care. [7]

The recommendations were developed based on a systematic literature review with a pre-defined methodology for assessing the quality of evidence and strength of recommendations. ASTRO considered studies published from 2010 to June 2026. Therefore, the document includes results from several large randomized trials that did not exist when the 2019 version was published. [8]

This is important to interpret. When a document states "recommended," it doesn't necessarily mean that multiple large studies have consistently shown an increase in overall survival. In some situations, the benefit is more compelling for local control, the likelihood of radical surgery, symptom reduction, or time to progression, while the evidence for increased survival remains mixed.

What exactly did management evaluate?

Clinical question	What was analyzed
When is RT needed?	Before surgery, after surgery, final treatment
Type of disease	Resectable, borderline, locally advanced
Dose	Conventional and hypofractionated treatment
SBRT	Indications and dose enhancement
Target	Tumor + areas of risk for microscopic spread
Technologies	IMRT, daily imaging, motion management
Adaptive RT	Replanning when anatomy changes
Relapse	Primary or repeated irradiation
Metastases	Oligometastatic/oligoprogressive disease
Palliative care	Pain, bleeding, obstruction

[9]

Why was it necessary to change the 2019 recommendations?

Over the past seven years, new data have accumulated indicating that surgery is not the only option for local tumor intervention. Modern multidrug chemotherapy better controls micrometastatic disease, and some patients survive long enough for local progression of the pancreatic tumor itself to become a significant cause of pain, bleeding, obstruction, and other complications. This has increased interest in more effective local treatments. [10]

At the same time, radiotherapy techniques have changed significantly. In the classic case, the pancreas is difficult to irradiate with high doses: the stomach, duodenum, and small intestine—structures sensitive to radiation damage—are located nearby. Furthermore, the tumor moves along with the diaphragm and upper abdominal organs with each breath. New systems for daily imaging, respiratory motion monitoring, and adaptive radiotherapy make it possible to reduce this geometric uncertainty. [11]

Data from randomized trials have also emerged. PREOPANC demonstrated a long-term benefit of a preoperative chemoradiotherapy strategy compared with immediate surgery in a combined population of resectable and borderline resectable cancer, although the initial analysis did not show a statistically significant benefit in overall survival. The ambiguity of these results explains why ASTRO retains the "conditionally recommended" designation for some situations rather than establishing a universal standard. [12]

PREOPANC-2 then showed that the contemporary preoperative FOLFIRINOX regimen was not statistically superior to the gemcitabine-containing chemoradiation strategy: median overall survival was 21.9 versus 21.3 months, hazard ratio 0.88, confidence interval 0.69–1.13. Thus, the current evidence base does not suggest that radiotherapy should replace effective systemic therapy; rather, the issue is one of appropriate sequencing and patient selection.[13]

Resectable cancer: Preoperative radiation therapy becomes acceptable, but not yet mandatory

For tumors that are technically resectable immediately, ASTRO now conditionally recommends preoperative chemoradiation if a neoadjuvant treatment strategy is chosen. This is a significant formulation, but the word "conditionally" is crucial: immediate surgery with systemic therapy remains an acceptable approach, and the optimal neoadjuvant strategy continues to be studied. [14]

The rationale for preoperative radiation is to target the tumor and surrounding microscopic growths before surgery, when the blood supply and anatomy have not yet been altered by the procedure. Theoretically, this should reduce the risk of local residual disease and increase the likelihood of an R0 resection—a procedure in which no tumor cells are found at the margins of the removed specimen. [15]

PREOPANC has become one of the important foundations for this approach. In a long-term analysis, a neoadjuvant chemoradiation strategy demonstrated superior long-term survival compared with immediate surgery in a combined cohort of resectable and borderline resectable tumors, although the difference in median survival was relatively small. This demonstrates an important principle: the median does not always fully reflect differences in the tail of the long-term survival curve. [16]

However, PREOPANC used systemic treatment regimens that are no longer fully consistent with current practice. Therefore, it cannot be mechanically translated into the rule that "every resectable cancer requires radiotherapy." PREOPANC-2, which used FOLFIRINOX, did not demonstrate the superiority of modern chemotherapy over a chemoradiation strategy, but it also did not prove the universal benefit of adding radiotherapy. Therefore, ASTRO leaves the decision to a multidisciplinary team. [17]

Approach to resectable tumor

Situation	Recommendation
You can operate immediately	Surgery remains an option
Preoperative treatment has been selected	Chemoradiation therapy is conditionally recommended
RT's main potential target	Local control and improvement of resection quality
Evidence of overall increase in OS	Ambiguous
Solution	Individual, multidisciplinary

[18]

After surgery, radiation therapy also remains, but it is now intended for more narrowly selected patients.

In the postoperative setting, the new recommendation also does not recommend irradiation of all patients. ASTRO conditionally considers chemoradiotherapy after multicomponent chemotherapy in selected patients, especially in the context of the new data from NRG Oncology/RTOG 0848. [19]

RTOG 0848 was significant because the overall study outcome and the outcome of individual pathological subgroups varied. In the overall population, the addition of chemoradiation after adjuvant systemic therapy did not create a universal benefit, but in node-negative patients (pN0), improvements in overall and disease-free survival were found. [20]

This is why the new recommendation appears unusual at first glance: postoperative chemoradiation therapy after multicomponent chemotherapy is conditionally considered primarily for patients with pathologically negative lymph nodes if they have not previously received preoperative radiation. This is an example of personalizing therapy based on pathological risk, rather than the previous idea of "irradiate after surgery or do not irradiate at all." [21]

But even here, ASTRO does not declare postoperative radiotherapy mandatory. The patient has already undergone major surgery and several months of systemic treatment, so the potential improvement in local control must be weighed against the additional toxicity and overall risk of distant metastases. [22]

Borderline resectable cancer: ASTRO's position here is much stronger

A borderline resectable tumor differs from a typically resectable tumor in that it is closely adjacent to or partially involves major vessels. The surgeon can technically attempt to remove the tumor, but the risk of a positive resection margin is significantly higher. It is for this category that the new recommendation significantly more strongly supports preoperative radiation or chemoradiation therapy. [23]

The goal of treatment is not necessarily to dramatically reduce the tumor size on CT scans. In pancreatic cancer, treatment response can manifest as fibrosis and a reduction in viable tumor tissue without a significant reduction in external size. The practical goal is to sterilize the area of tumor-vessel contact and increase the likelihood of R0 resection. [24]

PREOPANC and subsequent studies supported the idea that preoperative treatment can improve local surgical outcomes. However, PREOPANC-2 also demonstrated that the potent multiagent chemotherapy FOLFIRINOX can compete with chemoradiation alone: median overall survival was 21.9 and 21.3 months, respectively, and was not statistically different. This means that the question today is more about "who particularly needs local consolidation after effective systemic therapy?" rather than "chemotherapy or radiotherapy." [25]

Reassessment of resectability after neoadjuvant treatment is crucial. Even if imaging does not show dramatic tumor shrinkage, the patient may be a candidate for surgery if there is no progression and the surgical team is favorable. Therefore, ASTRO emphasizes the need for a collaborative decision among the radiation oncologist, surgeon, medical oncologist, and radiologist. [26]

Locally advanced cancer: Radiotherapy gains a prominent role

In locally advanced cancer, the tumor has invaded major vessels, making initial surgery impossible, but there are no distant metastases. The new guidelines recommend considering chemoradiation or radiation therapy as the final local treatment after multiagent chemotherapy if the disease has not progressed systemically. [27]

The primary goal here is local control. An uncontrolled pancreatic tumor can infiltrate the nerve plexuses, duodenum, stomach, and blood vessels, causing severe pain, bleeding, and obstruction of food and bile passage. Therefore, even if radiotherapy does not eliminate the risk of micrometastases, preventing local growth may in itself be clinically valuable. [28]

Historical data have been mixed. For example, the randomized LAP07 trial showed no benefit of chemoradiotherapy over continued chemotherapy in terms of overall survival after disease control with gemcitabine, although local control improved. More recent technologies and more potent systemic therapies have contributed to the reconsideration of this issue. The new recommendation, therefore, does not overturn previous negative data but rather attempts to define a more appropriate context for local treatment. [29]

CONKO-007 also revealed a complex picture: the addition of a chemoradiation component after induction therapy did not improve the primary outcome of R0 resections in the entire initially inoperable population and did not provide a universal survival benefit, although in patients who actually underwent surgery, the chemoradiation strategy may have increased the likelihood of a higher-quality resection. This further emphasizes that the benefit of radiotherapy is highly dependent on patient selection after systemic treatment. [30]

The most notable technical change: ASTRO supports dose enhancement

Conventional pancreatic radiotherapy has often been limited to relatively moderate biological doses due to the proximity of the stomach and duodenum. New guidelines allow for ablative or near-ablative doses in locally advanced disease, provided the clinic is able to accurately visualize the tumor and monitor its movement. [31]

For five-fraction stereotactic therapy, the guidelines distinguish between under-escalated regimens of approximately 33-40 Gy in five fractions and enhanced regimens of over 40 Gy, up to approximately 50 Gy in five fractions under appropriate conditions. For moderately hypofractionated therapy, one dose escalation option is approximately 60-67.5 Gy in 15 fractions. These are specialized oncology regimens, not universal "prescriptions" for every patient. [32]

Why is the difference so significant? The radiobiological effect depends nonlinearly on the size of each fraction. 50 Gy in five fractions creates a much higher biologically effective antitumor dose than the conventional distribution of a comparable physical dose into 25-30 small fractions. However, the cost of a geometric error of several millimeters increases sharply. [33]

This is why the recommendation links dose escalation to technological conditions. If the center does not have reliable daily volumetric imaging, respiratory monitoring, and the ability to adapt the plan in the event of dangerous gastric or intestinal intrusion, simply attempting to increase the dose may worsen the benefit-to-toxicity ratio. [34]

Examples of modes from the new guide

Approach	Rough outline
Usual elective dose	45-50.4 Gy in 25-28 fractions
Moderate hypofractionation of the elective zone	about 36-37.5 Gy in 15 fractions with simultaneous increase in tumor dose
Standard 5-fraction SBRT	approximately 33-40 Gy / 5
Dose-escalated SBRT	>40 to ≈50 Gy / 5
Dose-escalated moderate hypofractionation	approximately 60-67.5 Gy / 15

The specific dose depends on the location of the tumor, stomach, intestines, blood vessels, previous therapy and the capabilities of the center; the table is not a scheme for self-prescribing treatment. [35]

Why has adaptive radiotherapy become so important?

The position of the pancreas relative to the stomach and intestines changes from day to day. Even if the CT scan plan was perfect on Monday, on Tuesday a full stomach or a different position of a small bowel loop can place the sensitive organ directly in the high-dose zone. Adaptive radiation therapy was developed to address this problem. [36]

With this approach, new imaging is performed before the fraction, the current anatomy is assessed, and, if necessary, the plan is recalculated immediately before irradiation. The goal is not simply to "hit the tumor," but also to ensure that the permissible dose limits for the stomach, duodenum, and small intestine are met for the day. [37]

One of the key drivers of interest in this technology was the multicenter Phase II SMART (stereotactic magnetic resonance-guided on-table adaptive radiation therapy) trial. It utilized magnetic resonance-guided adaptive therapy with 50 Gy in five fractions, which corresponds to a biologically effective dose of approximately 100 Gy in a standard radiobiological model for tumors. [38]

The new recommendation, however, does not state that a magnetic resonance linear accelerator is mandatory for every patient. The key idea is broader: the higher the dose per fraction and the closer the tumor is to the gastrointestinal tract, the more important high-quality imaging, motion control, and the ability to adapt the plan become. [39]

Radiation therapy must take into account microscopic spread, not just visible tumor

One of the technically important provisions was maintaining selective coverage of anatomical risk zones during preoperative, postoperative, and definitive radiation therapy. That is, ASTRO does not recommend simply outlining a visible tumor on a CT scan and directing the dose exclusively there in all situations. [40]

Pancreatic cancer can spread microscopically along vascular and neural structures. This disease is not necessarily visible on CT or MRI scans, but it can be a source of local recurrence after surgery or radiation. [41]

Therefore, with conventional fractionation or moderate hypofractionation, a lower "elective" dose can be used for potentially diseased surrounding anatomical areas, while a higher dose is delivered to the visible tumor or the most at-risk vascular border. Guidelines cite, for example, elective ranges of approximately 45-50.4 Gy over 25-28 fractions. [42]

But with short ablative regimens, the tradeoff becomes more complex: expanding the high-dose zone automatically increases the impact on the gastrointestinal tract. Therefore, the challenge in modern planning is to separate risk zones and use multi-dose volumes, rather than simply irradiating everything with the same high dose. [43]

Isolated local recurrence after surgery: radiotherapy may again become a radical treatment

If, after surgical removal, cancer returns locally in the pancreatic bed or regional structures, but there are no distant metastases, the new recommendation suggests considering radiation or chemoradiation therapy with radical intent if the patient has not previously received radiation to this area. [44]

This differs from a purely palliative philosophy. In a truly isolated relapse, the local tumor may become the primary driver of further progression, and intensive treatment could theoretically provide long-term control. However, before making such a decision, it is especially important to rule out hidden systemic progression and assess the biology of the disease. [45]

The situation is even more complex for patients who have already received radiation therapy. ASTRO now conditionally allows re-irradiation, but requires detailed consideration of previous plans, total doses, and the condition of the stomach, duodenum, small intestine, liver, kidneys, and vascular structures. [46]

This approach is possible largely thanks to modern stereotactic and adaptive technology, but the evidence base is significantly weaker than for primary treatment. Therefore, repeat radiotherapy should be performed in centers capable of reconstructing the previous dose map and assessing the cumulative biological burden on normal tissue. [47]

The most unusual change: radiation is now considered even for limited metastases

Traditionally, the detection of metastases in pancreatic cancer almost automatically shifted treatment to a systemic approach: chemotherapy became the mainstay, while radiotherapy was used primarily for symptomatic relief. The new document conditionally recommends considering local treatment of all or individual metastatic lesions in oligometastatic or oligoprogressive disease. [48]

Oligometastatic disease refers to a limited number of metastases, making it theoretically possible to physically eradicate all known foci. Oligoprogression is a somewhat different situation: systemic therapy continues to control the bulk of the disease, but one or more foci become resistant and begin to grow. Local irradiation of such foci potentially eliminates the need to immediately change effective systemic therapy. [49]

A strong impetus for this direction was provided by the randomized phase II EXTEND trial. The pancreatic cohort included patients with no more than five metastatic lesions. The addition of metastasis-directed local therapy to systemic treatment statistically improved progression-free survival; the hazard ratio for progression or death was 0.43. [50]

However, EXTEND was a small study: the primary analysis included approximately 40 patients. Therefore, the new recommendation remains conditional rather than universal. It has not been proven that irradiation of multiple metastases should be used in every patient with limited spread, and there is no definitive confirmation of an overall survival benefit in a large phase III trial. [51]

Why EXTEND Changed the Conversation

Parameter	EXTEND
Design	Randomized phase II study
Metastases	≤5
Comparison	Systemic Therapy + MDT vs. Systemic Therapy
Pancreatic cohort	≈40 patients
Main outcome	Progression-free survival
HR of progression/death	0.43
Severe toxicity MDT ≥ grade 3	Not noted in the study
Enough for a universal standard?	No

[52]

Palliative radiotherapy: pain remains the most important indication

Intensive local treatment is not suitable for everyone with advanced pancreatic cancer. However, radiotherapy can quickly reduce tumor symptoms, so ASTRO recommends it for pain, tumor bleeding, or obstruction, if the patient's anatomy and condition allow for treatment. [53]

Pain associated with involvement of the nerve plexuses surrounding the celiac trunk is particularly characteristic. This pain sometimes requires high doses of opioids and significantly impairs quality of life. Radiation can reduce the tumor and inflammatory burden on these structures even when treatment no longer has a curative effect. [54]

The prospective PAINPANC study used a short regimen of 24 Gy in three 8 Gy fractions once weekly. In patients with moderate to severe pain, clinically significant pain reduction and a reduction in morphine equivalent requirements were observed, although the study was small and non-randomized.[55]

The guidelines also allow for more intensive dosing for pain relief in carefully selected patients if life expectancy and overall condition justify more complex treatment. However, in palliative care, the goal is fundamentally different: not the maximum dose per se, but maximum symptom relief with minimal therapeutic burden. [56]

What do IMRT, SBRT, IGRT, and adaptive RT mean?

Intensity-modulated radiation therapy (IMRT) allows for the intensity of individual beams to be altered and the dose distribution to be shaped around complex, three-dimensional tumors. This is particularly important for the pancreas due to its proximity to the stomach, duodenum, liver, kidneys, and spinal cord. ASTRO emphasizes the use of modern conformal techniques as the basis for safe treatment. [57]

Image-guided radiation therapy (IGRT) means checking the target position immediately before each fraction. For the pancreas, a single mark made a week before treatment is insufficient: internal organs shift daily. Therefore, the new recommendation makes daily imaging a central part of safe dose delivery. [58]

SBRT – stereotactic body radiation therapy – delivers a high dose in a small number of fractions, for example, five. Its advantage is a short course and the ability to significantly increase the biological dose to the tumor. A disadvantage is the extremely small margin for error: a few millimeters of bowel movement can make a greater difference than with traditional multi-week treatments. [59]

Adaptive RT goes even further: the treatment plan can be recalculated before a specific fraction, taking into account the current position of the stomach, intestines, and tumor. This is why ASTRO recommends adaptation for dose-escalated SBRT—the technology allows for an attempt to increase the tumor dose without proportionally increasing the risk of damage to adjacent organs. [60]

Technology	What is she doing?
IMRT	Forms a complex dose distribution
IGRT	Checks the tumor position before each fraction
Motion management	Takes into account movement during breathing
SBRT	High dose in a small number of fractions
MR-guided RT	MRI imaging of soft tissues
Adaptive RT	Recalculates the plan for the anatomy of a specific day
Dose escalation	Increases the biological dose of the tumor itself

[61]

Why recommendations don't mean the higher the dose, the better

Increasing the dose makes biological sense: pancreatic cancer is relatively resistant to moderate doses, and more intense local action potentially increases the likelihood of long-term control. However, the tumor is almost never isolated from the sensitive gastrointestinal tract. Therefore, the therapeutic window remains narrow. [62]

A high dose to the duodenum or stomach can potentially lead to ulceration, bleeding, stenosis, or perforation. Therefore, safe ablative therapy requires strict dose restrictions to organs at risk, and sometimes the physician deliberately reduces coverage of the portion of the tumor immediately adjacent to the intestine. [63]

There is also no large randomized trial definitively demonstrating that modern ablative SBRT improves overall survival for all patients with locally advanced cancer compared to optimal chemotherapy and standard dose. Much of the most impressive data comes from phase II trials and specialized centers. [64]

Therefore, the correct interpretation of the new recommendation is that dose escalation can now be reasonably considered in appropriate patients if the technique allows it to be done safely, rather than “all patients should be given 50 Gy in five fractions.” [65]

What the guidelines say—and what they don't say

Correct interpretation	Incorrect interpretation
The role of RT in pancreatic cancer has expanded	Radiation therapy is necessary for everyone
Neoadjuvant RT is acceptable in resectable disease	It is proven to be better than surgery for everyone.
In borderline resectability, RT has stronger support	After this, the operation will definitely become possible.
In locally advanced disease, RT improves local control	It is guaranteed to increase overall survival.
Dose escalation can be used in modern centers	The higher the dose, the better
Adaptive SBRT improves accuracy	It completely eliminates toxicity.
Postoperative RT is beneficial in selected pN0 patients	It is mandatory after any operation.
Reirradiation is possible	It is safe to re-irradiate any patient
Oligometastases can be treated locally in selected patients	Metastatic cancer has become curable with radiotherapy.
Palliative RT reduces symptoms	It replaces systemic treatment.

[66]

What questions still remain unanswered?

The main unresolved question is who exactly benefits from locally enhanced therapy. In pancreatic cancer, some patients rapidly develop distant metastases regardless of local control, and for them, additional aggressive radiation may not have time to provide clinical benefit. [67]

Therefore, biological selection after several months of systemic therapy is becoming increasingly important. If the tumor remains localized and no new lesions appear, this in itself may be a sign of more favorable biology and an argument for intensified local treatment. However, the optimal duration of such "selective" chemotherapy has not yet been definitively established. [68]

The second major area is the combination of radiotherapy with new targeted agents. ASTRO specifically highlights rapidly developing agents that target RAS signaling, as KRAS alterations are a key molecular feature of most pancreatic ductal adenocarcinomas. If systemic treatment becomes significantly more effective, targeting individual foci may become even more important. [69]

Finally, a direct comparison of different dosing strategies is needed: classical chemoradiotherapy, moderate hypofractionation, and five-fraction ablative SBRT. Currently, the new guidelines allow for multiple strategies rather than declaring one technology the universal winner. [70]

The main changes of ASTRO-2026 in one table

Clinical situation	The role of radiation therapy
Resectable cancer	Preoperative chemoradiation therapy - conditionally
Borderline resectable	Preoperative RT/CRT is recommended
After surgery	Selectively, after systemic therapy; new data especially for pN0
Locally common	RT/CRT after multicomponent chemotherapy
Inoperable due to health reasons	RT/CRT may be the definitive local treatment
Dose escalation	Recommended for consideration in modern visualization and motion management
SBRT	Short, high-precision treatment, including dose-escalating regimens
Adaptive RT	Recommended for dose-escalated SBRT
Local recurrence without previous RT	Radical irradiation is possible
Relapse after previous RT	Reirradiation is conditionally possible
Oligometastases	Local RT of all/part of the foci is conditionally possible
Oligoprogression	RT can destroy individual resistant foci
Pain	Palliative RT is recommended
Bleeding/obstruction	Palliative RT is recommended
Basic philosophy	Systemic therapy + individually selected local treatment

Results

The new ASTRO guidelines represent a significant shift in attitudes toward radiation therapy in pancreatic cancer. It is no longer viewed merely as an adjunct treatment for a few narrow clinical situations. Preoperative irradiation, definitive local treatment of locally advanced tumors, dose escalation, re-irradiation, and treatment of selected metastases are now integrated into a single, modern strategy. [71]

The firmest position remains for borderline resectable and locally advanced disease, where local control has obvious clinical significance. For routinely resectable disease, recommendations remain conditional, as current studies have not established that the addition of radiotherapy is necessary for every patient. [72]

Technologically, the most significant change is ASTRO's ability to support ablative dose escalation, up to approximately 50 Gy in five fractions under appropriate conditions. However, high dose delivery is inseparable from high-precision imaging, respiratory control, and plan adaptation: otherwise, attempts to improve local control could increase damage to the adjacent gastrointestinal tract. [73]

The most conceptually new area is oligometastatic cancer. The small, randomized EXTEND trial demonstrated a statistically significant improvement in progression-free survival with the addition of metastasis-directed local therapy to systemic treatment, and ASTRO now allows this approach in carefully selected patients. However, this is still the beginning of a new strategy, not proof that local radiation can replace systemic treatment in metastatic pancreatic cancer. [74]

As a result, the central conclusion of the guidelines can be formulated as follows: modern radiotherapy is becoming a tool for biologically selected local control—before surgery, after chemotherapy, during relapse, and sometimes even with limited metastases. But its effectiveness is determined not only by the amount of Gray, but by the correct patient selection, treatment timing, and technological precision. [75]

News source

Chuong MD, Jethwa KR, Ludmir E., et al. Radiation Therapy for Pancreatic Cancer: An ASTRO Clinical Practice Guideline. Practical Radiation Oncology. Published online August 11, 2026. This publication is a clinical practice guideline of the American Society for Radiation Oncology and updates the 2019 recommendations.

The guideline covers resectable, borderline resectable, locally advanced, recurrent, oligometastatic, and symptomatic pancreatic cancer, dose and fractionation, SBRT, adaptive radiotherapy, re-irradiation, target formation, and integration with systemic therapy and surgery.

DOI: 10.1016/j.prro.2026.07.002.