ASTRO 2026 Expands the Role of Radiation Therapy in Pancreatic Cancer: ASTRO | September 2026

Introduction:

The role of radiation therapy (RT) in pancreatic cancer has remained controversial, particularly as systemic therapy has improved. The updated ASTRO guideline incorporates newer trials and advances in SBRT, dose escalation, image guidance, and adaptive RT across resectable, borderline resectable, locally advanced, recurrent, and metastatic disease.

Why was this guideline needed?

Several important trials have emerged since the 2019 ASTRO guideline.

Modern RT can deliver higher doses while better protecting adjacent GI organs.

The optimal integration of RT with chemotherapy and surgery remains uncertain.

RT is increasingly being explored beyond localized disease.

Key Takeaways:

Multidisciplinary decision-making is recommended for all patients.

In resectable disease, preoperative and selected postoperative chemoradiation are conditionally recommended.

For borderline resectable disease, preoperative chemoradiation or RT is recommended.

In locally advanced pancreatic cancer, RT/chemoradiation after multiagent chemotherapy is recommended primarily to improve local control.

Modern options include conventional fractionation, moderate hypofractionation, and SBRT, depending on disease setting.

Dose escalation is increasingly supported for selected patients when adequate image guidance and motion management are available.

Adaptive RT is recommended for dose-escalated SBRT to protect adjacent stomach, duodenum, and bowel.

IMRT/VMAT is preferred over conventional 3-D conformal RT.

Elective coverage of high-risk perineural and regional nodal pathways is recommended in nonmetastatic disease.

RT is recommended for isolated locoregional recurrence without previous radiation; reirradiation can be considered selectively.

RT may be considered for selected oligometastatic or oligoprogressive disease.

Palliative RT remains important for pain, bleeding, and obstruction.

What’s New?

Compared with 2019, ASTRO moves toward a broader, technically sophisticated role for RT—particularly dose-escalated and adaptive radiation, while extending consideration to recurrence, reirradiation, and selected oligometastatic disease.

Bottom Line:

Radiation is becoming a more integrated component of multidisciplinary pancreatic cancer care. Modern image-guided, dose-escalated and adaptive techniques are expanding its role, but patient selection and sequencing with systemic therapy remain critical.