The short answer
Pancreatic ductal adenocarcinoma is sorted by whether surgery can remove it. Two chemotherapy backbones dominate, germline testing is recommended for everyone, and supportive care matters early.
PDAC is grouped as resectable, borderline resectable, locally advanced, or metastatic, and that grouping drives everything else.
Categories can change; chemotherapy sometimes shrinks borderline or locally advanced tumors enough for surgery to become possible.
The two main chemotherapy backbones are FOLFIRINOX (often modified) and gemcitabine with nab-paclitaxel.
Germline genetic testing is recommended for everyone with pancreatic adenocarcinoma regardless of family history; around one in ten carries an inherited variant.
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The full explanation.
What PDAC is
Pancreatic ductal adenocarcinoma is the most common pancreatic cancer. It starts in the cells lining the ducts. Those ducts carry digestive enzymes. It often causes few symptoms early. Many people are diagnosed only after other signs bring them in. Those include jaundice, back or abdominal pain, weight loss with no clear cause, or new diabetes.
This is a serious diagnosis. There is no useful way to soften that. But your own specifics matter more than the general statistics. Several things are worth doing early. They are easy to miss.
The four categories
Stage number matters less here than one question. Can surgery remove it? NCI describes four groups.
Resectable means the tumor "has not grown into major blood vessels near the tumor" and can be removed surgically.
Borderline resectable means it "has grown into a major blood vessel or nearby tissue or organs." Surgery might not remove it all.
Locally advanced means it "has grown into or close to nearby lymph nodes or blood vessels, so surgery cannot completely remove the cancer."
Metastatic means it has spread to other organs.
A pancreatic-protocol CT scan sets the category. Ideally a tumor board reviews it. That board should include a surgeon who does many pancreatic operations. Categories can change. Chemotherapy sometimes shrinks a borderline or locally advanced tumor. Surgery can then become possible.
Surgery
The Whipple procedure (pancreaticoduodenectomy) removes the head of the pancreas. It also takes the gallbladder and the bile duct. It takes part of the stomach and part of the small intestine. Distal pancreatectomy removes the body and tail. Total pancreatectomy removes the whole gland. These are major operations. Results are better at hospitals that do many of them. Ask how many this hospital does.
Two chemotherapy backbones
Two multi-drug regimens dominate. FOLFIRINOX combines fluorouracil, leucovorin, irinotecan, and oxaliplatin. A modified version (mFOLFIRINOX) is often used. The other is gemcitabine with nab-paclitaxel.
FOLFIRINOX is the harder of the two on the body. It is usually offered to people in good physical shape. Gemcitabine with nab-paclitaxel is often the better fit otherwise. Both are used before surgery, after surgery, and in advanced disease. The order differs. A regimen with liposomal irinotecan is another approved option.
Testing that is easy to miss
Guidelines recommend germline genetic testing for everyone with pancreatic adenocarcinoma. That holds even with no family history. About one in ten people carry an inherited variant. It is usually in BRCA1, BRCA2, PALB2, ATM, or a Lynch syndrome gene. This matters twice. Olaparib is approved as maintenance therapy for germline BRCA-mutated metastatic pancreatic cancer after platinum chemotherapy. And the result guides screening for your relatives.
Somatic (tumor) testing looks at the cancer itself. It can find mismatch repair deficiency or microsatellite instability. It can also find NTRK or RET fusions, KRAS G12C, and other changes. These open up specific drugs or trials. Tumor tissue is sometimes limited. Then ask whether a blood test would work.
Palliative care, from the start
NCI notes that palliative care "may be provided at any point during cancer care, from diagnosis to the end of life." Starting it early alongside cancer treatment "can improve their quality of life and mood, and may even prolong survival." ASCO recommends palliative care for everyone with advanced cancer.
Several problems here are very treatable. Poor fat absorption causes greasy, floating, urgent stools. It also causes weight loss. Pancreatic enzyme replacement therapy treats that directly. Many people are never offered it. A biliary stent opens a blocked bile duct. A celiac plexus block can ease pain that runs into the back. New or worsening diabetes needs its own plan. Ask for a dietitian early.
Worth asking
Ask which of the four groups you are in. Ask who decided. Ask whether germline and tumor testing are ordered. Ask about enzyme replacement. Ask for a palliative care referral now, not later.
When to get help sooner
- Call 911 or go to an emergency department if you get shaking chills with pain high in the belly, and your eyes or skin look yellow. An infected or blocked bile duct can turn serious within hours. This is a known risk after a biliary stent.
- Call your oncology team without delay, whatever the hour, if your temperature reaches 100.4°F (38°C) or higher while you are having chemotherapy. CDC treats fever during cancer treatment as an emergency, because chemotherapy can leave you with too few white cells to contain an infection. If you cannot reach them soon, go to an emergency department and say at the door that you are on chemotherapy.
- Call your care team the same day if yellowing comes back, your urine turns dark, or your stools go pale.
- Call your care team within a day or two if you cannot keep fluids down, your stools stay greasy and hard to flush, or the weight keeps falling off. Enzyme doses, sugar levels and pain plans can all be adjusted.
Sources
Words to know
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Common questions
What decides whether I can have surgery?
A pancreatic-protocol CT scan showing how the tumor relates to nearby major blood vessels, ideally reviewed by a multidisciplinary tumor board including a high-volume pancreatic surgeon. NCI describes four categories based on this: resectable, borderline resectable, locally advanced, and metastatic.
Why would chemotherapy come before surgery?
For borderline resectable and some locally advanced tumors, chemotherapy given first can shrink the tumor away from blood vessels, making complete removal possible, and it also reveals how the disease behaves before a major operation is undertaken.
Why is genetic testing recommended if no one in my family had this?
Around one in ten people with pancreatic adenocarcinoma carries an inherited variant, most often in BRCA1, BRCA2, PALB2, ATM, or a Lynch syndrome gene, and many have no suggestive family history. The result can open specific treatment options and has direct implications for relatives' screening.
Why are my stools greasy and why am I losing weight despite eating?
Pancreatic cancer often reduces the digestive enzymes reaching your intestine, so fat is not absorbed. Pancreatic enzyme replacement therapy addresses this directly. It is very treatable and commonly overlooked, so it is worth raising specifically.
Does palliative care mean giving up?
No. NCI notes palliative care may be provided at any point from diagnosis onward, and that starting it early alongside cancer treatment can improve quality of life and mood and may even prolong survival. ASCO recommends it for everyone with advanced cancer.
Questions to ask your doctor
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Written by: Cancer ExplainedSources last checked: 2026-08-13 what this meansLast updated: 2026-08-18Next planned review: 2027-01-30
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How this page was created
Cancer Explained does not originate medical claims. Every page restates guidance already published by the National Cancer Institute, the CDC, the USPSTF and the FDA, in plain language, with the source cited so you can check the original yourself. AI does the translating and organizing; automated checks test claims, citations, clarity and safety before anything publishes. We do not employ clinicians and do not intend to — our work is translation and navigation, not clinical judgment. Nothing here is personal medical advice, and no page can account for your particular situation.
Editorial status: Source checked — This page was written with AI assistance and checked line by line against the sources listed on it. That confirms the sources support what the page says. It is not a medical review, and it does not confirm the page is complete or right for your situation.
Human medical review: not completed. Pages here are not signed off by a clinician before they publish. That is not an oversight we are quietly working around: we restate published guidance and cite it, so the authority belongs to the source rather than to us, and every page names where its claims come from — you can verify us instead of trusting us. Where a volunteer clinician has reviewed a page, their name and credentials appear on it; where no name appears, no clinician has checked it. We are glad to have reviewers and are recruiting them, and we do not hold pages back waiting for one. Use this site to understand your situation and to ask better questions of the people treating you.
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