Novel radiotherapy modalities

The delivery and role of radiation therapy have evolved over the past decade. Historically, patients with pancreatic cancer have received standard chemotherapy and radiation for all stages of disease. This was delivered over 5–6 weeks and given concurrently with 5-fluorouracil or gemcitabine. While this approach has been effective at improving local control and pain, adjacent dose-limiting structures such as the stomach and bowel precluded achieving doses higher than 50 Gy. In addition, a large proportion of patients would develop acute and late toxicities that would sometimes prevent or limit subsequent systemic therapy. New radiation technologies now allow for the delivery of high doses of radiation that can result in durable local control and possibly achieve tumor sterilization. These advances include intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT), and heavy ion (proton) therapy. Now radiation therapy can be delivered much more precisely over 1–3 weeks and more easily combined with novel systemic therapies, targeted therapies, and immunotherapy. In addition, next-generation sequencing and imaging biomarkers can be used to better identify which patient is more or less likely to benefit from radiation therapy.