@hubby11 , Sorry to hear; that is indeed a scary diagnosis, but there are reasons to be hopeful.

It does indeed sound like surgery is not an option, at least not yet. Everyone is different, so the answer to a lot of questions will be, "It depends..." If she's otherwise fit and healthy, she might respond very well to aggressive chemo or a clinical trial. I've been stage 4 for a year and dealing pretty well with biweekly chemo. Others here have done so even longer.

But first things first: Make sure you've got a serious pancreatic cancer specialist onboard; ideally at a "center of excellence" in pancreatic cancer. (Think Mayo, MD Anderson, Memorial Sloan Kettering, Johns Hopkins, etc. if possible) but somewhere in that class that you might be able to travel to or relocate to for a while. Make sure you get CD/DVD copies (one for you, one to ship) of every scan she gets. Get login accounts for every electronic medical record and patient portal system at every institution you visit. (Some, like the MyChart system, can link and share records between institutions.) Keep paper copies of medical records, reports, and test results that you can forward immediately in case the electronic methods fail. Take pre-written lists of questions to every appointment so you don't forget the important ones. Take copious notes while there.

Consults can take a while to get, so start early. Ask if you can get the basic genetic tests done first. A germline test like Invitae can inform you if she has any inherited mutations that might be targetable by a specialized treatment. A somatic test like Guardant 360 can identify any mutations that just happened by chance, environmental cause, etc. These can also help guide specialized treatments. Both are blood tests you could do now w/o waiting for surgery or biopsy. Although the biopsy is close on the calendar, if there is any delay, you could have results from these tests in your back pocket already.

What kind of biopsy are they going to do? If it's via endoscopic ultrasound (EUS+ERCP), they typically take a very small (FNA - Fine Needle Aspiration) tissue sample from the pancreas or ducts. They can analyze it under a microscope during the surgery to make a quick determination of malignancy or not, which they usually send to another pathology lab after surgery for review.

But the tissue is not always large enough or preserved well enough to share, and sometimes when it is, they still don't send it out for further analysis, but you should ask if they can -- again so you have more data and get it sooner rather than later. Tempus Labs does various genetic tests on tumor tissue to determine if other targetable mutations or properties are present.

If she is not currently jaundiced, it suggests the bile ducts are not blocked, but they could be blocked later depending on the tumor location and growth rate. That might guide the endoscopic surgeon to implant a stent to keep the ducts open. Some stents for the common bile duct are made of plastic and some are made of metal, which last longer.

If she is a candidate for future surgery (e.g., Whipple if tumor is only in the head of the pancreas), they might be able to remove the stent at that time. If she is not a candidate for cancer surgery, she might need to have the stent replaced periodically, so a longer-lasting stent is desirable from the perspective of fewer replacements. Something to ask about up front...

If they do a core needle biopsy (percutaneous) or a laparoscopic procedure, they might be able to get more tissue, but you should still asked them to perform the most detailed "NGS" (Next-Generation Sequencing genetic) tests they can do.

There are 4 or 5 types of pancreatic cancer, so it is important for them to determine which kind.

It might be beneficial if they can also do a PET scan or make the upcoming scan a combined PET/CT to help identify any other spread -- again, sooner rather than later.

Having all the data you can get helps make the best decisions first. Despite all the amazing science and technology available, it's really tough getting access to it, but your first chance (before any treatment has begun) is your best chance.

Unfortunately, some of the promising clinical trials (vaccines, etc) only accept patients who have had no treatment yet. Your Catch-22 is finding one soon enough that you don't risk excessive cancer spread while waiting.

It is possible for a biopsy to miss cancerous cells (another story for later), but based on what you've shared so far, a common outcome is adenocarcinoma and recommendations to get a chemo port and immediately begin one of two "SoC" (Standard of Care) systemic (infused chemo) treatment.

The choice of chemo, if they go that route, is usually between a regimen based on Folfirinox (for younger, fitter patients) and a regimen based on Gemcitabine (possibly including Abraxane and/or Cisplatin) for others. But there's no guarantee one will work better than the other in a given patient. The tests mentioned above may help docs zero in on one or the other using more data than just patient age and fitness.

The systemic therapy options are topics with details best saved for another post, but in summary, pancreas specialists at a center of excellence working from all obtainable data can give you your best options up front.

I'll try to add more later. Hit us all up with questions -- everyone here wants to help and has different experiences to share.

Wishing you and your wife the best!