Pancreatic Cancer

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Treating Pancreatic Cancer TOPICS

Treating pancreatic cancer by stage

It is hard to stage pancreatic cancer accurately using imaging tests. Doctors must do their best to decide before surgery whether there is a good chance the cancer can be completely removed. Surgeons usually consider an exocrine pancreatic cancer resectable (completely removable by surgery) if it is staged as T1, T2, or T3. That means it doesn't extend far beyond the pancreas, especially into nearby large blood vessels (T4). There is no accurate way to assess the tumor’s spread to the lymph nodes before surgery.

Exocrine pancreatic cancer

Resectable: If imaging tests show a reasonable chance of completely removing the cancer, surgery should be done if possible, as it is the only chance to cure this disease. Based on where the cancer started, usually either a Whipple procedure (pancreaticoduodenectomy) or a distal pancreatectomy is used.

Unfortunately, even when surgery has removed all of the tumor that can be seen, the cancer often comes back. Studies have shown that giving chemotherapy (chemo) after surgery can delay the cancer's return by about 6 months. It might also help some patients live longer. Either gemcitabine (Gemzar) or 5-FU can be used for this. It is not yet clear if adding radiation to chemo would result in more of a benefit.

Some patients are given chemo, either alone or with radiation therapy (chemoradiation), before surgery. Some centers prefer giving chemo before surgery because the recovery after surgery is often long, which can delay or even prevent its use. But it is not yet clear that this approach is better than giving the treatment after surgery.

Locally advanced: Locally advanced cancers of the pancreas are those in which the tumor in the pancreas has grown into nearby blood vessels and other tissues, but has not spread to the liver or distant organs and tissues. These tumors have grown too far to be completely removed by surgery. Several studies have shown that removing part of the cancer does not help patients live longer. Therefore, surgery in these cancers is used mainly to relieve bile duct blockage or to bypass a blocked intestine caused by the cancer pressing on other organs.

The standard treatment options for locally advanced cancers are chemo and/or chemoradiation. Sometimes, this treatment will shrink the cancer enough to allow it to be removed completely with surgery. This treatment may help some patients live longer even if the cancer doesn't shrink enough to be able to be removed. When radiation is given, the chemo drug can be either gemcitabine or 5-FU.Giving chemo and radiation together may work better to shrink the cancer, but this combination has more side effects and can be harder to take than either treatment alone.

Metastatic (widespread): Pancreatic cancers often first spread within the abdomen (belly) and to the liver. They can also spread to the lungs, bone, and brain.

These cancers have spread too much to be removed by surgery or treated by radiation therapy alone. Even when imaging tests show that the spread is only to one area of the body, it has to be assumed that small groups of cancer cells (too small to be seen on imaging tests) are already present in other organs of the body.

One standard treatment for advanced pancreatic cancer is chemotherapy with gemcitabine. It can shrink the cancer and help patients live longer. People who get this treatment also seem to have fewer symptoms related to their cancer. Combining gemcitabine with albumin-bound paclitaxel (Abraxane, nab-paclitaxel) may help even more.

Adding other drugs to gemcitabine may also improve the chance the tumors will shrink and may help people live longer. So far, only erlotinib (Tarceva) and capecitabine (Xeloda) have been shown to help some patients live longer when given along with gemcitabine. Overall, the benefit of giving erlotinib along with gemcitabine was very small (patients lived about 2 weeks longer). Erlotinib doesn't seem to help all patients, so experts are trying to find a way to figure out who should get the drug and who should try something else. Capecitabine also only seemed to help some of the people who received it with gemcitabine. Most doctors give chemo with gemcitabine for pancreatic cancer, and consider adding another drug on a case-by-case basis.

Another option that may help patients live longer is a combination of chemo drugs called FOLFIRINOX. This consists of 4 drugs: 5-FU, leucovorin, irinotecan, and oxaliplatin. In one study, this treatment helped patients live longer than gemcitabine, but had more severe side effects, so it’s not for everyone. Also, there is a nationwide shortage of leucovorin, which can sometimes limit the ability of doctors to give FOLFIRINOX.

Because the treatments now available don't work well for most patients, people may want to think about taking part in a clinical trial of chemo combinations (with or without radiation therapy) and new targeted therapies.

Recurrent cancer: Cancer is called recurrent when it come backs after treatment. Recurrence can be local (in or near the same place it started) or distant. Distant recurrence of pancreatic cancer most often occurs first in the liver, but it may also spread to the lungs, bone, or other organs. When pancreatic exocrine cancer recurs, it is essentially treated the same way as metastatic cancer, and is likely to include chemo if the patient can tolerate it.

Cancer of the ampulla of Vater

The ampulla of Vater is the area where the pancreatic duct and the common bile duct empty into the duodenum (the first part of the small intestine). Cancer at this site can start in the pancreatic duct, the duodenum, or the common bile duct. Surgery with the Whipple procedure is often successful as cancer treatment with a 5-year survival rate of 30% to 50%. More advanced ampullary cancers are treated like pancreatic cancer. In many patients, ampullary cancer cannot be distinguished from pancreatic cancer until surgery has been done. Post-operative chemoradiotherapy is often recommended for patients who have had a successful resection of ampullary carcinoma.

Pancreatic neuroendocrine tumors (PNETs)

Resectable: If the tumor is resectable, it will be removed by surgery. The procedure used depends on the type of tumor, its size, and its location in the pancreas. Laparoscopy may be done before resection to better locate and stage the tumor. Surgery can range from as little as enucleation to as much as a Whipple procedure (pancreatoduodenectomy). Lymph nodes are often removed to check for tumor spread.

Before any surgery, medicines are often given to control the symptoms caused by the tumor. Drugs to block stomach acid (like proton pump inhibitors) are used for gastrinomas. Often, people with insulinomas are treated with diazoxide to keep the blood sugar from getting too low. If the tumor was visible on somatostatin receptor scintiography, octreotide (Somatostatin) may be used to control any symptoms.

After surgery, the patient will be watched closely for signs that the cancer may have come back or spread.

Unresectable: PNETs are generally slow growing so lab tests and imaging are used to monitor the patient and look for signs of tumor growth. Many patients with cancers that have spread outside the pancreas benefit from treating symptoms like diarrhea or hormone problems with drugs like octreotide, diazoxide, and proton pump inhibitors. Often, chemo or targeted therapy is delayed until the patient is having symptoms that can’t be controlled with other drugs or has signs of tumor growth on scans. When treatment is started, either sunitinib (Sutent) or everolimus (Afinitor) may be used. Surgery or ablative techniques may also be used to treat metastases in the liver.

Last Medical Review: 01/28/2013
Last Revised: 02/05/2014