How Pancreatic Cancer Is Treated

Treatments for pancreatic cancer may include surgery, chemotherapy, targeted therapy, and clinical trials focused on newer treatments, such as immunotherapy. Due to limited options that extend life to a significant degree when surgery is not possible, the National Cancer Institute recommends considering a clinical trial.

Treatment options currently available can be classified as:

  • Curative: These treatments are done with the hope of achieving long-term survival with the disease.
  • Palliative: These treatments that may not extend survival, but improve quality of life for those living with the disease.

Treatments that address cancer itself can be further categorized as:

  • Local treatments: These are treatments that treat cancer where it originated, and include surgery and radiation therapy.
  • Systemic treatments: These treatments are designed to address cancer cells anywhere in the body (including metastases) and include chemotherapy and some of the newer medications available in clinical trials.

Here, an overview of the options currently available for treatment of both early and advanced pancreatic cancers.

Surgery

Surgery is the only treatment option that offers the chance to "cure" cancer, or at least increase the chance for long-term survival. That said, only around 15 percent to 20 percent of people with pancreatic cancer are candidates for surgery.

Unfortunately, it can be difficult, even with the imaging tests we have available, to know whether cancer has spread to the point where surgery is inadvisable before the surgery itself is done. (Treating pancreatic cancers that have spread, including stage 3 and stage 4 tumors, does not increase survival but does significantly lessen the quality of life.) During surgery, doctors discover that cancer has spread too far for the procedure to be considered a good option roughly 20 percent of the time.

Some physicians recommend doing a laparoscopic biopsy (a test in which several small incisions are placed in the abdomen and a probe is placed in order to remove a small piece of the pancreas and explore the surrounding area) before surgery is considered. Doing so may reduce the chance of unnecessary surgery and the subsequent pain and complications of it.

Challenges and Considerations

The pancreas lies just behind the stomach and is next to several vital structures. Directly behind the pancreas is a collection of major blood vessels. If a tumor is described as "locally advanced," it means that the tumor may be enveloping these major blood vessels, making the removal of all the tumor without damaging the vessels a near-impossibility. When this happens, a person may or may not be a candidate for surgery. Certain high-volume centers are potentially able to remove and reconstruct blood vessels to varying degrees, however, so some cancers that were previously thought to be inoperable are now potentially operable. 

Understanding the anatomy is also helpful for those who learn they have borderline resectable disease. This includes people who have cancer that envelopes 50 percent or less of a blood vessel. There is no standard treatment for this situation, but some physicians believe that giving chemotherapy (with or without radiation therapy) to shrink the tumor might do so enough that it can be removed surgically.

Procedures

If you are considered a candidate for surgery, the following options may be performed:

  • Whipple Procedure (Pancreaticoduodenectomy): The Whipple procedure is the most common procedure done for pancreatic cancer and is an option for people who have cancer of the head of the pancreas and an early stage case. In this surgery, the gallbladder, common bile duct, a large part of the pancreas (including the head), part of the duodenum, part of the stomach, the spleen, and nearby lymph nodes are removed. Part of the body and the tail of the pancreas are left behind in order to preserve its function (the production of digestive enzymes and hormones).
  • Whipple Procedure Variations: There are several variations on the classic Whipple procedure that preserve more of the stomach and first part of the small intestine, most commonly known as pylorus-preserving pancreaticoduodenectomy. These procedures are done to help minimize certain postoperative complications. 
  • Distal Pancreatectomy: Cancers in the body or tail of the pancreas are seldom operable, but when they are, the tail of the pancreas may be removed with or without the spleen.
  • Total Pancreatectomy: Total pancreatectomy is essentially the same as a Whipple procedure, but differs in that the entire pancreas is removed. This is done when it's necessary to remove all the visible tumor.

Side Effects and Complications

All of the surgical options for pancreatic cancer are very major surgeries, and complications or death are not uncommon. Common risks include the risks associated with general anesthesia, bleeding, infections, and the development of blood clots after surgery. The risk of blood clots is very high in people with pancreatic cancer, and surgery adds to this risk. Using compression devices on the legs during and after surgery, as well as blood thinners can reduce this to some degree.

The most common long-term complication of surgery is a recurrence of cancer, and this is, unfortunately, far too common. The chance that pancreatic cancer will recur after surgery depends on many factors, and only your surgeon will be able to estimate what this may mean for you. 

Each procedure can also result in other issues. For example, in pylorus-preserving pancreaticoduodenectomy, removal of part of the stomach and the first part of the small intestine can result in dumping syndrome, a condition that can cause significant diarrhea shortly after eating. It can also increase the chance of bile reflux, a condition where the bile goes the wrong direction and enters the stomach resulting in inflammation and discomfort.

When total pancreatectomy is performed, all pancreatic function is, of course, completely lost. There is no production of insulin, glucagon, or digestive enzymes. Diabetes is inevitable and insulin therapy and enzyme replacement are necessary following surgery.

Whether you will need supplemental enzymes or hormones after part of the pancreas is removed depends on several factors, including the amount of damage to the pancreas from the tumor prior to surgery. Fortunately, people do not need their entire pancreas to make an adequate amount of insulin, and living a normal life is possible after surgery.

Palliative Surgery

Surgery may also be done for people with pancreatic cancer to reduce symptoms but not cure the disease. It's very common for the common bile duct to be blocked by these tumors. When this occurs, a stent may be placed (via endoscopy) or surgery to bypass the duct may be done.

Choosing a Hospital

If you are a candidate for surgery, it is extremely important that you seek care at a hospital that does a large volume of these surgeries. That means choosing a facility that performs more than 15 pancreatic cancer surgeries each year and can report a lower risk of death and a shorter hospital stay.

Chemotherapy

Chemotherapy may be used in a few ways for people with pancreatic cancer.

Neoadjuvant chemotherapy: Neoadjuvant chemotherapy refers to the use of chemotherapy before surgery in order to shrink a tumor so that surgery is possible (as discussed above).

Adjuvant chemotherapy: Adjuvant chemotherapy refers to chemotherapy that is used in addition to surgery. Pancreatic cancers commonly recur following surgery, meaning that cancer cells are often left behind (but may be too small to be seen on imaging tests). When chemotherapy is used after surgery, it's thought to improve survival by three to four months.

Palliative chemotherapy: Most of the time when chemotherapy is considered for pancreatic cancer, it is given with the hopes that it will extend life, but not cure cancer. Overall, chemotherapy results in small, but significant improvements in length of survival. 

Drugs most commonly used include:

  • Abraxane (albumin-bound paclitaxel)
  • Gemzar (gemcitabine)
  • 5-FU (fluorouracil)
  • Onivyac (irinotecan liposome injection)

These drugs are usually given in combination and may be given along with targeted therapy, immunotherapy, or sometimes, radiation therapy. The drugs are given intravenously at certain intervals (such as once a week for three weeks, followed by one week off) for a number of cycles.

A three-drug combination, Folfirinex (5-FU/leucovorin, irinotecan, and oxaliplatin) appears to work quite well, but is more toxic than other options and is used primarily for people in good general health (those who have a good performance status). A 2018 review of studies looking at various combinations of drugs found that Folfirinex had the greatest effect on lengthening survival.

Side Effects of Chemotherapy

The side effects of chemotherapy can be significant and include hair loss; nausea and vomiting (though treatments to reduce these symptoms have improved tremendously in recent years); bone marrow suppression resulting in lowered counts of white bloods, red blood cells (anemia), and platelets, and more.

Targeted Therapy

Targeted therapies are drugs that target specific pathways in the growth of cancer cells. Since these treatments are aimed specifically at cancer cells they often (but not always) have fewer side effects than chemotherapy.

An oral drug that is sometimes used for people with pancreatic cancer, Tarceva (erlotinib) works by blocking a path in the growth of the cancer cells. Rather than killing the cancer cells, it essentially starves them and stops their replication. Tarceva is usually used along with Gemzar. The most common side effects of Tarceva include an acne-like rash and diarrhea.

Clinical Trials

There are a number of clinical trials in progress for pancreatic cancer testing various combinations of the above treatments, as well as newer treatments such as immunotherapy. While some of the treatments are just beginning to be studied with pancreatic cancer, they have sometimes led to dramatic control of advanced cancers, such as lung cancer, and bring hope that better treatments for pancreatic cancer will be available in the future.

Complementary Medicine (CAM)

At the current time, there are no alternative treatments that show any effectiveness in treating pancreatic cancer. Some alternative treatments, however, may help people cope with the symptoms caused by cancer and cancer treatments, and many of the larger cancer centers now offer integrative options. Examples include acupuncture, meditation, massage therapy, and yoga.

Supplements

Many people seek out dietary and herbal supplements when they learn about the prognosis of pancreatic cancer. It's important to note that some vitamin and nutritional supplements may decrease the effectiveness of cancer treatments

Research in the lab has looked at a few remedies used in Ayurveda, such as triphala, and nigella sativa (black caraway). While there have been promising findings showing an inhibition of the growth of human pancreatic cells grown in a test tube, we don't know if these compounds would have any effect on humans themselves. In addition, these supplements are largely unregulated in the United States and could possibly interfere with other treatments. This is a good reminder, however, to talk to your oncologist about any vitamins, minerals, or dietary supplements you are/are thinking about taking.

Interestingly, research looking at cancer cachexia (the syndrome of weight loss, loss of appetite, and loss of muscle mass that affects the majority of people with pancreatic cancer) has found that omega-3 fatty acids may be helpful—important, as there is very little that truly makes a difference in this syndrome. Since cachexia is thought to be the direct cause of death in 20 percent of people with cancer, this is worth talking to your oncologist about. There are many sources of dietary omega-3s, and most of the time oncologists recommend getting nutrients through diet rather than supplements. 

Palliative Care

Palliative care is not the same as hospice, and can actually be used even for people with highly curable tumors. It focuses on the health and wellbeing of a person living with cancer, rather than the treatment of cancer itself. Palliative care is actually the mainstay of treatment for the majority of people who are diagnosed with pancreatic cancer. This may include surgery or chemotherapy, as noted above, but also other options.

Examples include optimal pain management; control of other physical symptoms, such as digestive issues; nutritional support; and emotional support for stress, anxiety, and depression. Palliative care can also be helpful in addressing spiritual concerns, caregiver needs and communication, and practical issues ranging from insurance to financial and legal support.

Many cancer centers now offer consults with a palliative care team to make sure symptoms are addressed as well as possible. 

Home Remedies and Lifestyle

Since the quality of life with pancreatic cancer is of utmost importance, measures that improve it are paramount. Eating a healthy diet may not make a difference with your cancer, but most people feel better when they eat a diet rich in fruits and vegetables. Exercise is helpful and, perhaps counterintuitively, may help reduce cancer cachexia.

Some people wonder if it is worth it to quit smoking after being diagnosed, especially with advanced pancreatic cancer. The answer is yes. There are several strong reasons why quitting after a diagnosis of cancer can be very helpful. 

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