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There are 2 general types of surgery used for pancreatic cancer:
Potentially curative surgery is used when imaging tests suggest that it is possible to remove all the cancer.
Palliative surgery may be done if imaging tests show that the tumor is too widespread to be completely removed. This is done to relieve symptoms or to prevent certain complications like a blocked bile duct or intestinal tract.
Several studies have shown that removing only part of the cancer does not help patients live longer. Pancreatic cancer surgery is one of the most difficult operations a surgeon can do. It is also one of hardest for patients. There may be complications and it may take several weeks for patients to recover. Patients need to weigh the potential benefits and risks of such surgery carefully.
Potentially curative surgery
Most curative surgery is designed to treat cancers at the head of the pancreas. Because these cancers are near the bile duct, some of them cause jaundice and are found early enough to be removed. Surgeries for other parts of the pancreas are mentioned below, but these are only done when it’s possible to remove all of the cancer.
Three procedures are used to remove tumors of the pancreas:
Pancreaticoduodenectomy (Whipple procedure): This is the most common operation to remove a cancer of the exocrine pancreas and it is also sometimes used to treat cancers of the endocrine pancreas. It removes the head of the pancreas and sometimes the body of the pancreas as well. Part of the stomach, small intestine, and lymph nodes near the pancreas are also removed. The gallbladder and part of the common bile duct are removed and the remaining bile duct is attached to the small intestine so that bile from the liver can continue to enter the small intestine.
This is a complex operation that requires much skill and experience. It carries a relatively high risk of complications that may even be fatal. When the operation is done in small hospitals or by doctors with less experience, more than 15% of patients may die as a result of surgical complications. In contrast, when this operation is performed in cancer centers by surgeons experienced in the procedure, less than 5% of patients die as a direct result of complications from surgery. Still, even in the best of hands, many patients suffer complications from the surgery. These can include:
Leaking from the various connections that the surgeon has to make
Infections
Bleeding
Trouble with the stomach emptying itself after eating
For patients to have the best outcomes, they should be treated by a surgeon who does many of these operations and have the operation at a hospital where many of them are done. In general, people having this type of surgery do better when it is performed at a hospital that does at least 20 Whipple procedures per year.
At the time of diagnosis, only about 10% of cancers of the pancreas appear to be contained entirely within the pancreas. Only about half of these turn out to be truly resectable once the surgery is started. Although surgery offers the only real chance to cure exocrine pancreatic cancer, it doesn’t always lead to a cure. Even if all visible tumor is removed, often some cancer cells have already spread to other parts of the body. These cells eventually grow into new tumors and cause many problems — even death. This is why the cancer comes back later in most patients who had surgery that appeared to completely remove a cancer of the exocrine pancreas.
Long-term success rates for pancreatic neuroendocrine tumors (PNETs) are often much better. These tumors are more likely to be cured with surgery.
The spleen helps the body fight infections, so having it removed means an increased risk of infection with certain bacteria. To help with this, doctors recommend that patients get certain vaccines before a Whipple procedure.
Distal pancreatectomy: This operation removes only the tail of the pancreas or the tail and a portion of the body of the pancreas. The spleen is usually removed as well. This operation is used more often to treat PNETs found in the tail and body of the pancreas. It is seldom used to treat cancers of the exocrine pancreas because these tumors have usually already spread by the time they are found.
Your doctor might recommend certain vaccines before this operation because the spleen will be removed.
Total pancreatectomy: This operation was once used for tumors in the body or head of the pancreas. It removes the entire pancreas and the spleen. It is now seldom used to treat exocrine cancers of the pancreas because there doesn't seem to be an advantage in removing the whole pancreas. It is possible to live without a pancreas. But when the entire pancreas is removed, people are left without any islet cells, the cells that make insulin. These people develop diabetes, which can be hard to manage because they are totally dependent on insulin shots and because the islet cells also make other hormones that help maintain blood sugar levels.
Palliative surgery
If the cancer has spread too far to be completely removed, any surgery being considered would be palliative (intended to relieve or prevent symptoms). Because pancreatic cancer can progress quickly, most doctors do not advise surgery for palliation. Sometimes surgery may begin with the hope it will cure the patient, but the surgeon discovers this is not possible. In this case, the surgeon may continue the operation as a palliative procedure to relieve or prevent symptoms.
Cancers growing in the head of the pancreas can block the common bile duct as it passes through this part of the pancreas. This can cause pain and digestive problems because bile can't get into the intestine. The bile chemicals will build up in the body. There are 2 options for relieving bile duct blockage.
Surgery can reroute the flow of bile from the common bile duct directly into the small intestine, bypassing the pancreas. This requires a large incision in the abdomen, and it may take weeks to completely recover. One advantage is that during this procedure, the surgeon may be able to cut the nerves leading to the pancreas or inject them with alcohol. This may reduce or get rid of any pain that may be caused by the cancer.
Sometimes, the stomach connection to the duodenum (the first part of the small intestine) is rerouted at this time as well. Often, late in the course of pancreatic cancer, the duodenum becomes blocked by cancer, which can cause pain and vomiting that requires surgery. Bypassing the duodenum before this happens can help avoid a second operation.
A second approach to relieving a blocked bile duct does not involve surgery. Instead, a stent (small tube) is placed in the duct to keep it open. This is usually done through an endoscope (a long, flexible tube) while the patient is sedated. The doctor passes the endoscope down the patient's throat and all the way into the small intestine. The doctor can then insert the stent into the bile duct through the endoscope. The stent, which is usually made of metal, helps keep the bile duct open and resists compression from the surrounding cancer. After several months, the stent may become clogged and may need to be cleared. Larger stents are also used to keep the duodenum (or other parts of the small intestine) open if it is in danger of being blocked.
In general, the use of endoscopically placed stents has replaced surgery to relieve bile duct obstruction. Stents can also be placed before surgery to relieve jaundice before the pancreas is removed.
Surgery to treat pancreatic neuroendocrine tumors and cancers
In addition to the procedures described above, some less extensive procedures may be used to remove PNETs. Often laparoscopy is done first to better locate the tumor and see how far it has spread.
Sometimes if the tumor is small, just the tumor itself is removed. This is called enucleation. This operation may be done using a laparoscope, so that only a few small incisions are needed. This operation may be all that is needed to treat an insulinoma, since this type of tumor is often benign.
Small gastrinomas (2 inches or less) may also be treated with enucleation, but sometimes the duodenum (the first part of the small intestine) is removed as well. Larger gastrinomas may require a pancreaticoduodenectomy or a distal pancreatectomy, depending on the location of the tumor.
The lymph nodes around the pancreas are also removed in some cases so that they can be checked for signs of cancer spread.
Surgery may be used to remove metastases if a PNET has spread. This can be used when it has spread to the liver (the most common site of spread) and the lungs. Removing metastases can improve symptoms and prolong life in patients with PNETs. In rare cases, liver transplantation might be used to treat PNETs that have spread to the liver.
Ablative techniques for pancreatic cancer
When a pancreatic neuroendocrine tumor has spread to other sites, the metastases can be removed by surgery and by other techniques as well. By treating metastases, symptoms can improve and the patient might live longer. These techniques are most often used to treat cancer that has spread to the liver. Sometimes these treatments are also used to treat areas of metastases from pancreatic exocrine cancer when there are only a few of them.
Radiofrequency ablation: In radiofrequency ablation (RFA), a probe (like a needle) is inserted into the tumor. Radiofrequency waves travel through the probe to heat and destroy the tumor.
Microwave thermotherapy: This procedure is similar to RFA, except microwaves are used to heat and destroy the abnormal tissue.
Cryosurgery: In cryosurgery, a probe is inserted into the tumor which freezes the tissue with liquid nitrogen or liquid carbon dioxide. The area being frozen is destroyed. This technique is also known as cryoablation.
Embolization: For an embolization procedure, a catheter is used to find the artery feeding the tumor. Usually the catheter is inserted into a blood vessel in the groin, and then threaded up to the small artery that feeds the tumor. Contrast dye may need to be injected into the catheter to find the right artery. Then a substance is injected into the blood vessel, cutting off the blood supply to the tumor. This kills the tumor.
When the substance injected is plain, tiny beads (called microspheres), the procedure is known as transarterial embolization or TAE. If radioactive beads are used, it is called radioembolization. This treatment delivers radiation to the tumor as well as cutting off the tumor’s blood supply. Sometimes chemotherapy drugs are injected into the artery feeding the tumor just before the beads are injected. This is called transarterial chemoembolization or TACE.
Radiation therapy for pancreatic cancer
Radiation therapy uses high-energy x-rays (or particles) to kill cancer cells. It can be helpful in treating exocrine pancreatic cancer. Pancreatic neuroendocrine tumors (PNETs) don’t respond well to radiation, so it is rarely used to treat these tumors. Radiation is sometimes used to treat PNETs that have spread to the bone and are causing pain.External beam radiation therapy is the type of radiation therapy most often used in treating cancers of the exocrine pancreas. This treatment focuses the radiation on the cancer from a machine outside the body. Having this type of radiation therapy is like having an x-ray, except that each treatment lasts longer, and the patient usually receives 5 treatments per week over a period of weeks or months.
Patients may receive preoperative (before surgery) or postoperative (after surgery) treatment. If surgery is planned, preoperative treatment is often preferred because postoperative treatment often has to be delayed for several weeks while the patient recovers from surgery. Treatment right after surgery can interfere with wound healing.
Radiation therapy combined with chemotherapy (called chemoradiation or chemoradiotherapy) may be used in patients whose exocrine pancreatic tumors are too widespread to be removed by surgery. It is also sometimes used after surgery, to help keep the cancer from coming back.
Some of the common side effects of radiation therapy include:
Mild skin changes (like a sunburn)
Nausea and vomiting
Diarrhea
Fatigue
Poor appetite
Weight loss
Radiation can also lower blood counts and can increase the risk of serious infection.
Usually these effects go away a few weeks after the treatment is complete. When radiation is given with chemotherapy the side effects are often worse. Ask your doctor what side effects to expect and how to prevent or relieve them.
Chemotherapy for pancreatic cancer
Chemotherapy (chemo) uses anti-cancer drugs injected into a vein or given by mouth. These drugs enter the bloodstream and reach all areas of the body, making this treatment potentially useful for cancers that have metastasized (spread) beyond the organ they started in.
Chemotherapy for exocrine pancreatic cancer
Chemo may be used at any stage of pancreatic cancer. It is commonly used when the cancer is advanced and can’t be removed completely with surgery. Chemo may also be used after the cancer has been removed with surgery to try to kill any cancer cells that have been left behind (but can't be seen). This type of treatment is called adjuvant treatment. This lowers the chance that the cancer will come back later. Chemo can also be given before surgery to try to shrink the tumor. This is known as neoadjuvant treatment.
When chemo is given along with radiation, it can help the radiation work better. This, known as chemoradiation or chemoradiotherapy, has more severe side effects.
Gemcitabine (Gemzar®) is the chemo drug used most often to treat pancreatic cancer. Another commonly used drug is 5-fluorouracil (5-FU).
Sometimes, other drugs may be used along with gemcitabine or 5-FU, such as cisplatin, irinotecan (Camptosar®, CPT-11), paclitaxel (Taxol®), docetaxel (Taxotere®), capecitabine (Xeloda®), or oxaliplatin (Eloxitan®).
Chemo drugs kill cancer cells but also damage some normal cells. This can lead to side effects, which depend on the type of drugs, the amount taken, and the length of treatment. Common short-term side effects include:
Nausea and vomiting
Loss of appetite
Hair loss
Mouth sores
Diarrhea
Because chemo can damage bone marrow, where new blood cells are made, blood cell counts might become low. This can result in:
Increased chance of infection (from a shortage of white blood cells)
Bleeding or bruising after minor cuts or injuries (from a shortage of platelets)
Fatigue and shortness of breath (from too few red blood cells)
Many of the chemo drugs used for pancreatic cancer can cause diarrhea. Other side effects can occur depending on what chemo drugs are used. For example, cisplatin can cause kidney damage (called nephropathy). Doctors try to prevent this problem by giving the patient lots of fluid before and after the drug is given. Both cisplatin and oxaliplatin can cause nerve damage (called neuropathy). This can lead to symptoms of numbness, tingling, or even pain in the hands and feet. For a day or so after treatment, oxaliplatin can cause nerve pain that gets worse with exposure to cold. This often causes pain when swallowing that is worse when trying to swallow cold foods or liquids. If you will be getting chemo, ask your cancer care team about the drugs being used and what side effects to expect.
Most side effects disappear once treatment is stopped. If you do have side effects, there are treatments that can help reduce them or make them go away. For example, drugs can be given to prevent or reduce nausea and vomiting.
Targeted therapy for exocrine pancreatic cancers
As researchers have learned more about the gene changes in cells that cause cancer, they have been able to develop newer drugs that specifically target these changes. These drugs are often referred to as targeted therapy. They work differently from standard chemotherapy drugs and often have different (and less severe) side effects.
A pill called erlotinib (Tarceva®) has helped some patients with advanced pancreatic cancer. Erlotinib targets a protein on the surface of cancer cells called EGFR, which normally prompts cancer cells to grow. When combined with gemcitabine, it has been shown to work slightly better than gemcitabine alone. Some people may benefit more from this combination than others. Common side effects of erlotinib include an acne-like rash, diarrhea, loss of appetite, and feeling tired.
Chemotherapy for pancreatic neuroendocrine tumors
Chemo is not often very helpful in treating these tumors, so it isn't often used. When chemo is used the preferred drugs are doxorubicin (Adriamycin®) and streptozocin. Sometimes a special form of doxorubicin known as liposomal doxorubicin (Doxil®) has been used instead of the regular drug. In this form, the drug is dissolved in fat droplets, which allows it to be given with less serious side effects. Other chemo drugs that have been helpful in treating these tumors include fluorouracil (5-FU), dacarbazine (DTIC), and temozolomide (Temodar®). Some recent studies have found that combining temozolomide with thalidomide or with capecitabine (Xeloda) can be helpful.
Targeted therapy for pancreatic neuroendocrine tumors
The drug sunitinib (Sutent®) attacks both blood vessel growth and other targets that stimulate cancer cell growth. When used to treat patients with PNETs with spread outside of the pancreas, it has been shown to slow tumor growth and help patients live longer. This drug is a pill that is taken once a day to treat pancreatic NETs. The most common side effects are nausea, diarrhea, changes in skin or hair color, mouth sores, weakness, and low blood cell counts. Other possible effects include tiredness, high blood pressure, heart problems, bleeding, hand-foot syndrome (redness, pain, and skin peeling of the palms of the hands and the soles of the feet), and low thyroid hormone levels. This drug is approved by the FDA to treat PNETs that cannot be removed with surgery or have spread outside the pancreas.
Everolimus (Afinitor®) works by blocking a cell protein known as mTOR, which normally promotes cell growth and division. When used to treat patients with PNETs that have spread outside of the pancreas, it has been shown to slow tumor growth. It's not yet clear if this drug helps patients live longer. Everolimus is a pill taken once a day to treat PNETs. Common side effects of this drug include mouth sores, an increased risk of infections, nausea, loss of appetite, diarrhea, skin rash, feeling tired or weak, fluid buildup (usually in the legs), and increases in blood sugar and cholesterol levels. A less common but serious side effect is damage to the lungs, which can cause shortness of breath or other problems. This drug is approved by the FDA to treat PNETs that cannot be removed with surgery or have spread outside the pancreas.
Other drugs for treating pancreatic neuroendocrine tumors
Somatostatin analogs: Octreotide (Sandostatin®) is an agent chemically related to a natural hormone, somatostatin. It is very helpful for some patients with PNETs. It can stop the tumor from releasing its hormone into the bloodstream. This reduces symptoms and helps patients feel better. This drug can be expected to help anyone with a tumor that can be seen on somatostatin receptor scintigraphy.
Octreotide can help reduce diarrhea in patients with VIPomas, glucagonomas, and somatostatinomas. It also helps the rash of glucagonomas. This drug may even stop tumors from growing. The main side effects are pain at the site of the injection, and rarely, stomach cramps, nausea, vomiting, headaches, dizziness, and fatigue. Octreotide causes sludging of bile in the gallbladder which can lead to gallstones. It can also make the body resistant to the action of insulin, making pre-existing diabetes more difficult to control. This drug is not often used in treating insulinomas, because its effects on the release of other hormones can cause worse problems with blood sugars.
The standard version of octreotide is short-acting and is given as an injection 2 to 4 times a day. This drug is also available in a long-acting form (called Sandostatin LAR Depot) that only needs to be given once a month, which may help patients more than the short-acting version. A similar drug, lanreotide (Somatuline® Depot), is also available. It is also given as an injection once a month. A newer drug called pasireotide is currently being studied.
Diazoxide is a drug that can block insulin release from the pancreas. It can be used to prevent low blood sugars (hypoglycemia) in patients with insulinomas. This drug is often used to normalize blood glucose levels before surgery, to make the operation safer for the patient.
Proton pump inhibitors block acid secretion from the stomach. These drugs often need to be taken in higher than usual doses, but are very helpful in preventing ulcers in patients with gastrinomas. Examples of these drugs include omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), and others.
Pain control in pancreatic cancer
Pain in the abdomen or back can be a major problem for people with pancreatic cancer, especially the exocrine type. Treatment is available to help relieve this pain. If you are having any pain, please be sure to tell your doctor or nurse right away. Pain is easier to treat if the treatment is started when you first have it. You and your doctor or nurse can talk about the best ways to treat your pain. A pain specialist can also help develop a treatment plan.
There are proven ways to relieve pain from pancreatic cancer. For most patients, treatment with morphine or other similar drugs (opiates) will reduce the pain considerably. Many people are reluctant to take these drugs because they fear becoming addicted, but studies have shown that the risk of this is low if the patient takes the drug for pain as directed by the doctor.
Pain medicines work best when they are given regularly on a schedule. They do not work as well if they are only used when the pain becomes severe. Several long-acting forms of morphine and other opioid agents can be taken in pill form and only need be given once or twice a day. There is even a long acting form of the drug fentanyl that is applied as a patch every 3 days.
Common side effects of these drugs are nausea and sedation (feeling sleepy), which often get better over time. Constipation is a common side effect that will not get better and so needs to be treated. Most people on these drugs need to take laxatives daily.
Sometimes certain procedures may be needed to treat pain. For example, cutting or injecting alcohol into some of the nerves behind the pancreas that carry pain sensations can improve pain and allow you to use lower doses of opiate drugs. This can be done during surgery to remove the cancer, but it can also be done without surgery under the guidance of endoscopic ultrasound.
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.
Adding other drugs to gemcitabine may 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.
What happens after treatment for pancreatic cancer?
For some people with pancreatic cancer, treatment may remove or destroy the cancer. Completing treatment can be both stressful and exciting. You will be relieved to finish treatment, yet it is hard not to worry about cancer coming back. (When cancer returns, it is called recurrence.) This is a very common concern among those who have had cancer.
It may take a while before your fears lessen. But it may help to know that many cancer survivors have learned to live with this uncertainty and are living full lives.
For most people with pancreatic exocrine cancer (and some patients with pancreatic neuroendocrine tumors), the cancer never goes away completely. These people may get regular treatments with chemotherapy, radiation therapy, or other therapies to try to help keep the cancer in check. Learning to live with cancer that does not go away can be difficult and very stressful. It has its own type of uncertainty.
Follow-up care
When treatment ends, your doctors will still want to watch you closely. It is very important to go to all of your follow-up appointments. During these visits, your doctors will ask questions about any problems you may have and may do exams and lab tests or x-rays and scans to look for signs of cancer or treatment side effects. Almost any cancer treatment can have side effects. Some may last for a few weeks to months, but others can last the rest of your life. This is the time for you to talk to your cancer care team about any changes or problems you notice and any questions or concerns you have.
After your cancer treatment is finished, you will probably need to still see your cancer doctor for many years. So, ask what kind of follow-up schedule you can expect.
It is important to keep health insurance. Tests and doctor visits cost a lot, and even though no one wants to think of their cancer coming back, this could happen.
Nutrition
People with exocrine pancreatic cancer often lose their appetite and suffer weight loss and weakness. These symptoms may be caused by treatment or by the cancer itself. When possible, people are often advised to try to eat high-energy foods as well as supplements. Many patients need to take pancreatic enzymes in pill form in order to help digest food so that it can be absorbed. A nutritionist may be able to help with this. In some cases the doctors may put a feeding tube into the stomach to improve nutrition and energy levels. This is usually temporary.
If treatment for pancreatic cancer stops working
If cancer keeps growing or comes back after one kind of treatment, it is possible that another treatment plan might still cure the cancer, or at least shrink it enough to help you live longer and feel better. But when a person has tried many different treatments and the cancer has not gotten any better, the cancer tends to become resistant to all treatment. If this happens, it's important to weigh the possible limited benefits of a new treatment against the possible downsides. Everyone has their own way of looking at this.
This is likely to be the hardest part of your battle with cancer — when you have been through many medical treatments and nothing's working anymore. Your doctor may offer you new options, but at some point you may need to consider that treatment is not likely to improve your health or change your outcome or survival.
If you want to continue to get treatment for as long as you can, you need to think about the odds of treatment having any benefit and how this compares to the possible risks and side effects. In many cases, your doctor can estimate how likely it is the cancer will respond to treatment you are considering. For instance, the doctor may say that more chemo or radiation might have about a 1% chance of working. Some people are still tempted to try this. But it is important to think about and understand your reasons for choosing this plan.
No matter what you decide to do, you need to feel as good as you can. Make sure you are asking for and getting treatment for any symptoms you might have, such as nausea or pain. This type of treatment is called palliative care.
Palliative care helps relieve symptoms, but is not expected to cure the disease. It can be given along with cancer treatment, or can even be cancer treatment. The difference is its purpose — the main purpose of palliative care is to improve the quality of your life, or help you feel as good as you can for as long as you can. Sometimes this means using drugs to help with symptoms like pain or nausea. Sometimes, though, the treatments used to control your symptoms are the same as those used to treat cancer. For instance, radiation might be used to help relieve bone pain caused by cancer that has spread to the bones. Or chemo might be used to help shrink a tumor and keep it from blocking the bowels. But this is not the same as treatment to try to cure the cancer.
At some point, you may benefit from hospice care. This is special care that treats the person rather than the disease; it focuses on quality rather than length of life. Most of the time, it is given at home. Your cancer may be causing problems that need to be managed, and hospice focuses on your comfort. You should know that while getting hospice care often means the end of treatments such as chemo and radiation, it doesn't mean you can't have treatment for the problems caused by your cancer or other health conditions. In hospice the focus of your care is on living life as fully as possible and feeling as well as you can at this difficult time. You can learn more about hospice and this phase of cancer in our documents called Hospice Care and Nearing the End of Life. They can be read online, or call us to have free copies mailed to you.
Staying hopeful is important, too. Your hope for a cure may not be as bright, but there is still hope for good times with family and friends — times that are filled with happiness and meaning. Pausing at this time in your cancer treatment gives you a chance to refocus on the most important things in your life. Now is the time to do some things you've always wanted to do and to stop doing the things you no longer want to do. Though the cancer may be beyond your control, there are still choices you can make.
What`s new in pancreatic cancer research and treatment?
Research into the causes, diagnosis, and treatment of pancreatic cancer is under way in many medical centers throughout the world.
Genetics and early detection
Scientists are learning more about some of the changes in DNA that cause cells in the pancreas to become cancerous. Inherited changes in genes such as BRCA2, p16, and the genes responsible for hereditary non-polyposis colorectal cancer (HNPCC) can increase a person's risk of developing pancreatic cancer. Researchers are now looking at how these and other genes may be altered in cases of pancreatic cancer that do not seem to be inherited. They have discovered that pancreatic cancer does not form suddenly. It develops over many years in a series of steps known as pancreatic intraepithelial neoplasia or PanIN. In the early steps, such as PanIN 1, there are changes in a small number of genes, and the duct cells of the pancreas do not look very abnormal. In later steps such as PanIN 2 and PanIN 3, there are abnormalities in several genes and the duct cells look more abnormal.
Researchers are using this information to develop tests for detecting acquired (not inherited) genetic changes in pancreatic cancer pre-cancerous conditions. One of the most common DNA changes in these conditions affects the KRAS oncogene and alters regulation of cell growth. New diagnostic tests are often able to recognize this change in samples of pancreatic juice collected during an ERCP (endoscopic retrograde cholangiopancreatography).
For now, imaging tests like endoscopic ultrasound (EUS), ERCP, and genetic tests for changes in certain genes (such as KRAS) are options for people with a strong family history of pancreatic cancer. But these tests are not recommended for widespread testing of people at average risk who do not have any symptoms.
Treatment
The major focus of much research is on finding better treatments for pancreatic cancer. Improving surgery and radiation therapy are major goals, as is determining the best combination of treatments for people with certain stages of cancer.
Chemotherapy
Many clinical trials are testing new combinations of chemotherapy drugs for exocrine pancreatic cancer. Studies have looked to see if combining gemcitabine with other drugs would help patients live longer. Adding cisplatin, docetaxel, or irinotecan doesn't seem to be helpful, but adding capecitabine (Xeloda) or nab-paclitaxel (Abraxane®) does seem to help patients live longer. Also, the combination of gemcitabine, irinotecan, and celecoxib (an arthritis drug) shows promise. Other studies are testing the best ways to combine chemotherapy with radiation therapy or newer targeted therapies.
Targeted therapies
As researchers have learned more about what makes pancreatic cancer cells different from normal cells, they have started to develop newer drugs that should be able exploit these differences by attacking only specific targets. These "targeted therapies" may provide another option for treating pancreatic cancer. They may prove to be useful along with, or instead of, current treatment regimens. In general, they seem to have fewer side effects than traditional chemotherapy drugs. Looking for new targets to attack on cancers is an active area of research.
Growth factor inhibitors: Many types of cancer cells, including pancreatic cancer cells, have certain molecules on their surface that help them to grow. These molecules are called growth factor receptors. One example is epidermal growth factor receptor (EGFR). Several drugs that target EGFR are now being studied. One, known as erlotinib (Tarceva), is already approved for use along with gemcitabine.
Anti-angiogenesis factors: All cancers depend on new blood vessels to nourish their growth. To block the growth of these vessels and thereby starve the tumor, scientists have developed anti-angiogenesis drugs. These are being studied in clinical trials and may be used in patients with pancreatic cancer.
Other targeted therapies: Many drugs targeting other aspects of cancer cells are now being studied for use in pancreatic cancer. For example, drugs that target the action of farnesyl transferase, an enzyme that is thought to stimulate the growth of many cancers, are now being tested. Other drugs, such as sunitinib, have several different targets.
Immune therapy
Immune therapies attempt to boost a person's immune system or give them ready-made components of an immune system to attack cancer cells. Some studies of these treatments have shown promising results.
One form of immune therapy injects man-made monoclonal antibodies into patients. These immune system proteins are made to home in on a specific molecule, such as carcinoembryonic antigen (CEA), which is sometimes found on the surface of pancreatic cancer cells. Toxins or radioactive atoms can be attached to these antibodies, which bring them directly to the tumor cells. The hope is that they will affect cancer cells while leaving normal cells alone. For use in pancreatic cancer, these types of treatments are available only in clinical trials at this time.
Radiation therapy
Some current studies are looking at different ways to give radiation to treat exocrine pancreas cancer. One study is looking at the effect of intraoperative radiation therapy, in which a single large dose of radiation is given to the pancreas at the time of surgery (in the operating room). Another study is looking at using a special type of radiation called proton beam radiation with chemo.
Individualization of therapy
Some drugs seem to work better if certain types of mutations can be found in the patient's tumor. For example, erlotinib may work better in patients if their tumors have a particular change in the gene for EGFR. This concept is an area of intense study. There might also be some genetic alterations that affect how well gemcitabine will work in a particular patient. Identifying markers that may predict how well a drug will work before it is given is an important area of research in many types of cancer.
New treatments for pancreatic neuroendocrine cancers
Many pancreatic neuroendocrine tumors have receptors for somatastatin on their cells. These tumors can be treated with octreotide and other drugs like it. A new drug has been developed in which the octreotide has been labeled with radiation. This drug shrunk some tumors and kept others from growing in an early trial. It also helped patients live longer.
