Pancreatic CancerLast Updated: January 13, 2012 This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/11 Overview
Pancreatic cancer is a disease in which normal cells in the pancreas stop working correctly and grow uncontrollably. These cancerous cells can build up and form a mass called a tumor. As it grows, a pancreatic tumor can affect the function of the pancreas, grow into nearby blood vessels and organs, and eventually metastasize (spread) to other parts of the body. About the pancreas The pancreas is a pear-shaped gland located in the abdomen between the stomach and the spine. It is about six inches in length and is made up of two major components:
Types of pancreatic cancer There are several types of pancreatic cancer, depending on whether the cancer began in the exocrine or endocrine component. Exocrine tumors. These are the most common type of pancreatic cancer. About 95% of people with pancreatic cancer have adenocarcinoma, which starts in gland cells. These tumors usually start in the ducts of the pancreas, called ductal adenocarcinoma, or, much less commonly, in the acini, called acinar adenocarcinoma. Much rarer types of exocrine pancreatic tumors include: adenosquamous carcinomas, squamous cell carcinomas, and giant cell carcinomas. Endocrine tumors. These are also called islet cell tumors or pancreatic neuroendocrine tumors (PNETs). They are much less common than exocrine tumors, making up about 1% of pancreatic cancers. A pancreatic neuroendocrine tumor can be functioning, meaning it makes hormones, or nonfunctioning, meaning it doesn’t make hormones. A functioning neuroendocrine tumor is named based on the hormone the cells normally make:
This section covers pancreatic ductal adenocarcinoma. To learn more about tumors that start in the endocrine component of the pancreas, read about islet cell tumors and neuroendocrine tumors. Find out more about basic cancer terms used in this section. Looking for More of an Overview? If you would like additional introductory information, explore these related items on Cancer.Net:
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This year, an estimated 43,920 adults (22,090 men and 21,830 women) in the United States will be diagnosed with pancreatic cancer. It is estimated that 37,390 deaths (18,850 men and 18,540 women) from this disease will occur this year. Pancreatic cancer is the tenth most common cancer in men and women, and the fourth leading cause of cancer death in men and women. As explained in the Overview, most pancreatic cancers are adenocarcinomas, and these statistics are for that type of pancreatic cancer. Because pancreatic cancer can often be difficult to diagnose, it is often not found until advanced stages when the cancer can no longer be removed with surgery and has spread from the pancreas to other parts of the body. The overall one-year survival rate (percentage of people who survive at least one year after the cancer is detected, excluding those who die from other diseases) of people with pancreatic cancer is 26%, and the five-year survival rate (percentage of people who survive at least five years after the cancer is detected, excluding those who die from other diseases) is approximately 6%. If the cancer is detected at an early stage where surgical resection (surgical removal of the tumor) is possible, the five-year survival rate is about 22%. Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of people with this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with pancreatic cancer. Because the survival statistics are measured in one-year or five-year intervals, they may not represent advances made in the treatment or diagnosis of this cancer. Learn more about understanding statistics. Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2012. Medical Illustrations
Risk Factors
A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices. The following factors may raise a person’s risk of developing pancreatic cancer: Age. The risk of developing pancreatic cancer increases with age. Most people who develop pancreatic cancer are older than 45; 90% are older than 55 and 70% are older than 65. However, adults of any age can be diagnosed with pancreatic cancer. Gender. More men are diagnosed with pancreatic cancer than women. Race/ethnicity. Black people are more likely than Asian, Hispanic, or white people to develop pancreatic cancer. People of Ashkenazi Jewish heritage are also more likely to develop pancreatic cancer (see Family history, below). Smoking. Smokers are two to three times more likely to develop pancreatic cancer than nonsmokers. Obesity and diet. Regularly eating foods high in fat is a risk factor for pancreatic cancer. Research has shown that obese and even overweight men and women have a higher risk of dying from pancreatic cancer. Diabetes. The sudden onset of type 2 diabetes can be an early symptom of pancreatic cancer. Whether diabetes itself is a risk factor for the development of pancreatic cancer has been a topic of great interest for many years with large studies reaching different conclusions. It is now believed that long-term diabetes does increase a person’s risk of developing pancreatic cancer. Family history. A person’s chance of developing this cancer increases three-fold if a first-degree relative (mother, father, sister, or brother) developed pancreatic cancer. That risk increases even further if more first-degree relatives are affected. Also, melanoma that runs in families and certain hereditary forms of colon, breast, and ovarian cancers are associated with an increased risk of developing pancreatic cancer. Several treatment centers are developing pancreatic cancer registries to learn more about the role of family history. Read more about the genetic conditions that increase the risk of pancreatic cancer. Chronic pancreatitis. Pancreatitis is the inflammation of the pancreas, a painful disease of the pancreas. Some research suggests that having chronic pancreatitis may increase the risk of developing pancreatic cancer. Hereditary pancreatitis. Hereditary pancreatitis (HP) is a condition associated with recurrent pancreatitis (inflammation of the pancreas) and an increased risk of pancreatic cancer. Learn more about hereditary pancreatitis. Chemicals. Exposure to certain chemicals (such as pesticides, benzene, certain dyes, and petrochemicals) may increase the risk of developing pancreatic cancer. Hepatitis B infection. Hepatitis viruses are viruses that infect the liver. One study has shown that a previous hepatitis B infection was twice as common in people with pancreatic cancer than in people without the cancer. More research is needed to learn more about this link. Symptoms and Signs
People with pancreatic cancer may experience the following symptoms or signs. Sometimes, people with pancreatic cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom or sign on this list, please talk with your doctor. Doctors often refer to pancreatic cancer as a silent disease because there are not many noticeable symptoms early on. When there are symptoms, they are similar to the symptoms of other medical conditions, such as ulcers or pancreatitis. Also, there are currently no blood tests that can reliably find the cancer when it is in an early stage. As the cancer grows, symptoms may include:
Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you’ve been experiencing the symptom(s) and how often. If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms. Diagnosis
Doctors use many tests to diagnose cancer and find out if it has metastasized. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:
If a doctor suspects that a person has pancreatic cancer, he or she will first ask about the person's medical history and examine the person to look for signs of the disease. An appropriate and timely diagnosis is very important, ideally performed at a center that has experience with the disease. The tests listed below may be used to diagnose pancreatic cancer. Physical examination. The doctor will examine the skin and eyes to see if they are yellow, which is a sign of jaundice. Jaundice can be from a tumor in the head of the pancreas blocking the normal flow of bile (a substance produced in the liver) into the small intestine. However, many patients with pancreatic cancer do not have jaundice when the cancer is diagnosed. The doctor will also feel the abdomen for changes caused by the cancer, although the pancreas itself, located in the back of the upper abdomen, can rarely be felt. An abnormal buildup of fluid in the abdomen, called ascites, may be another sign of cancer. Blood tests. The doctor may take samples of blood to check for abnormal levels of bilirubin and other substances. Bilirubin is a chemical that may reach high levels in patients with pancreatic cancer due to blockage of the common bile duct by a tumor. There are many other non-cancerous causes of an elevated bilirubin level, such as hepatitis, gallstones, or mononucleosis. CA 19-9 is a tumor marker (substance in the body that may be found at higher levels if cancer is present) that can be measured in the blood, and is often higher in people with pancreatic cancer. An elevated CA 19-9 test by itself should not be used to make the diagnosis of pancreatic cancer, as high levels of CA 19-9 also can be a sign of other, noncancerous conditions, such as pancreatitis, cirrhosis of the liver, and blockage of the common bile duct. Imaging tests help doctors find out where the cancer is located and whether it has spread from the pancreas to other parts of the body. However, pancreatic cancer often does not develop as a single large tumor, which means it can sometimes be difficult to see on imaging tests. Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. A contrast medium (a special dye) is usually injected into a patient’s vein to provide better detail. Many cancer centers use a special type of CT scan called a pancreatic protocol CT scan. This scan focuses specifically on the pancreas using different levels of detail to make clearer images. It is used to find out exactly where the tumor is in comparison to nearby organs and vessels and help decide if the tumor could be removed with surgery. Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. This substance is absorbed mainly by organs and tissues that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body. A PET scan is often done in combination with a CT scan, with the images placed over each other (called a fusion or integrated CT-PET scan). PET scans are done routinely at some but not all cancer centers for the diagnosis and staging of pancreatic cancer. However, they are not yet considered a standard test to diagnose pancreatic cancer. A PET scan alone should never be used instead of a high-quality CT scan. Ultrasound. An ultrasound uses sound waves to create a picture of the internal organs. There are two types of ultrasound devices: transabdominal and endoscopic.
Endoscopic retrograde cholangiopancreatography (ERCP). In this procedure performed by a gastroenterologist, an endoscope (a thin, lighted tube) is passed into the small intestine through the mouth and stomach. A catheter (smaller tube) is passed through the endoscope and into the bile ducts and pancreatic ducts. Dye is injected into the ducts, and the doctor then takes x-rays that can show whether a duct is compressed or narrowed. Often, a plastic or metal stent can be placed across the obstructed bile duct during ERCP to help relieve any jaundice. Samples of the tissue can be taken during this procedure and can sometimes help confirm the diagnosis of cancer. The patient is lightly sedated during this procedure. Percutaneous transhepatic cholangiography (PTC). In this x-ray procedure, a thin needle is inserted through the skin and into the liver. A dye is injected through the needle, so the bile ducts show up on x-rays. By looking at the x-rays, the doctor can tell whether there is a blockage of the bile ducts. Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed from the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease). One biopsy technique used to remove pancreas tissue is called fine needle aspiration, in which a needle is inserted into the pancreas to suction out cells. An x-ray or CT-guided ultrasound is used to help guide the needle. Other ways to collect a sample of pancreas tissue involve the use of ERCP, EUS, or surgery. If the cancer has spread to other organs, a biopsy may be obtained from one of these other sites (such as the liver). A surgical biopsy can be done either by opening the abdomen or by using a laparoscopic approach to provide openings for a tiny camera and surgical instruments, which requires much smaller incisions. Some patients, when having surgery or certain types of biopsies, choose to have some of the tissue removed frozen and sent to independent laboratories that look at genetic and molecular features. This process may help predict which treatments may work best. Performing these tests has not yet been thoroughly studied. However, with the increase in new drugs called targeted therapies (see Treatment), it is an area of increasing interest and scientific focus. It is important to note that many insurance companies do not reimburse for these types of tests yet. Talk with your doctor for more information. Learn more about what to expect when having common tests, procedures, and scans. After these diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called staging. Learn more about the first steps to take after a diagnosis of cancer. Staging
Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and whether it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). As with Diagnosis, it is important for the staging of pancreatic cancer to be done at a center with experience in staging pancreatic cancer. There are different stage descriptions for different types of cancer. Doctors use several systems to stage pancreatic cancer. The method used to stage other cancers, the TNM classification, is not often used for pancreatic cancer; however, for completeness, it is discussed below. The more common way to classify pancreatic cancer is to divide it into three categories based on whether it can be removed with surgery and where it has spread: Resectable. This type of pancreatic cancer can be surgically removed. The tumor may be located only in the pancreas or extend beyond it, but it has not grown into important arteries or veins in the area. There is no evidence that the tumor has spread to areas outside of the pancreas. Approximately 10% to 15% of patients are diagnosed at this stage. Locally advanced. This type is still located only in the area around the pancreas, but it cannot be surgically removed because it has grown into nearby arteries or veins, or the tumor has grown into nearby organs. There is no evidence of spread to any distant parts of the body. Approximately 35% to 40% of patients are diagnosed at this stage. Metastatic. The tumor has spread beyond the area of the pancreas and to other organs, such as the liver or distant areas of the abdomen. Approximately 45% to 55% of patients are diagnosed at this stage. By classifying each cancer into one of these categories, the health care team can then plan the best treatment strategy. A fourth category that is sometimes used, which can also be a subcategory of “Locally advanced,” is borderline resectable disease. This refers to a tumor that cannot be surgically removed at the present time, but if the tumor responds well to chemotherapy and/or radiation therapy, may potentially be able to be removed at a later date. TNM Staging System Doctors frequently use a tool called the TNM system to stage other types of cancer. Because doctors generally classify a tumor during surgery, and because many patients with pancreatic cancer do not undergo surgery, the TNM system is not used as much for pancreatic cancer as it is for other diseases. The TNM system judges three factors: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to the rest of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments. TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:
Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. This helps the doctor develop the best treatment plan for each patient. Specific tumor stage information listed below. TX: The primary tumor cannot be evaluated. T0: No evidence of cancer was found in the pancreas. Tis: Refers to carcinoma in situ (which is very early cancer that has not spread.) T1: The tumor is in the pancreas only, and it is 2 centimeters (cm) or smaller in size. T2: The tumor is in the pancreas only, and it is larger than 2 cm. T3: The tumor extends beyond the pancreas, but the tumor does not involve the major arteries or veins near the pancreas. T4: The tumor extends beyond the pancreas into major arteries or veins near the pancreas. A T4 tumor is unresectable (unable to be completely removed during surgery). Node. The "N" in the TNM staging system is for lymph nodes. Lymph nodes are tiny, bean-shaped organs located throughout the body that normally help fight infection and disease as part of the body's immune system. In pancreatic cancer, regional lymph nodes are those lymph nodes near the pancreas and distant lymph nodes are those lymph nodes in other parts of the body. NX: The regional lymph nodes cannot be evaluated. N0: The cancer was not found in the regional lymph nodes. N1: The cancer has spread to regional lymph nodes. Distant metastasis. The "M" in the TNM system indicates whether the cancer has spread to other parts of the body. MX: Distant metastasis cannot be evaluated. M0: The disease has not metastasized. M1: There is metastasis to another part of the body, including distant lymph nodes. Distant spread of pancreatic cancer occurs mainly in the liver, peritoneum (lining of the abdominal cavity), and lungs. Cancer stage grouping Doctors assign the stage of the cancer by combining the T, N, and M classifications. Stage 0: Refers to cancer in situ, in which the cancer has not yet invaded outside the duct (or tube) in which it originated (Tis, N0, M0). Stage IA: The tumor is 2 cm or smaller in the pancreas. It has not spread to lymph nodes or other parts of the body (T1, N0, M0). Stage IB: A tumor larger than 2 cm is in the pancreas. It has not spread to lymph nodes or other parts of the body (T2, N0, M0). Stage IIA: A tumor extends beyond the pancreas, but the tumor has not spread to nearby arteries or veins. It has not spread to any lymph nodes or other parts of the body (T3, N0, M0). Stage IIB: A tumor of any size has not spread to nearby arteries or veins. It has spread to lymph nodes but not to other parts of the body (T1, T2, or T3; N1; M0). Stage III: A tumor has spread to nearby arteries, veins, and/or lymph nodes but has not spread to other parts of the body (T4, N1, M0). Stage IV: Any tumor that has spread to other parts of the body (any T, any N, M1). Recurrent: Recurrent cancer is cancer that comes back after treatment. If there is a recurrence, the cancer may need to be staged again (re-staging) using the system above. Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition (2010) published by Springer-Verlag New York, www.cancerstaging.net. Treatment
This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, see the Clinical Trials and Current Research sections. Treatment overview In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. Descriptions of the most common treatment options for pancreatic cancer are listed below. The current treatment options for pancreatic cancer are surgery, radiation therapy, chemotherapy, and targeted therapy. Supportive care options, which are used to manage the patient’s symptoms, are also included. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health. Learn more about making treatment decisions. When detected at an early stage, pancreatic cancer has a much higher chance of being successfully treated. However, there are also treatments that can help control the disease for patients with later stage pancreatic cancer to help them live longer. Surgery Surgery for pancreatic cancer includes removing all or part of the pancreas, depending on the location and size of the tumor in the pancreas. A surgical oncologist is a doctor who specializes in treating cancer using surgery. Learn more general information about cancer surgery. Surgery for pancreatic cancer may be combined with radiation therapy and/or chemotherapy (see below). These may be given either before (called neoadjuvant therapy) or after surgery (called adjuvant therapy), although they are most often given afterwards. If it is unclear whether a cancer can be removed surgically (called borderline resectable) at the time of diagnosis, radiation therapy and/or chemotherapy may be given first to try to shrink the tumor so it can be removed with surgery. Different types of surgery are performed depending on the purpose of the surgery: Laparoscopy. Sometimes, the surgeon may choose to start with a laparoscopy. During a laparoscopy, several small holes are made in the abdomen and a tiny camera is passed into the body while a patient is under anesthesia (sedated). This helps the surgeon to determine if the cancer has spread to other parts of the abdomen. If it has, surgery to remove the primary tumor is generally not appropriate. Surgery to remove the tumor. Different types of surgery are used depending on where the tumor is located in the pancreas. In all of the surgeries discussed below, nearby lymph nodes are removed as part of the operation.
After surgery, the patient will need to stay in the hospital for several days and will probably need to rest at home for about one month. Side effects of surgery include weakness, tiredness, and pain for the first few days after the procedure. Other side effects caused by the removal of the pancreas include difficulty digesting food and diabetes from the loss of insulin (produced by the pancreas). See Supportive care below for more information on relieving these side effects. Radiation therapy Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time. Learn more about radiation therapy. Radiation therapy is commonly given for pancreatic cancer in the following situations:
External-beam radiation therapy is the type of radiation therapy used most often for pancreatic cancer, and treatment usually takes five to six weeks with once-daily doses of radiation (termed standard-fractionation). Newer types of radiation therapy, such as stereotactic radiosurgery (for example, Cyberknife), are being used for pancreatic cancer because they can provide more localized treatment and need only one or a small number of treatment sessions. However, these newer types of radiation therapy have not been compared with standard-fractionation radiation therapy and should not be considered a replacement for it. Often, chemotherapy (see below) will be given at the same time as radiation therapy because it can enhance the effects of the radiation therapy (called radiosensitization). Combining chemotherapy and radiation therapy may occasionally help shrink the tumor enough so it can be removed by surgery. However, chemotherapy given at the same time as radiation therapy often has to be given at lower doses than when given alone. Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished. Chemotherapy Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time. Adjuvant chemotherapy. Adjuvant chemotherapy is given after a pancreatic tumor is removed with surgery to prevent the cancer from coming back. Currently, the standard adjuvant chemotherapy uses gemcitabine (Gemzar) alone. Ongoing clinical trials are looking at combinations of different drugs for adjuvant treatment, including more aggressive combinations similar to those used for advanced pancreatic cancer (see First-line chemotherapy, below). Chemotherapy given before surgery is called neoadjuvant treatment and is much less common than adjuvant treatment for pancreatic cancer. First-line chemotherapy. This is the first treatment used for patients with either locally advanced or metastatic pancreatic cancer (see Staging). Gemcitabine alone has been shown to increase survival and the amount of time it takes for the disease to come back. It has been the standard of care for patients with advanced pancreatic cancer since its approval in 1997, but combinations of drugs may be more effective than gemcitabine alone. Several two-drug combinations have been tested in clinical trials, including:
Some of these studies suggest combination treatment may be more effective; however, there tends to be more side effects when two or more drugs are used together. Combination treatments are best for patients who are able to carry out their usual activities of daily living without help. The choice of which specific combination to use varies depending on the cancer center and often depends on the oncologist’s experience with the drugs and the different side effects. Other combinations that are being studied include gemcitabine plus nanoparticle albumin-bound paclitaxel (Abraxane), and the 3-drug combination of gemcitabine, docetaxel (Taxotere), and capecitabine, called GTX. Recently, a large study demonstrated that a combination of drugs called FOLFIRINOX (5-FU, leucovorin [Wellcovorin], irinotecan [Camptosar], and oxaliplatin) significantly improved the survival of patients with advanced pancreatic cancer compared to those who received gemcitabine alone. FOLFIRINOX is an appropriate first-line treatment for patients with advanced pancreatic cancer. However, patients who received this combination had more side effects, and it should be used only for patients who are in good physical condition and otherwise healthy despite the cancer. Second-line chemotherapy. If a tumor continues to grow after first-line treatment, patients may benefit from additional treatment with different drugs if the patient’s overall health is good. For example, one study showed that the combination of 5-FU and oxaliplatin is effective for some patients as second-line treatment after they had received prior treatment with a gemcitabine-based regimen. Learn more about second-line treatment. Off-label use. This is when a drug is used to treat conditions not listed on the label or is given differently than the instructions on the label. Off-label drug use in pancreatic cancer treatment is common for many reasons. First, drugs are generally approved for treating only a particular type or stage of cancer. Second, many cancer treatments use a combination of drugs and one or more of the drugs is often being used off label. Drug regimens are also constantly changing as doctors study new combinations to improve patient care. Side effects. The side effects of chemotherapy depend on which drugs the patient receives. These include poor appetite, nausea, vomiting, diarrhea, mouth sores, hair loss, and a lack of energy. People receiving chemotherapy also are more likely to get infections and bruise and bleed easily because chemotherapy decreases bone marrow production of white blood cells, red blood cells, and platelets. Certain drugs used in pancreatic cancer are also associated with specific side effects. For example, capecitabine can cause redness and discomfort on the palms of the hands and the soles of the feet. This condition is called hand-foot syndrome. Oxaliplatin (one of the drugs used in the FOLFIRINOX regimen) can cause cold sensitivity and numbness and tingling in the fingers and toes (called peripheral neuropathy). These side effects typically go away between treatments and after the treatments have ended. The doctor can suggest ways to relieve these side effects by reading the Supportive care section below. Palliative chemotherapy. Any chemotherapy regimens discussed above may help relieve the symptoms of pancreatic cancer (called palliative care or supportive care; see below), such as lessening pain, improving a patient’s energy and appetite, and stopping or slowing weight loss. When making decisions about palliative chemotherapy, it’s important that you and your doctor weigh the benefits with the possible side effects and consider how treatment might affect your quality of life. Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases. Targeted therapy Targeted therapy is a treatment that targets the cancer’s specific genes, proteins or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to normal cells, usually leading to fewer side effects than other cancer medications. Recent studies show that not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. As a result, doctors can better match each patient with the most effective treatment whenever possible. In addition, many research studies are taking place now to find out more about specific molecular targets and new treatments directed at them. Learn more about targeted treatments. The targeted therapy erlotinib is approved by the U.S. Food and Drug Administration (FDA) for patients with advanced pancreatic cancer in combination with gemcitabine. Erlotinib blocks the effect of the epidermal growth factor receptor (EGFR), a protein that can become abnormal and help cancer grow and spread. Side effects of erlotinib include a skin rash similar to acne. Learn more about skin reactions to targeted therapies. Supportive care In addition to treatment to slow, stop, or eliminate the cancer (also called disease-directed treatment), an important part of cancer care is relieving a person’s symptoms and side effects. It includes supporting the patient with his or her physical, emotional, and social needs, an approach called palliative or supportive care. People often receive disease-directed therapy and treatment to ease symptoms at the same time. Supportive care for people with pancreatic cancer includes: Relieving bile duct or small intestine blockage. If the tumor is blocking the common bile duct or small intestine, placement of a stent (a tiny tube that helps keep the blocked area open and can be either metal or plastic) can be performed to relieve the blockage using nonsurgical approaches, such as ERCP, PTC, or endoscopy (see the Diagnosis section for more information). These stents are typically placed inside the body, but sometimes, a tube may need to be placed through a hole in the skin of the abdomen to drain fluid from the abdomen, called percutaneous drainage. Sometimes, a patient may need surgery to create a bypass, even if the tumor itself cannot be completely removed. Improving digestion and appetite. A special diet, medications, and specially prescribed enzymes may help a person digest food better if their pancreas is not working well or has been partially or entirely removed. Meeting with a nutritionist is also often very helpful for patients who are losing weight and have a poor appetite because of their disease. Controlling diabetes. If a person develops diabetes due to the loss of insulin produced by the pancreas (more common after a total pancreatectomy), the doctor often prescribes insulin. Relieving pain and other side effects. Radiation therapy may be given to help relieve pain, and gemcitabine has also been shown to improve cancer-related symptoms, such as weight loss, pain, and weakness. Opioid analgesics (morphine-like drugs) are often needed to help reduce pain. Special types of nerve blocks (such as a celiac plexus block, which helps relieve abdominal pain) done by pain specialists may also be used. During a nerve block, the nerves are injected with either an anesthetic to stop pain for a short time or a medication that destroys the nerves and can relieve pain for a longer time. A nerve block can be performed either percutaneously (through the skin) or endoscopically (through an endoscope that is placed through the mouth and past the stomach). Learn more about managing pain. Recommended supportive care may also include complementary and alternative therapies. Recurrent pancreatic cancer Once your treatment is complete and there is a remission (absence of cancer symptoms; also called “no evidence of disease” or NED), talk with your doctor about the possibility of the cancer returning. Many survivors feel worried or anxious that the cancer will come back. Learn more about coping with this fear. If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence). When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. The treatment of recurrent pancreatic cancer is similar to the treatments described above and usually involves chemotherapy (see first-line and second-line chemotherapy above). Radiation therapy or surgery may also be used to help relieve symptoms (see above). Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Advanced pancreatic cancer If disease-directed treatment is not successful, this may also be called advanced cancer. This diagnosis is stressful, and it may be difficult to discuss. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Learn more about advanced cancer care planning. Find out more about common terms used during cancer treatment. About Clinical Trials
Doctors and scientists are always looking for better ways to treat patients with pancreatic cancer. To make scientific advances, doctors create research studies involving people called clinical trials. Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials are often among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment. There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage the late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease. Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating pancreatic cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with pancreatic cancer. Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials. To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options so that the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different than the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Patients who participate in a clinical trial may stop participating if the treatment is not working, if they have many severe or life-threatening side effects, or if they choose to leave the clinical trial for any personal or medical reason. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care, particularly after the clinical trial ends or if they choose to leave the clinical trial before it ends. Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find clinical trials. For specific topics being studied for pancreatic cancer, learn more in the Current Research section. Patients who participate in a clinical trial may stop participating at any time for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trials ends, and/or if the patient chooses to leave the clinical trial before it ends. Side Effects
Cancer and its treatment can cause a variety of side effects. Abdominal and/or back pain are common side effects of pancreatic cancer. Pain medications and a nerve block (see Treatment) can help relieve the pain associated with pancreatic cancer. Doctors have made major strides in recent years not only in treating pain but also in addressing nausea, vomiting, and other physical side effects associated with pancreatic cancer and cancer treatments. Many such treatments used today are less intensive but as effective as treatments used in the past. Fear of treatment side effects is common after a diagnosis of cancer, but it may be helpful to know that preventing and controlling side effects is a major focus of your health care team. Before treatment begins, talk with your doctor about possible side effects of the specific treatments you will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of cancer, its location, the individual treatment plan (including the length and dosage of treatment), and your overall health. Common side effects for each treatment option are described in detail within the Treatment section. Ask your doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health care team. Also, be sure to communicate with your doctor about side effects you experience during and after treatment. Care of a patient’s symptoms and side effects is an important part of a person’s overall treatment plan; this is called palliative or supportive care. It helps people with cancer at any stage of illness be as comfortable as possible. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. Be sure to talk with your doctor about the level of caregiving that you may need during this time, as family caregivers play an important part in the care of people with pancreatic cancer. Learn more about caregiving. In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. For many patients, a diagnosis of pancreatic cancer is very stressful and at times difficult to bear. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies. Learn more about the importance of addressing such needs, including concerns about managing the cost of your cancer care. A side effect that occurs months or years after treatment is called a late effect. Treatment of late effects is an important part of survivorship care. Learn more about late effects or long-term side effects by reading the After Treatment section or talking with your doctor. After Treatment
After treatment for pancreatic cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. ASCO offers cancer treatment summary forms to help keep track of the cancer treatment you received and develop a survivorship care plan once treatment is completed. For people who have had surgery, follow-up visits every three to six months with the oncologist are typically recommended. Blood tests, including monitoring of liver function tests and the tumor marker CA 19-9, may be done during these visits. CT scans do not need to be performed regularly, but they may be used depending on a person’s symptoms and any changes found during the physical examination or with the blood work. People recovering from pancreatic cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about the next steps to take in survivorship, including making positive lifestyle changes. Find out more about common terms used after cancer treatment is complete. Current Research
Doctors are working to learn more about pancreatic cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you. Early detection. Because the best chance of successful treatment is when pancreatic cancer is detected early, ongoing research is focused on finding and using special blood tests, diagnostic imaging tools, and other approaches to find pancreatic cancer at its earliest stages, even at precancerous stages (known as pancreatic intraepithelial neoplasia, or PanIN lesions), before it spreads. These screening approaches are typically being used for people who have a particularly high risk for pancreatic cancer, such as those with a strong family history or a known genetic condition that increases the risk of pancreatic cancer. It is not yet known if these screening tools could be used effectively for the general population. Genetic studies. In cancer, damaged or abnormal genes cause uncontrolled cell growth. Many of the new developments are based on fixing or correcting damaged genes and proteins. Genetic studies are being done to find the damaged genes that are involved in pancreatic cancer. Once such genes are found, doctors can begin to screen people who may be at risk for pancreatic cancer. Learn more about the genetics of pancreatic cancer. Immunotherapy. Immunotherapy (also called biologic therapy) is designed to boost the body’s natural defenses to fight cancer. It uses materials either made by the body or in a laboratory to bolster, target, or restore immune system function. One example of immunotherapy is a cancer vaccine, which stimulates a person’s immune system to recognize and attack cancer cells. A number of clinical trials have been done or are underway to study vaccines in a variety of types of cancer, including pancreatic cancer. Depending on the circumstances, vaccines may be given either after, during, or instead of chemotherapy. Learn more about immunotherapy. Targeted therapy.As discussed in the Treatment section, erlotinib is the only targeted therapy currently approved for pancreatic cancer, in combination with gemcitabine. Other drugs that may help block tumor growth and spread are being studied for pancreatic cancer, both as single drugs and as part of combination therapy. However, no targeted therapies (including bevacizumab [Avastin] and cetuximab [Erbitux]) have been shown to increase survival for patients with pancreatic cancer. One type of targeted therapy that is actively being studied blocks a cancer signaling pathway called Hedgehog. Learn more about targeted treatments. Gene therapy. Gene therapy is the delivery of specific genes to cancer cells, which are often carried by specially designed viruses. These include normal genes that are delivered into the center of cancer cells; as the cancer cells divide, the working genes that were inserted in the cell replace the abnormal genes that contribute to cancer growth. Chemotherapy. Several other drugs have shown promise for advanced pancreatic cancer and have been studied in combination with gemcitabine. These include new formulations of paclitaxel (Taxol) that may improve drug delivery, such as nanoparticle albumin-bound paclitaxel (Abraxane) and EndoTAG. These drugs are currently being tested in clinical trials. Another drug called tegafur-gimeracil-oteracil potassium (TS-1) is a drug similar to capecitabine in how it works; it is approved for use in parts of Asia, but is not widely available in the United States. Cancer stem cells.Pancreatic cancer stem cells are cells in the tumor that may be particularly resistant to standard therapies. Research is currently focused on identifying treatments that may specifically target those cancer stem cells. Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current pancreatic cancer treatments in order to improve patients’ comfort and quality of life. Learn more about common statistical terms used in cancer research. Looking for More about Current Research? If you would like additional information about the latest areas of research regarding pancreatic cancer, explore these related items:
Or, choose “Next” (below, right) to continue reading this detailed section. Questions to Ask the Doctor
Talking often with the doctor is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your cancer care and treatment. You are also encouraged to ask additional questions that are important to you.
Patient Information Resources
In addition to Cancer.Net, there are other sources of information about this type of cancer available online. Cancer.Net maintains a list of national, not-for-profit organizations that may be helpful in finding additional information, services, and support. As always, be sure to talk with your doctor about questions you may have about information you find about this disease. View organizations that offer information on this specific type of cancer. |
