Pancreatic cancer is a disease in which normal cells in the pancreas malfunction and begin to grow uncontrollably. These cancerous cells can eventually interfere with proper functioning of the pancreas, grow outward to involve adjacent blood vessels and organs, and metastasize (spread) to other parts of the body.

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 composed of two major components: exocrine and endocrine. The exocrine component, made up of ducts and acini (small sacs on the end of the ducts), produces enzymes (specialized proteins) that are released into the small intestine to help the body digest and break down food, particularly fats. The endocrine component of the pancreas is made up of specialized cells clustered together in islands within the organ, called islets of Langerhans. These cells produce hormones, the most critical one being insulin, an important substance that helps control the amount of sugar in the blood.

The most commonly seen pancreatic cancer is called ductual adenocarcinoma, or simply, adenocarcinoma. Tumors that begin in the islets of Langerhans are known as islet cell tumors, pancreatic neuroendocrine, or neuroendocrine tumors, and rarely occur. These neuroendocrine tumors may produce chemicals such as insulin, or may grow without producing such hormones (non-functioning). If the tumor produces a hormone(s), the hormone(s) may cause metabolic imbalances, such as a very low blood sugar level (such as the case with insulinomas) or a very high blood sugar level (such as with glucagonomas), or other problems like severe diarrhea (a symptom of VIPomas, which produce a substance called vasoactive intestinal peptide). It is important to distinguish a neuroendocrine tumor from an adenocarcinoma of the pancreas because each act and are treated very differently from one another. Pancreatic neuroendocrine tumors are discussed in greater detail in a separate section; the remainder of this article will focus on adenocarcinomas.

Because pancreatic cancer often does not cause specific symptoms early on in its development, it may not be detected until the cancer has metastasized beyond the pancreas to other areas of the body, such as the liver, lungs, or the peritoneum (the tissue lining the abdomen).

Statistics

In 2008, an estimated 37,680 adults (18,770 men and 18,910 women) in the United States will be diagnosed with pancreatic cancer. It is estimated that 34,290 deaths (17,500 men and 16,790 women) from this disease will occur this year. Pancreatic cancer is the tenth most common cancer in men and the fourth leading cause of cancer death in men and women. Most pancreatic cancers are adenocarcinomas, and it is to those tumors that the following statistics apply.

The overall one-year relative survival rate (percentage of patients who survive at least one year after the cancer is detected, excluding those who die from other diseases) of patients with pancreatic cancer is 24%, and the five-year relative survival rate (percentage of patients who survive at least five years after the cancer is detected, excluding those who die from other diseases) is approximately 5%. If the cancer is detected at an early stage where surgical resection (surgical removal of the tumor) is possible, the five-year relative survival rate is about 20%.

Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of cases of 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 five-year (or some-times one-year) intervals, they may not represent advances made in the treatment or diagnosis of this cancer.

Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2008.

To learn about the cancer terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: Basic Oncology Terms.

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The pancreas is comprised of the head, body, and tail. Pancreatic cancer most commonly arises at the head of the pancreas.

A risk factor is anything that increases a person’s chance of developing cancer. Some risk factors can be controlled, such as smoking, and some cannot be controlled, such as age and family history. 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 communicating them to 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 cases occur in people older than 60.

Gender. More men are diagnosed with pancreatic cancer than women.

Race. Black people are more likely than Asians, Hispanics, or white people to develop pancreatic cancer.

Smoking. Smokers are two to three times more likely to develop pancreatic cancer than nonsmokers.

Obesity and diet. Eating a high-fat diet 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 about the degree of risk that diabetes confers. It is now believed that long-term diabetes does increase an individual’s risk of developing pancreatic cancer to a modest degree.

Family history. A person’s chance of developing this cancer increases three-fold if a first-degree relative (mother, father, sister, or brother) had pancreatic cancer. That risk increases even further if more first-degree relatives are affected. Melanoma that runs in families and certain hereditary forms of colon, breast, and ovarian cancer are also associated with an increased risk of developing pancreatic cancer. Read more about The Genetics 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. For more information on this condition, visit Cancer.Net’s Guide to Hereditary Pancreatitis.

Chemicals. Exposure to certain chemicals (such as pesticides, benzene, certain dyes, and petrochemicals) may increase the risk of developing pancreatic cancer.

People with pancreatic cancer may experience the following symptoms. 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 on this list, please talk with your doctor.

Doctors often refer to pancreatic cancer as a silent disease because it usually does not cause any symptoms in the beginning. Also, there are currently no blood tests that can reliably detect the cancer while it is in its early stage. As the cancer grows, symptoms may include:

• Yellow skin and eyes, darkening of the urine, itching, and clay-colored stool, which are signs of obstructive jaundice (blockage of the bile ducts)
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• Pain in upper abdomen or upper back
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• Painful swelling of an arm or leg due to a blood clot
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• Burning feeling in stomach or other gastrointestinal discomforts
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• Floating stools with a particularly bad odor, due to malabsorption of fats
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• Weakness
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• Loss of appetite
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• Nausea and vomiting
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• Unexplained weight loss

Doctors use many tests to diagnose cancer and determine 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 pancreatic 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:

• Age and medical condition
• The type of cancer
• Severity of symptoms
• Previous test results

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.

The following tests 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 result from a tumor at the head of the pancreas obstructing normal flow of bile (a substance produced in the liver) into the small intestine. 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, is rarely palpable, meaning the doctor cannot feel it. The presence of ascites (an abnormal buildup of fluid in the abdomen), may be another sign of cancer.

Laboratory 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. Many other causes of an elevated bilirubin exist, such as hepatitis, gall stones, or mononucleosis. CA 19-9 is a tumor marker (substances in the body that may be found at higher levels if cancer is present) that can be measured in the blood, and is frequently elevated in individuals with pancreatic cancer. An elevated CA 19-9 test by itself should not be used to make the diagnosis of pancreatic cancer, as CA 19-9 can be elevated in other noncancerous conditions as well (such as pancreatitis, cirrhosis of the liver, and blockage of the common bile duct).

Imaging procedures allow doctors to determine where the cancer is located and whether it has spread from the pancreas to other areas of the body. However, a pancreatic tumor often does not develop as a single large tumor mass, and therefore can sometimes be difficult to see on imaging.

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.

Positron emission tomography (PET) scan. In a PET scan, radioactive sugar molecules are injected into the bloodstream. Cancer cells absorb sugar more quickly than normal cells, so they light up on the PET scan. PET scans are often used to complement information gathered from CT scan, magnetic resonance imaging (MRI, see below), and physical examination. Sometimes, CT and PET scans can be performed after each other and the images are fused together (called fusion PET/CT). While used frequently in other types of cancer, PET scans are not routinely used to diagnose and monitor patients with pancreatic cancer.

Magnetic resonance imaging (MRI). MRI uses magnetic fields, not x-rays, to produce detailed images of the body. MRI is used in select instances when a CT scan either cannot be performed for some reason or fails to yield conclusive results.

Ultrasound. An ultrasound uses sound waves to create a picture of the internal organs. A tumor generates different echoes of the sound waves than normal tissue does, so when the waves are bounced back to a computer and changed into images, the doctor can locate masses inside the body. There are two types of ultrasound devices: transabdominal and endoscopic.

• A transabdominal ultrasound device is placed on the abdomen and is slowly moved around by the doctor to produce an image of the pancreas and surrounding structures.
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• The endoscopic ultrasound (EUS) device consists of a thin, lighted tube that is passed through the patient's mouth and stomach and down into the small intestine in order to take a picture of the pancreas. This procedure is very specialized and requires a gastroenterologist (a doctor who specializes in the function and disorders of the gastrointestinal tract, including stomach, intestines, and associated organs) who has special training in this area. It is generally done under sedation, so the patient sleeps through the procedure.

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 the jaundice. Brushings, which can be obtained during this procedure, sometimes help confirm the diagnosis of cancer. The patient is lightly sedated during this procedure.

Percutaneous transhepatic cholangiography (PTC). In this 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 technique to obtain pancreas tissue is fine needle aspiration, in which a needle is inserted into the pancreas to aspirate (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 performed either by opening the abdomen or by using a laparoscopic approach to provide openings for a camera and surgical instruments.

Some patients, when having surgery or certain types of biopsies, elect to have some of their excess specimen frozen and sent to independent laboratories to have genetic and molecular profiles performed on their specimens. This process may help predict which treatments a patient may potentially respond to. The use of biospecimens in this manner has not been fully confirmed scientifically in controlled studies. However, with the increase in new drugs called targeted agents, 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.

To learn about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: Newly Diagnosed.

To learn more about what to expect during common diagnostic tests, read Cancer.Net: Tests and Procedures.

Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if 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). 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 routinely applied to pancreatic cancer; however, for completeness, it is discussed below. A more common classification is one that places pancreas cancer into three categories:

Resectable. This type of pancreatic cancer can be surgically removed. A tumor may lie within the pancreas or extend beyond it, but there is no involvement of the critical arteries or veins in the area. There is no evidence of any spread to areas outside of the pancreas. Approximately 10% to 15% of patients are diagnosed at this stage.

Locally advanced. This type is still confined to the area around the pancreas, but cannot be surgically removed because there is involvement of the critical arteries or veins, or the tumor directly extends to involve surrounding organs. There is no evidence of spread to any distant areas 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 involves 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 three categories, the oncology team can then plan a treatment strategy that is best suited to manage the disease.

TNM Staging System

Doctors also frequently use a tool called the TNM system to stage a 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 with pancreatic cancer as it is in other diseases.

The TNM system uses three criteria to judge the stage of the cancer: 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:

• How large is the primary tumor and where is it located? (Tumor, T)
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• Has the tumor spread to the lymph nodes? (Node, N)
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• Has the cancer metastasized to other parts of the body? (Metastasis, M)

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, there are regional lymph nodes (lymph nodes near the pancreas) and distant lymph nodes (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 (T1a, 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 (T1b, N0, M0).

Stage IIA: A tumor extends beyond the pancreas, but the tumor has not spread to nearby arteries/veins. It has not spread to any lymph nodes or other parts of the body.

Stage IIB: A tumor of any size has not spread to nearby arteries/veins. It has spread to lymph nodes but not to other parts of the body (T1, T2, 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 pancreatic cancer

Pancreatic cancer is called recurrent if the cancer has recurred (come back) after it was treated. It may be a locoregional recurrence (recurs within or close to the pancreas), or it may be a distant recurrence (recurs in another part of the body, such as in distant organs, bones, or distant lymph nodes).

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, Sixth Edition (2002) published by Springer-Verlag New York, www.springer-ny.com.

The treatment of pancreatic cancer depends on the size and location of the tumor, whether the cancer has spread, and the person’s overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan.

If detected at an early stage, pancreatic cancer has a much higher chance of being successfully treated. However, there are treatments that can help control the disease even in patients with advanced pancreatic cancer that allows them to live longer. Many doctors advise people with pancreatic cancer to enroll in clinical trials, where they can participate in studies to test new drugs or therapies that may potentially treat the cancer.

The current treatment options for pancreatic cancer are surgery, radiation therapy, or chemotherapy. The specific treatment, alone or in combination, that is appropriate depends on many factors.

Surgery

Surgery may involve removing all or part of the pancreas, depending on the location and size of the cancer within the pancreas. If the cancer is still confined to the head of the pancreas, the surgeon may perform a Whipple procedure. This is an extensive operation where the surgeon removes the head of the pancreas and part of the small intestine, bile duct, and stomach, and then reconnects the digestive tract and biliary system. An experienced surgeon should perform this procedure.

If the cancer is located in the tail of the pancreas, the common operation is a distal pancreatectomy, in which the surgeon removes the tail and body of the pancreas, as well as the spleen. If the cancer diffusely involves the pancreas, or is present at multiple sites within the pancreas, a total pancreatectomy may be required, where the surgeon removes the entire pancreas, part of the small intestine, a portion of the stomach, the common bile duct, the gallbladder, the spleen, and nearby lymph nodes.

Sometimes before one of the above major operations, the surgeon may choose to start with a laparoscopy, in which several small holes are made in the abdomen, while a patient is under anesthesia, through which a tiny camera can be passed. This allows the surgeon to assess whether the cancer has spread to other areas within the abdominal cavity, in which case undertaking the full operation to remove the primary tumor would not be necessary.

Surgery may be combined with radiation therapy and/or chemotherapy. These may be given either before (neoadjuvant) or after surgery (adjuvant therapy), although they are most often administered postoperatively. The purpose of giving radiation therapy and chemotherapy is to try to decrease the likelihood of the cancer returning. For patients with borderline resectable cancer at diagnosis, radiation therapy and/or chemotherapy may be given first to try and increase the chance of resection. Gemcitabine (Gemzar)-based chemotherapy is commonly given after surgery, based on evidence that it improves disease-free survival. The role of radiation therapy after surgery remains somewhat controversial, although it is frequently used for individuals who have a high risk of their cancer coming back in the area of surgery (if it is a large tumor, or if there were close or positive surgical margins [area of tissue around the tumor site]).

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). In some instances, the patient may need surgery to create a bypass, even if the tumor itself cannot be completely removed.

Side effects of surgery include weakness, tiredness, and pain after the first few days after the procedure. The doctor can prescribe medicine to provide relief. The patient will need to stay in the hospital for several days and will probably need to rest at home for about one month. It may be difficult to digest food due to the removal of all or part of the pancreas. A special diet and medications may help. Also, the doctor can prescribe hormones and enzymes to replace those lost by the removal of the pancreas. Another common side effect is the development of diabetes due to the loss of insulin (produced by the pancreas), especially following a total pancreatectomy. In this situation, the doctor usually prescribes insulin.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. Radiation therapy is commonly given in pancreatic cancer in the following contexts: after surgery (although this remains controversial, as mentioned above); before surgery to try and “downstage” a borderline resectable tumor; for patients with locally advanced disease; and in select instances in patients with metastatic disease, (for example, severe pain relief).

Newer radiation therapy techniques, such as stereotactic radiosurgery (for example, Cyberknife), are starting to play more of a role in the treatment of pancreatic cancer, with the advantage that they can provide more localized treatment and require only single treatment sessions. However, these approaches have not been compared with the more conventional approach of delivering external-beam radiation therapy and should not be considered a replacement for it.

Often, chemotherapy will be administered simultaneously (at the same time) with radiation therapy because it can enhance the effects of the radiation therapy (called radiosensitization).

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. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished. 

The most common first-line chemotherapy used for the treatment of pancreatic cancer is gemcitabine. Gemcitabine has been shown not only to improve survival outcomes in patients with advanced pancreatic cancer, but also to improve cancer-related symptoms (for example, weight loss, pain, and weakness) in some of patients. A number of large studies have been conducted to evaluate whether combining gemcitabine with other chemotherapy (such as fluorouracil [5-FU, Adrucil] or platinum compounds, including cisplatin [Platinol], carboplatin [Paraplatin], and oxaliplatin [Eloxatin]) is more effective than gemcitabine alone. Some studies suggest modest improvements in outcomes using combination therapy; however, these combination treatments also tend to be associated with greater side effects. One large study demonstrated a modest survival benefit for patients with advanced pancreatic cancer receiving gemcitabine in combination with an oral medication called erlotinib (Tarceva) compared with gemcitabine alone. On this basis, erlotinib was approved by the U.S. Food and Drug Administration (FDA) in November 2005 for use in advanced pancreatic cancer in combination with gemcitabine. Another large study conducted in Europe demonstrated a survival benefit using another gemcitabine-containing drug combination, gemcitabine plus capecitabine (Xeloda). Therefore, while gemcitabine alone has represented the standard of care for patients with advanced pancreatic cancer since its approval in 1997, this standard may be evolving as certain combination regimens demonstrate small but real advantages without excessive side effects for patients. These combination regimens are best for patients with a good performance status, which is a measure of patient’s general strength and vigor.

For patients who are interested, participation in a clinical trial represents a good option. In order to make the progress needed to improve outcomes for pancreatic cancer, research must identify better approaches. Newer targeted therapies that target faulty genes or proteins that contribute to cancer growth and developmentare being actively investigated in individuals with pancreatic cancer (see Current Research).

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 undergoing 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. These side effects go away between treatments and after the treatments have ended. The doctor can suggest ways to relieve these side effects.

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications you've been prescribed, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions through Cancer.Net’s Drug Information Resources, which provides links to searchable drug databases.

Advanced pancreatic cancer

In advanced disease, the cancer has metastasized outside of the pancreas to nearby lymph nodes and to distant organs. In patients where the cancer has spread to other organs away from the pancreas, chemotherapy alone is generally the treatment of choice. The patient may also consider enrolling in clinical trials of new treatments. Radiation therapy or surgery are primarily for palliation (relief of symptoms).

For patients with locally advanced disease, the combination of chemotherapy and radiation therapy may, in rare instances, shrink the tumor enough so it can be removed by surgery, referred to as downstaging (see Radiation section above).

Pancreatic cancer that returns after treatment is known as recurrent cancer. The treatment options are generally the same as metastatic cancer, and usually center on chemotherapy, although surgery and radiation therapy may again be used for palliative purposes. Additionally, medication or a nerve block to reduce pain may be given. Clinical trials that test new therapies may also be available.

To learn about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: During Treatment.

Doctors and scientists are always looking for better ways to treat patients with pancreatic cancer. A clinical trial is a way to test a new treatment in order to prove that it is safe, effective, and possibly better than a standard treatment. Patients who participate in clinical trials are 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.

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 finding new drugs and other therapies is 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.

To join a clinical trial, patients must complete a learning process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so 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. 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 cancer clinical trials.

Cancer and its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments used in the past. Doctors also have many ways to provide relief to patients when such side effects do occur.

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 the person's overall health.

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 if they do happen. Also, be sure to communicate with your doctor about side effects you experience during and after treatment. For more information on the most common side effects of cancer and different treatments, along with ways to prevent or control them, visit Cancer.Net's section on Managing Side Effects, based on ASCO's curriculum.

In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Learn more about the importance of addressing these needs in Cancer.Net's section on Caring for the Whole Patient.

For more information on late effects or long-term side effects, please read the After Treatment section or talk with your doctor.

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.

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, can be checked during these visits. Routinely, CT scans do not need to be performed, but they may be appropriate depending on an individual’s symptoms and any abnormalities detected 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, 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 Healthy Living After Cancer.

To learn about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: After Treatment.

Research for pancreatic cancer is ongoing. The following advances may still be under investigation in clinical trials and may not be approved or available at this current time. Always discuss all diagnostic and treatment options with your doctor.

Early detection. Because the best chance of successful treatment occurs when pancreatic cancer is detected early, a number of efforts are ongoing to use specialized blood tests, diagnostic imaging tools, and other approaches to detect pancreatic cancer at its earliest stages, even at precancerous stages, before it has had the opportunity to spread. These screening efforts are typically being used for individuals at particularly high risk for pancreatic cancer, such as those with a strong family history or a known genetic predisposition to pancreatic cancer. It remains uncertain whether these tools will have broader applicability for the general population at large.

Genetic studies. In cancer, damaged or abnormal genes cause unregulated cell growth. Many of the new developments are based on fixing or correcting damaged genes and proteins. Genetic studies are being done to find defective genes that are involved in pancreatic cancer. Once genes are identified, doctors can begin to screen people who may be at risk for pancreatic cancer.

Biologic therapy. Biologic therapies represent newer treatment approaches designed to treat cancer based on researchers’ increasing understanding of the biology underlying disease processes. This includes:

• Immunotherapy, such as cancer vaccines, that stimulate a person’s immune system to recognize and attack cancer cells.
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• Specially designed viruses that carry normal genes into the core of cancer cells. As the cancer cells divide, functional genes replace defective ones. This is called gene therapy.
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• Antibodies and small molecule inhibitors that target a particular molecular feature of cancer cells. A number of these agents have already been approved in other cancer types and have been or are actively being studied in pancreatic cancer as part of large clinical trials nationwide. Erlotinib, which was approved for pancreatic cancer in 2005, is a small molecule inhibitor that disrupts signaling through a pathway called epidermal growth factor receptor (EGFR). This EGFR can be overactivated and lead to tumor cell growth. Other agents targeting different pathways important to tumor cell survival, division, and metastasis are under active investigation, both as single agents and as part of combination therapy. Some of the other agents that are being studied are bevacizumab (Avastin), an angiogenesis inhibitor (an antibody that disrupts new blood vessel formation to tumor cells), cetuximab (Erbitux), an antibody that disrupts signaling through EGFR, and axitinib, a VEGF (vascular endothelial growth factor) inhibitor.
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• Specifically designed vectors (DNA carriers) that introduce the gene TNF-alpha (for a therapeutic, anti-tumor protein into the tumor)
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• Exatecan, a topoisomerase (DNA enzyme) inhibitor
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• A number of trials of vaccines have been conducted or are in progress. To date, there have been no vaccines with sufficient outcomes for them to become a standard treatment. However, new vaccines are under testing through clinical trials.

Multidrug therapy. Multidrug therapy combines existing drugs to fight pancreatic cancer. Researchers think that killing cancer cells with different kinds of drugs may be more effective than using a single drug.

The website, www.cancermap.org, is the National Cancer Institute’s Cancer Research Map, a listing of all public and privately funded research in pancreatic cancer.

Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor:

• What type of pancreatic cancer do I have?
  
  
• Is my cancer limited to the pancreas?
  
  
• What is the stage of the disease? What does this mean?
  
  
• What are my treatment options?
  
  
• Is surgery a possibility to remove the cancer?
  
  
• How experienced is my surgeon in performing this type of operation?
  
  
• If surgery is not a possibility, what are my other options to treat my cancer?
  
  
• Can chemotherapy control my cancer?
  
  
• Should I receive radiation therapy? Why or why not?
  
  
• What is the goal of each treatment?
  
  
• What clinical trials are open to me?
  
  
• What treatment, or combination of treatments, do you recommend? Why?
  
  
• What are the possible short-term and long-term side effects of each treatment?
  
  
• What is my prognosis (chance of recovery)?
  
  
• What follow-up tests will I need, and how often will I need them?
  
  
• What support services are available to me? to my family?

Hirshberg Foundation for Pancreatic Cancer Research
2990 S. Sepulveda Blvd., Ste. 300C
Los Angeles, CA  90064
Phone: 310-473-5121
www.pancreatic.org

Lustgarten Foundation for Pancreatic Cancer Research
1111 Stewart Ave.
Bethpage, NY  11714
Toll Free: 866-789-1000
Phone: 516-803-2304
www.lustgarten.org

Michael Rolfe Pancreatic Cancer Foundation
910 W. Van Buren St., 3^rd Floor
Chicago, IL  60607
Phone: 312-492-7337
www.rolfefoundation.org

Pancreatica.org
149 Bonifacio Pl.
Monterey, CA  93940
Phone: 831-658-0600
www.pancreatica.org

Pancreatic Cancer Action Network (PanCAN)
2141 Rosecrans Ave., Ste. 7000
El Segundo, CA  90245
Toll Free: 877-2-PANCAN (726226)
www.pancan.org

View all of Cancer.Net's Patient Information Resources.