Treatment

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.

This section outlines treatments that are the standard of care (the best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials as a treatment option when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, visit the Clinical Trials section.

When 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.

The current treatment options for pancreatic cancer are surgery, radiation therapy, and/or chemotherapy. The specific treatment plan recommended depends on many factors. Descriptions of the most common treatment options for pancreatic cancer are listed below.

Surgery

Surgery may involve removing all or part of the pancreas, depending on the location and size of the cancer within the pancreas. A surgical oncologist is a doctor who specializes in treating cancer using surgery. 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. In all of the above surgeries, nearby lymph nodes are removed as part of the operation.

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, through which a tiny camera can be passed while a patient is under anesthesia. This allows the surgeon to determine 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 appropriate.

In general, surgery may be combined with radiation therapy and/or chemotherapy. These may be given either before (neoadjuvant therapy) or after surgery (adjuvant therapy), although they are most often given afterwards. The purpose of giving radiation therapy and chemotherapy is to try to decrease the likelihood of the cancer returning. 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 and increase the chance of resection. Gemcitabine (Gemzar)-based chemotherapy is commonly given after surgery, based on evidence that it improves disease-free and overall 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 that contained cancer or may contain cancer]).

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. Learn more about cancer surgery.

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. Radiation therapy is commonly given in pancreatic cancer in the following situations: 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 occasionally in patients with metastatic disease, (for example, for relief of severe pain).

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 one or a small number of treatment sessions. However, these approaches have not been compared with the more conventional approach of delivering external-beam radiation therapy, which typically takes five to six weeks, and should not be considered a replacement for it.

Often, chemotherapy will be given simultaneously (at the same time) with radiation therapy because it can enhance the effects of the radiation therapy (called radiosensitization). However, chemotherapy given at the same time as radiation therapy generally 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. Learn more about radiation therapy.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. Some people may receive chemotherapy in their doctor's office; others may go to the hospital. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a specific time.

The most common first-line chemotherapy used for the treatment of pancreatic cancer is gemcitabine. Gemcitabine has been shown to improve survival outcomes in patients with advanced pancreatic cancer, as well as improve cancer-related symptoms (for example, weight loss, pain, and weakness) in some patients. A number of large studies have been conducted to evaluate whether combining gemcitabine with other drugs (such as fluorouracil [5-FU, Adrucil], capecitabine [Xeloda], or platinum compounds, including cisplatin [Platinol], 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 2005 for use in advanced pancreatic cancer in combination with gemcitabine. Another large study conducted in Europe suggested a survival benefit using the combination of gemcitabine plus capecitabine (Xeloda), although final results of this study have not yet been published. 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 treatments demonstrate small but real advantages with manageable side effects for patients. These combination treatments are best for patients with good general strength and vigor.

Additionally, if a tumor continues to grow following first-line treatment with a gemcitabine-based therapy, there may still be a benefit from additional treatment using different drugs if the patient’s overall health remains strong. For instance, one recently reported study showed that the combination of 5-FU and oxaliplatin is effective in some patients as second-line treatment.

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. Certain drugs used in pancreatic cancer are also associated with specific side effects. Erlotinib, for example, frequently causes a skin rash similar to acne, and 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. These side effects typically go away between treatments and after the treatments have ended. The doctor can suggest ways to relieve these side effects.

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.

Advanced pancreatic cancer

In advanced disease, the cancer has metastasized beyond 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 to improve a person’s quality of life).

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 Therapy section above).

Recurrent cancer

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.

Find out more about common terms used during cancer treatment.