Treatment of Pancreatic Cancer

There are a number of treatment options available to physicians and oncologists who are treating cases of pancreatic cancer. The specific methods they avail themselves of are largely determined by the type, stage, and location of the tumor. The four most common techniques employed in pancreatic treatment (which are often executed in varying combinations with one-another) are surgery, radiation therapy, chemotherapy and clinical trials.


Surgery:

Surgical removal of a malignant tumor offers the best chances for a patient’s body to take long-term control over all types of pancreatic cancer, and to recover from their disease. 

  • When is Surgery Used? In general, patients who have discovered their cancer in either stage one or stage two – when it is localized, and before it has spread and grown - have tumors that are considered respectable (removable by surgery). 
  • Stage three and four tumors are almost always considered unrespectable, and are rarely candidates for surgery. Sometimes, however, patients with stage three or four pancreatic cancer employ methods of radiation therapy to shrink their tumor, which, if successful, may potentially lead to surgery becoming an option. Even if surgery cannot be utilized as a curative measure, it can still be considered for palliative (pain relieving) measures.
  • How Should I Choose a Surgeon? All forms of pancreatic cancer surgery are complicated, and it is prudent to find an experienced surgeon at a hospital that performs a high volume of these procedures. Numerous studies show that when patients undergo pancreatic surgery that is conducted by a physician who tackles the procedure frequently, the outcome is usually better, and fewer complications typically arise.
  • Are Pancreatic Cancer Surgeries Conducted With Other Treatments? Oftentimes, before a surgery is undertaken, a patient will be prescribed a course of treatment called neoadjuvant therapy, which is often comprised of chemotherapy, radiation therapy, or both. The purpose of neoadjuvant treatment is to shrink the size of the tumor and make it easier to remove during surgery. If blood vessels (meaning veins and arteries), have been affected by the tumor, neoadjuvant therapy could potentially improve the chances for a complete surgical removal. Conversely, adjuvant therapy is a course of treatment that is administered following a surgery. Patients can be at risk for a recurrence and reappearance of a cancer following surgery – even a successful surgery. Adjuvant therapy’s aim is to kill the microscopic cancer cells that may still be present post-surgery, and prevent the recurrence of a tumor.
  • What are The Different Types of Pancreatic Surgeries? There are three primary surgeries physicians perform for cases of pancreatic cancer, which are determined based on the location and size of the tumor.

The Whipple Procedure: The Whipple Procedure, or pancreaticoduodenectomy, is major surgery that usually takes between five and eight hours to complete, and is the most common surgery performed to remove tumors in the pancreas.  In a standard Whipple, the surgeon removes the head of the pancreas, the gallbladder, part of the duodenum (the uppermost portion of the small intestine), a portion of the stomach called the pylorus, and the lymph nodes near the head of the pancreas. The surgeon then reconnects the remaining pancreas and digestive organs so that pancreatic digestive enzymes, bile, and stomach contents will flow into the small intestine during digestion. 

Following a whipple, it can take a patient anywhere from several months to an entire year before they begin to feel somewhat normal again. The digestive system takes time to adjust, and often patients need to make permanent changes to their diet to aid in the recovery process.

Distal Pancreatectomy: A distal pancreatectomy is a procedure that is performed if a tumor is located within the body or tail of the pancreas.  During the surgery the body and the tail of the pancreas are removed, and sometimes the spleen is as well, while all other organs are left in place. This is a relatively rare pancreatic cancer surgery, due to the fact that tumors found in the body and tail of the pancreas are often not discovered until they are in their later stages, and have become unresectable.

Total Pancreatectomy: A total pancreatectomy is the complete removal of the entire pancreas. As with a whipple procedure, the gallbladder, part of the duodenum, the bottom portion of the stomach and local lymph nodes are removed along with the pancreas; the spleen may also be removed.

Because a pancreatectomy results in the total removal of the pancreas, patients who undergo the procedure become diabetic following its completion, and for the rest of their lives they will require regular insulin injections to control their blood sugar level. Patients will also require pancreatic enzyme supplements with meals in order to properly digest food.

Radiation Therapy:

Radiation therapy uses high-energy waves or particles to eradicate cancer cells and/or prevent them from growing. Unlike chemotherapy (which affects the entire body), radiation therapy takes aim at specific targets, and is considered a local treatment. Radiation therapy is often utilized before or after surgery, to either shrink a tumor or wipe out its remnants post-op, and protect against a recurrence. 

Physicians can prescribe courses of external radiation therapy (meaning they use proton beams or high intensity x-rays) and internal radiation therapy (brachytherapy – in which radiation is delivered through small amounts of radioactive material that is implanted in or near the cancer), though external is much more common for pancreatic cancer.

Receiving radiation therapy following a surgery, as part of adjuvant therapy is very common, and some studies have shown it greatly improves a patient’s prognosis.

Chemotherapy:

Chemotherapy is a course of cancer treatment that utilizes a mixture of drugs to destroy cancer cells by thwarting their attempts to grow and divide. It may be used in addition to surgery (either before or after a procedure – to either shrink a tumor prior to surgery, or eradicate its remnants following one), or as a primary course of action for tumors that are determined to be inoperable.

Chemotherapy can be both a highly effective undertaking and a harmful enterprise to undertake, as treatments not only attack malignant cells, but all rapidly dividing cells – including those that nourish a person’s body.  (Common side effects from chemotherapy include: fatigue, gastrointestinal discomfort, loss of appetite, lowered blood cell counts, and hair loss). However, most physicians agree that chemotherapy is an essential component of successful pancreatic cancer therapy, and the odds of a patient’s recovery drastically increases when an order of chemotherapy is employed in their treatment.  

The three most common chemotherapy drugs approved by the United States Food and Drug Administration for the treatment of pancreatic cancer are albumin-bound paclitaxel (ABRAXANE®), gemcitabine (Gemzar®) and fluorouracil (5-FU).

Clinical Trials:

Clinical trials are important research studies that evaluate novel treatment options prior to their widespread implantation. They are the principal methods researchers utilize to cultivate new treatment options for those afflicted with pancreatic cancer, and they can offer patients wholly new, sometimes radical, treatment options. Patients who enroll in such programs often enjoy the benefits of highly monitored promising new drugs and cutting edge courses of treatment.

Finding Clinical Trials: To search for a clinical study near you, the Rolfe Foundation encourages you to utilize the National Cancer Institute’s (NCI) Clinical Trials Search Function: which you can find below. If you live in the northeast, or have the ability to travel there, the Rolfe Foundation has particularly close ties to the work conducted by the excellent physicians of the Sydney Kimmel Comprehensive Care Center at Johns Hopkins Medicine in Baltimore, Maryland.

Search NCI Clinical Trials.

 

Considering Clinical Trials: If you are thinking of participating in a clinical trial, the Rolfe Foundation suggests you consider asking the following questions of your physicians:

Questions to Ask When Contemplating a Clinical Trial (from clincaltrials.gov):

  1. What is being studied?
  2. Why do researchers believe the intervention being tested might be effective? Why might it not be effective? Has it been tested before?
  3. What are the possible interventions that I might receive during the trial?
  4. How will it be determined which interventions I receive (for example, by chance)?
  5. Who will know which intervention I receive during the trial?  Will I know?  Will members of the research team know?
  6. How do the possible risks, side effects, and benefits of this trial compare with those of my current treatment?
  7. What will I have to do?
  8. What tests and procedures are involved?
  9. How often will I have to visit the hospital or clinic?
  10. Will hospitalization be required?
  11. How long will the study last?
  12. Who will pay for my participation?
  13. Will I be reimbursed for other expenses?
  14. What type of longterm follow-up care is part of this trial?
  15. If I benefit from the intervention, will I be allowed to continue receiving it after the trial ends?
  16. Will results of the study be provided to me?
  17. Who will oversee my medical care while I am in the trial?
  18. What are my options if I am injured during the study?

Targeted Therapy:

Targeted therapy is a type of cancer treatment that employs drugs to confront unique aspects of cancer cells, thereby inflicting little damage to healthy cells. For example, targeted therapies can be directed to block the cellular receptors or pathways that a physician suspects are playing a role in the development of cancer; this process can thereby effectively stop (or severely limit) the growth of a tumor.

There are not many courses of targeted therapy that are commonly utilized for cases of pancreatic cancer. The majority of targeted therapies that are employed are largely used in advanced cases where surgery is not an option (often in conjunction with other treatments such as chemotherapy and/or radiation therapy).

Targeted therapy is a promising field in the front lines of pancreatic cancer research, and is often a component of clinical trials.

Personalized Medicine:

Personalized medicine takes advantage of the knowledge that genetic differences in cancer patients can impact how well they respond to treatment.

Prior to the advent of personalized medicine, cancer patients with a specific type and stage of cancer usually received the same treatment. Advancements in research, however, soon made it evident that some treatments worked well for some patients but not as well for others. While cancer patients may still receive a standard treatment plan (such as surgery to remove a tumor), the attending physician may also recommend a more personalized cancer treatment plan.

The goal of personalized medicine is to discover the genetic mutations unique to a particular patient’s biological makeup, and those that are unique to that patient’s tumor. Physicians order biopsies to perform genetic tests, and may then use the information gleaned (called a molecular profile) to determine a course of treatment wholly unique for that patient, ostensibly by targeting the tumor-specific mutations unique to a given patient (a process called targeted therapy).

While it may be beneficial to discuss personalized medicine with your physicians, it is important to know that personalized medicine is a relatively new field in the world of pancreatic cancer, and is largely still an area of research. The primary obstacles being:

Not all genetic mutations that play a role in cancer development can be identified in a tumor. While some mutations are indeed identifiable in a tumor, there may not yet exist drugs that can target those specific mutations.