Pancreatic Cancer Treatments

This information is an interpretation of various studies that have been published in medical journals. The information below represents various views of nurses and doctors who serve on the American Cancer Society’s Cancer Information Database Editorial Board. Keep in mind that the information provided in this article is not designed to be taken as medical advice or to replace the opinion and judgment of your personal cancer care team. It is simply designed to help you make informed decisions together with your doctor. The general treatment options that will be discussed may not be what your doctor recommends, and there may be various reasons why. You should take the time to find out what specific treatments doctors recommend for you.

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Surgery for Pancreatic Cancer

Two kinds of surgery can be done to treat pancreatic cancer: potentially curative surgery and palliative surgery. The former is done when it is deemed possible to remove the tumor or resect it after the tests. Whereas the latter is done to relieve symptoms if the cancer is deemed too widespread to be removed.

Before the surgery, a ‘staging laparoscopy’ will be done. This is where the doctor makes small incisions to insert a laparoscope into the body to determine the extent of the cancer and if it would be possible to resect it. Biopsy samples may also be collected during the laparoscopy.

Potentially curative surgery

Studies have shown that removing only a part of pancreatic cancer does not improve survival rates. So potentially curative surgery is only performed if the surgeon believes that the entire cancer can be completely removed. This is a very complex surgery with a high risk of complications, and it can take weeks or months for patients to fully recover.

Less than 20% of pancreatic cancers appear to be confined to the pancreas when initially detected. Even in these cases, some cancers may be found to be inoperable during surgery due to excessive growth. This can lead to either stopping the operation or proceeding with a smaller procedure aimed at relieving or preventing symptoms. This is because the planned extensive surgery would be unlikely to cure the cancer and could still result in major side effects, prolonging recovery time and delaying other treatments.

Surgery offers the only realistic chance to cure pancreatic cancer, but it does not always lead to a cure. Even if all visible cancer is removed, some cancer cells may have already spread to other parts of the body. They can potentially grow into new tumors over time, making them difficult to treat. Curative surgery is mainly performed for cancers in the head of the pancreas, as they often cause jaundice, allowing for early detection and complete removal. But surgeries for other parts of the pancreas are also done if it is possible to remove all of the cancer.

Pancreaticoduodenectomy

This is also called the Whipple procedure. This is the most common surgery for dealing with cancer in the head of the pancreas.

The surgeon removes the head of the pancreas and sometimes the body as well, along with nearby structures like part of the small intestine, bile duct, gallbladder, lymph nodes, and occasionally part of the stomach. The remaining bile duct and pancreas are then reconnected to the small intestine to allow bile and digestive enzymes to flow. The small intestine (or stomach and small intestine) is reattached to restore digestive continuity. This complex operation, typically performed through a large abdominal incision but sometimes laparoscopically, carries a high risk of life-threatening complications. Outcomes are significantly better when the surgery is performed by experienced surgeons at major cancer centers that frequently conduct the procedure. The complication rates are often below 5% compared to 15% at smaller hospitals with less experience. Having the surgery at a high-volume center performing at least 15-20 Whipple procedures annually is crucial for the best possible outcome.

But even under the most favorable circumstances, the following side effects can still be expected:

  • Leaking from the various connections between organs
  • Infections
  • Bleeding
  • Trouble with the stomach emptying after eating
  • Digestion problems
  • Weight loss
  • Changes in bowel habits
  • Diabetes
Distal Pancreatectomy

This operation involves the surgical removal of the tail of the pancreas or the tail and a portion of the body, along with the spleen. Since the spleen plays a crucial role in fighting infections, its removal increases the risk of certain bacterial infections. This necessitates specific vaccinations before the surgery. The procedure is employed to treat cancers located in the tail and body regions of the pancreas. However, by the time many of these tumors are detected, they have often already metastasized, rendering surgery an unsuitable option in numerous cases.

Total Pancreatectomy

This operation removes the entire pancreas, as well as the gallbladder, part of the stomach and small intestine, and the spleen. It may be considered if the cancer has spread throughout the pancreas but is still potentially removable. However, this extensive surgery is used less frequently than other procedures because it does not seem to provide a significant advantage, and it can lead to major side effects. Living without a pancreas necessitates insulin injections to manage diabetes, as the insulin-producing cells are removed, and pancreatic enzyme supplements are required to aid digestion. Additionally, patients must receive certain vaccinations before the surgery due to the removal of the spleen, which plays a role in fighting infections.

Palliative Surgery for Pancreatic Cancer

If the pancreatic cancer has spread too extensively to be completely removed, any surgery being considered would be palliative. This means it is aimed at relieving symptoms rather than curing the disease. Since pancreatic cancer can progress rapidly, most doctors do not recommend major palliative surgery, especially for patients in poor health. In some cases, surgery may be initiated with curative intent. But if the surgeon discovers during the operation that complete removal is not feasible, a less extensive palliative bypass surgery may be performed. This involves bypassing blockages caused by tumors in the head of the pancreas that obstruct the common bile duct, leading to pain, digestive issues, jaundice, nausea, and vomiting. The two main options to relieve bile duct blockage are bypass surgery to reroute the bile or inserting a small tube (stent) into the duct to keep it open.

Stent Placement

The most common approach to relieving a blocked bile duct caused by pancreatic cancer is to insert a stent (usually a small metal tube) through an endoscope passed down the throat and into the small intestine during a procedure. This is called endoscopic retrograde cholangiopancreatography (ERCP). Alternatively, it can also go through the skin during percutaneous transhepatic cholangiography (PTC). The stent helps keep the bile duct open even if the surrounding cancer applies pressure. Although it may become clogged after several months and require clearing or replacement. Larger stents can also be used to keep parts of the small intestine open if at risk of blockage. Bile duct stents may be placed before curative surgery, typically a couple of weeks prior, to help relieve jaundice and lower the risk of surgical complications.

Bypass surgery

For individuals who are healthy enough, another option for relieving a blocked bile duct caused by pancreatic cancer is bypass surgery. This involves rerouting the flow of bile from the common bile duct directly into the small intestine, bypassing the pancreas. It typically requires a large abdominal incision and can take weeks to recover. In some cases, the surgery can be performed laparoscopically, using several small incisions and specialized long surgical tools (keyhole surgery).

While placing a stent is often easier with a shorter recovery period, bypass surgery can offer certain advantages. It may provide longer-lasting relief than a stent, which may need to be cleared or replaced over time. Surgery is also an option if a stent cannot be placed for some reason. Additionally, during the procedure, the surgeon may be able to cut or inject alcohol into the nerves around the pancreas, potentially reducing or eliminating pain caused by the cancer reaching these nerves. In some cases, the end of the stomach is also disconnected from the duodenum and reconnected farther down the small intestine (gastric bypass). Thiscan help avoid potential future blockages and associated pain and vomiting. However, bypass surgery is still a major operation, so it's crucial to discuss the potential benefits and risks with the doctor and ensure you are healthy enough to undergo the procedure.

Ablation or Embolization Treatments for Pancreatic Cancer

Ablation and embolization are different ways of removing tumors that do not require surgery. They rarely cure the cancer alone, but they can be utilized if a patient is deemed too unhealthy to survive surgery.

Ablation

Ablation destroys tumors with extreme heat or extreme cold. This process can be effective if the tumor is smaller than an inch across. The following ablation methods may be used, depending on what your doctor deems most appropriate for your case:

  • Radiofrequency ablation (RFA)
  • Microwave thermotherapy
  • Ethanol (alcohol) ablation
  • Cryoablation

Embolization

Embolization involves injecting substances directly into the artery to block blood flow to cancer cells and kill them off. This may work for tumors larger than 2 inches across. The following types of embolization may be used depending on your case:

  • Arterial embolization
  • Chemoembolization
  • Radioembolization
Side Effects of Ablation and Embolization

Serious side effects are rare but still possible. The most common side effects of ablation and embolization usually occur in the short term, after the procedure, and may be as follows:

  • Abdominal pain
  • Fever
  • Bleeding
  • Infection
  • Nausea
  • Blood clots

Radiation Therapy for Pancreatic Cancer

Radiation therapy uses high-energy X-rays to kill cancer cells and can help treat some pancreatic cancers. It may be given after surgery (adjuvant treatment), often in combination with chemotherapy (chemoradiation or chemoradiotherapy), to reduce the risk of cancer recurrence. For borderline resectable tumors, radiation and chemotherapy may be administered before surgery (neoadjuvant treatment) to try to shrink the tumor and facilitate complete removal.

In cases where the cancer has spread beyond the pancreas and cannot be surgically removed, radiation therapy combined with chemotherapy may be used as part of the main treatment. Radiation is sometimes also used to help alleviate symptoms, such as pain, in people with advanced cancers or those who are not healthy enough for other treatments like surgery.

The type of radiation most commonly used to treat pancreatic cancer is external beam radiation therapy (EBRT), which focuses radiation from a source outside the body on the cancer. The procedure is painless and similar to getting an x-ray but with stronger radiation. Each treatment lasts only a few minutes, although setup time for positioning can be longer. Radiation treatments are typically given 5 days a week for several weeks.

Potential side effects of radiation therapy include:

  • Redness, blistering, and peeling
  • Nausea and vomiting
  • Diarrhea
  • Lethargy
  • Appetite loss
  • Weight loss
  • Lower blood counts, lead to increased infection chances

Chemotherapy for Pancreatic Cancer

Chemotherapy drugs are powerful anti-cancer drugs usually injected into the vein or taken as pills. They are useful for cancers in the advanced stages because they can reach further into the systems of the body. They are administered in cycles, with a rest period in between, because these drugs can easily wear down the patient.

For advanced pancreatic cancer, the following chemo drugs are used:

  • Gemcitabine
  • 5-fluorouracil (5-FU) or capecitabine (an oral 5-FU drug)
  • Irinotecan or liposomal irinotecan (Onivyde)
  • Platinum drugs: cisplatin or oxaliplatin
  • Taxanes: paclitaxel, docetaxel, or albumin-bound paclitaxel (Abraxane)

For adjuvant and neoadjuvant treatments, the following drugs are used:

  • Gemcitabine
  • 5-fluorouracil (5-FU)
  • Oxaliplatin
  • Albumin-bound paclitaxel (Abraxane)
  • Capecitabine (an oral 5-FU drug)
  • Cisplatin
  • Irinotecan

Chemotherapy is taxing on the body and is sure to cause some immediate side effects which may include:

  • Nausea and vomiting
  • Appetite loss
  • Hair loss
  • Mouth sores
  • Diarrhea or constipation
  • Blood problems like increased infection chances, less clotting, and shortness of breath due to lack of RBC

More extreme side effects of chemo can also occur:

  • Cisplatin, oxaliplatin, and paclitaxel can cause nerve damage, leading to numbness, tingling, or pain in the hands and feet.
  • Oxaliplatin can also cause nerve pain worsened by cold exposure for a day or so after treatment.
  • Cisplatin can damage the kidneys, so doctors try to prevent this by giving the patient lots of intravenous (IV) fluids before and after the drug is administered.
  • Cisplatin can affect hearing, so doctors may ask patients if they experience ringing in the ears or hearing loss during treatment.

Targeted Therapy for Pancreatic Cancer

There are special drugs outside of chemotherapy drugs that can be used to specifically target either mechanisms or proteins that help feed the tumors and allow them to grow. The following targeted drugs are used for pancreatic cancer treatment:

Erlotinib

Erlotinib (Tarceva) is a targeted therapy drug that inhibits the EGFR protein, which promotes cancer cell growth. For people with advanced pancreatic cancer, erlotinib can be given in combination with the chemotherapy drug gemcitabine, potentially providing greater benefit for some patients. It is taken orally as a once-daily pill. Common side effects include an acne-like rash on the face and neck, diarrhea, loss of appetite, and fatigue. More serious but less common side effects can involve lung, liver, or kidney damage; stomach or intestinal perforations; severe skin conditions; and bleeding or blood clotting issues.

PARP inhibitors

In a small subset of pancreatic cancers, the tumor cells harbor mutations in one of the BRCA genes (BRCA1 or BRCA2), which are involved in a DNA repair pathway. Olaparib (Lynparza) is a PARP inhibitor drug that blocks another DNA repair pathway. By inhibiting both pathways, this drug makes it extremely difficult for tumor cells with a BRCA mutation to repair damaged DNA, often leading to their death. Olaparib can be used to treat advanced pancreatic cancer in people with a known or suspected BRCA gene mutation, whose cancer has not progressed after at least 4 months of chemotherapy that included a platinum drug like oxaliplatin or cisplatin.

While olaparib has demonstrated the ability to shrink or slow the growth of some advanced pancreatic cancers, its impact on overall survival is not yet clear. The drug is taken orally, typically twice a day. Potential side effects include: 

  • Nausea
  • Vomiting
  • Diarrhea or constipation
  • Fatigue
  • Dizziness
  • Loss of appetite
  • Taste changes
  • Anemia
  • Low white blood cell counts (increased infection risk)
  • Abdominal pain
  • Muscle and joint pain. 

Less common but more serious side effects can involve lung inflammation and the development of certain blood cancers, such as myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML).

NTRK Inhibitors

A small subset of pancreatic cancers harbor mutations in one of the NTRK genes, which can drive abnormal cell growth and cancer development. Larotrectinib (Vitrakvi) and entrectinib (Rozlytrek) are targeted therapies that inhibit the proteins produced by the mutated NTRK genes. They can be used to treat advanced pancreatic cancer with an identified NTRK gene alteration, typically when the cancer continues to progress despite other treatments. These oral medications are taken as once or twice daily pills. Common side effects include dizziness, fatigue, nausea, vomiting, constipation, weight gain, and diarrhea. Less frequent but more serious adverse effects may involve abnormal liver tests, cardiac issues, and confusion.

Immunotherapy for Pancreatic Cancer

Immunotherapy for cancer treatment involves manipulating the ‘checkpoint proteins’ of the immune system to help the body fight cancer more vigorously. The immune system has checkpoints that prevent it from cannibalizing healthy tissue and organs. By applying immune checkpoint inhibitors, doctors can override this control system and let your immune system loose on the cancer cells.

PD-1 inhibitors

Pembrolizumab (Keytruda) is a drug that targets the PD-1 checkpoint protein on T cells, which normally helps prevent these immune cells from attacking the body's cells. By blocking PD-1, this drug boosts the immune system's response against pancreatic cancer cells and can often shrink tumors. It is administered as an intravenous (IV) infusion every 2 or 3 weeks.

The Common side effects include fatigue, cough, nausea, itching, skin rash, decreased appetite, constipation, joint pain, and diarrhea. But by removing the brakes on the immune system, pembrolizumab can sometimes cause the immune system to attack other parts of the body. This may lead to potentially serious or life-threatening problems in the lungs, intestines, liver, hormone-making glands, kidneys, or other organs. It is crucial to promptly report any new side effects to the healthcare team. If severe side effects occur, treatment may need to be stopped, and high doses of corticosteroids may be given to suppress the overactive immune response. Careful monitoring and management of side effects are essential when using this immunotherapy drug.

If you or a loved one have suffered from a misdiagnosis or delayed diagnosis for your pancreatic cancer or from negligence during your treatment that caused you more harm, contact us at 833-PORTER9, or e-mail us at info@porterlawteam.com to discuss the details of our experience representing other clients and the results we were able to obtain in the past for clients who are suffering as you are. In many ways, our results speak for themselves, and we will stand ready to help you and your family in your time of greatest need.

Last Updated on March 25, 2024 by Michael S. Porter
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