Treating pancreatic cancer by stage

cancer treatments

Most of the time, the treatment of pancreatic cancer is based on its stage – how far it has spread in the body. But other factors, such as a person’s overall health, can also affect treatment options. Talk to your doctor if you have any questions about the treatment plan he or she recommends.

It is hard to stage pancreatic cancer accurately using imaging tests. Doctors do their best to decide before treatment whether there is a good chance the cancer is resectable – that is, if it can be removed completely. But sometimes cancers turn out to have spread farther than was first thought.

Exocrine pancreatic cancer

Resectable: Surgeons usually consider pancreatic cancer to be resectable if it looks like it is still within the pancreas or doesn’t extend far beyond the pancreas. Most pancreatic cancers that have reached nearby large blood vessels are not resectable.

If imaging tests show a reasonable chance of removing the cancer completely, surgery is the preferred treatment if possible, as it offers the only realistic chance to cure this disease. Based on where the cancer started, usually either a Whipple procedure (pancreaticoduodenectomy) or a distal pancreatectomy is used. Sometimes even when a cancer is thought to be resectable, it becomes clear during the surgery that not all of it can be removed. If this happens, continuing the operation might do more harm than good. The surgery might be stopped, or the surgeon might continue with a smaller operation with a goal of relieving or preventing problems such as bile duct blockage.

Even when surgery has removed all of the tumor that can be seen, the cancer often comes back. Giving chemotherapy (chemo), either alone or with radiation therapy (chemoradiation), after surgery (known as adjuvant treatment ) might help some patients live longer. The chemo drugs most often used are gemcitabine (Gemzar) or 5-FU.

Some patients are given chemo, either alone or with radiation therapy, before surgery (known as neoadjuvant treatment ). Some doctors prefer giving chemo before surgery because the recovery after surgery is often long, which can delay or even prevent its use. Neoadjuvant treatment might also help shrink the tumor, which could make surgery easier. But it is not yet clear that this approach is better than giving the treatment after surgery. Some people who get neoadjuvant treatment might also be given chemo after surgery if they are healthy enough.

Borderline resectable: A small number of pancreatic cancers have reached nearby blood vessels but have not grown deeply into them or surrounded them. These cancers might still be removable by surgery, but the odds of removing all of the cancer are lower, so they are considered borderline resectable .

These cancers are often treated first with neoadjuvant chemotherapy (sometimes along with radiation). Imaging tests (and sometimes laparoscopy) are then done to make sure the cancer hasn’t grown too much to be removed. As long as it hasn’t, surgery is then done to remove it. This might be followed by more chemotherapy.

Another option might be to have surgery as the first treatment, followed by adjuvant chemotherapy (and possibly radiation). If, during the surgery, it becomes clear that not all of the cancer can be removed, continuing the operation might do more harm than good. The surgery might be stopped, or the surgeon might continue with a smaller operation with a goal of relieving or preventing problems such as bile duct blockage.

Locally advanced (unresectable): Locally advanced cancers have grown too far into nearby blood vessels or other tissues to be removed completely by surgery, but have not spread to the liver or distant organs and tissues. Surgery to try to remove these cancers does not help patients live longer. Therefore, if surgery is done in these cancers, it is to relieve bile duct blockage or to bypass a blocked intestine caused by the cancer pressing on other organs.

The standard treatment options for locally advanced cancers are chemo and/or chemoradiation. This treatment may help some patients live longer even if the cancer doesn’t shrink. Giving chemo and radiation together may work better to shrink the cancer, but this combination has more side effects and can be harder to take than either treatment alone.

Metastatic (widespread): Pancreatic cancers often first spread within the abdomen (belly) and to the liver. They can also spread to the lungs, bone, and brain.

These cancers have spread too much to be removed by surgery. Even when imaging tests show that the spread is only to one other part of the body, it has to be assumed that small groups of cancer cells (too small to be seen on imaging tests) have already reached other organs of the body.

Chemotherapy is the main treatment for these cancers. It can sometimes shrink or slow the growth of these cancers for a

time and might help people live longer, but it is not expected to cure the cancer.

Gemcitabine is the drug used most often. It can be used alone (especially for people in poor health), or it can be combined with other drugs like albumin-bound paclitaxel (Abraxane), erlotinib (Tarceva), or capecitabine (Xeloda).

Another option that may help patients live longer is a combination of chemo drugs called FOLFIRINOX. This consists of 4 drugs: 5-FU, leucovorin, irinotecan (Camptosar), and oxaliplatin (Eloxatin). This treatment might help patients live longer than getting gemcitabine alone, but it can have more severe side effects, so its use is limited to people who are otherwise healthy. There is a nationwide shortage of leucovorin at this time, which can sometimes limit the ability of doctors to give FOLFIRINOX.

Other treatments might also be used to help prevent or relieve symptoms from these cancers. For example, radiation therapy or some type of nerve block might be used to help relieve cancer pain, or a stent might be placed during an endoscopy to help keep the bile duct open.

Because the treatments now available don’t work well for many people, you may want to think about taking part in a clinical trial of new drugs or combinations of drugs.

Recurrent cancer: Cancer is called recurrent when it come backs after treatment. Recurrence of pancreatic cancer most often occurs first in the liver, but it may also spread to the lungs, bone, or other organs. When pancreatic cancer recurs, it is essentially treated the same way as metastatic cancer. This will likely include chemo if the person can tolerate it. Other treatments such as radiation therapy or stent placement might be used to help prevent or relieve symptoms from the cancer.

Cancer of the ampulla of Vater

The ampulla of Vater is the area where the pancreatic duct and the common bile duct empty into the duodenum (the first part of the small intestine). Cancer at this site (known as ampullary cancer ) can start in the pancreatic duct, the duodenum, or the common bile duct. In many patients, ampullary cancer can’t be distinguished from pancreatic cancer until surgery has been done.

These cancers often cause early symptoms such as jaundice, so they are often found while they are still resectable. Surgery with the Whipple procedure is often successful in treating these early stage cancers. Postoperative chemoradiotherapy is often recommended after surgery.

More advanced ampullary cancers are treated like pancreatic cancer.

Pancreatic neuroendocrine tumors (NETs)

Treatment of pancreatic NETs depends to a large extent on whether they can be removed completely or not. These tumors are more likely to be resectable than exocrine pancreas cancers. Most NETs that have not spread to distant parts of the body are resectable. Even some NETs that have spread might be resectable if they have not spread too far (such as only to a small extent in the liver).

Resectable: If the tumor is resectable, it will be removed by surgery. The procedure used depends on the type of tumor, its size, and its location in the pancreas. Laparoscopy may be done before resection to better locate and stage the tumor. Surgery can range from as little as enucleation (removing just the tumor) to as much as a Whipple procedure (pancreaticoduodenectomy). Lymph nodes are often removed to check for tumor spread.

Before any surgery, medicines are often given to control any symptoms caused by the tumor. Drugs to block stomach acid (like proton pump inhibitors) are used for gastrinomas. Often, people with insulinomas are treated with diazoxide to keep the blood sugar from getting too low. If the tumor was visible on somatostatin receptor scintigraphy (OctreoScan), octreotide (Somatostatin) may be used to control any symptoms.

Surgery alone is all that is needed for many pancreatic NETs, but after surgery, close monitoring is important to look for signs that the cancer may have come back or spread.

Unresectable: These tumors can’t be removed completely with surgery. Pancreatic NETs are often slow growing, so lab and imaging tests are used to monitor the tumor(s) and look for signs of growth.

People with cancers that have spread outside the pancreas often have symptoms like diarrhea or hormone problems. These can often be helped with drugs like octreotide, lanreotide, diazoxide, and proton pump inhibitors. Lanreotide might also slow the growth of the tumor.

If further treatment is needed, chemo or targeted drugs (such as sunitinib or everolimus) might be used, but this is usually delayed until the patient is having symptoms that can’t be controlled with other drugs or has signs of tumor growth on scans. Surgery or ablative techniques may also be used to treat metastases in the liver.

Last Medical Review: 06/11/2014

Last Revised: 01/09/2015

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