Pancreatic Cancer

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Treatment depends on the type of pancreatic cancer, stage of the disease, and the patient's general health. Your test results will help your doctor plan a treatment program for you. Your doctor will discuss the risks and benefits of various treatment options with you and your family. Ask your medical team about your concerns so that you will understand and feel comfortable with your treatment decision.

The purpose of cancer treatment is to remove the cancer, shrink the tumor, or stop its growth. Generally, there are three forms of treatment for pancreatic cancer: surgery, chemotherapy, and radiation treatment. These treatments may be used alone or in combination, depending on the stage of the cancer. Surgery removes the cancer, and chemotherapy and radiation treatment work to kill or stop the growth of cancer cells.

This section has more information on:

  • Staging of Pancreas Cancer
  • Surgery
  • Treatment for Jaundice
  • Treating Pain Caused by Pancreatic Cancer
  • Chemotherapy and Radiation Treatment
  • Palliative Care
  • Staging of Pancreatic Cancer

    Staging is the process of describing the extent or spread of the disease at the time of diagnosis. It is essential in choosing the treatment and assessing prognosis. Doctors determine a cancer's stage based on the tumor's size, location, and whether it has spread to other areas of the body.

    Every person is unique, and your age, disease, and overall health will affect how your body responds to cancer and treatment. If you have questions about your prognosis, ask your doctor. Your doctor will know about your specific case and can discuss these concerns with you. Based on experience, he or she can advise you about what to expect—not just about life expectancy—but also about ways to improve the quality of your life.

    • Stage 0: Cancer is found only in the lining of the pancreas. Stage 0 is also called carcinoma in situ.
    • Stage I: Cancer is found only in the pancreas. Stage I is divided into stage IA and stage IB, based on the tumor size.
    • Stage IA: Tumor is 2 centimeters or smaller
    • Stage IB: Tumor is larger than 2 centimeters
    • Stage II: Cancer may have spread directly to nearby tissue and organs, or it may have spread to lymph nodes near the pancreas. Stage II is divided into stage IIA and IIB, based on where the cancer has spread.
    • Stage IIA: Cancer has grown outside the confines of the pancreas, but has not spread to nearby lymph nodes.
    • Stage IIB: Cancer has spread to nearby lymph nodes and may have spread to nearby tissue and organs.
    • Stage III: Cancer has spread to the major blood vessels near the pancreatic and may have spread to nearby lymph nodes. Stage III cancers are not generally surgically removable.
    • Stage IV: Cancer has spread to distant organs, such as the liver and lung. It also may have spread to organs and tissues near the pancreas or to lymph nodes.
    • Many doctors who treat pancreatic cancer prefer a simple staging system with only these three stages:

      • Potentially Resectable
      • Locally Advanced
      • Metastatic
      • Potentially resectable

        Potentially resectable pancreatic cancer is considered operable, or removable by surgery. In this case, the pancreatic cancer has not spread beyond the region of the pancreas and does not involve important blood vessels or organs around the pancreas. Potentially-resectable tumors account for no more than 20 percent of all cases of pancreatic cancer. The majority of patients have more advanced disease at the time of diagnosis.

        Patients with potentially resectable cancer may have preoperative therapy. Preoperative therapy is radiation and/or chemotherapy given before surgery. Postoperative therapy is given after surgery. Preoperative therapy offers several advantages over treatment using immediate surgery. Immediate surgery may prevent patients from receiving postoperative therapy due to poor recovery, whereas preoperative therapy allows all potential surgery patients to receive either chemotherapy and/or radiation treatment. Patients who are candidates for potentially resectable disease are generally well patients and make good candidates for preoperative therapy. Also, preoperative chemotherapy allows early treatment to microscopic metastasis.

        Of the patients who have immediate surgery for pancreatic cancer, at least 20 to 25 percent do not recuperate well enough to undergo chemotherapy or radiation treatment, or they require a long recovery period in order to receive such treatment.

        The primary goal of preoperative and adjuvant (post-operative) therapy is to reduce the risk of the cancer recurring locally or metastasizing to other organs.

        A secondary goal of preoperative therapy is for the tumor to respond to the treatment by shrinking or becoming smaller. A smaller tumor may allow for more complete surgical removal of the tumor and preservation of nearby tissue and organs. Based upon the stage of your cancer, your doctor may advise that you receive treatment before or after surgery.

        Locally Advanced

        Locally advanced pancreatic cancer has not spread beyond the pancreas but involves vital blood vessels or other organs. It is impossible to surgically remove the tumor at this stage, but surgery may be used to relieve symptoms such as a bile obstruction or jaundice.

        Approximately 50 percent of patients are diagnosed with locally advanced pancreatic cancer. Symptoms are usually directly related to the primary tumor. Historically, chemotherapy and radiation have been the standard treatments for patients with locally advanced disease. However, treatment strategies are always evolving and the sequence of particular treatments can vary (chemotherapy first, then chemotherapy plus radiation, or chemotherapy plus radiation, followed by more chemotherapy).

        Metastatic

        Metastatic—This pancreatic cancer has spread to other organs or areas outside of the pancreas. The cancer can no longer be surgically removed.

        Progress in the treatment of metastatic pancreatic cancer has been slow and the prognosis for these patients remains very poor. Symptom relief—including pain management—will be a primary goal of therapy.

        Discussions about end-of-life issues and planning are appropriate for patients diagnosed with metastatic pancreatic cancer.

        Surgery

        Potentially curative surgery is used when diagnostic tests suggest that it is possible to remove all the cancer. Most curative surgery is designed to treat cancers in the head of the pancreas, near the bile duct. Some of these cancers are found early enough because they block the bile duct and cause symptoms.

        Surgeries for other parts of the pancreas are mentioned below, but these are performed only when complete removal of the cancer will be possible.

        There are three procedures used to remove tumors of the pancreas:

        • Pancreaticoduodenectomy (Whipple procedure)
        • Distal Pancreatectomy
        • Total Pancreatectomy
        • Patients whose cancer cannot be surgically removed may have:

          • Palliative Procedures
          • Pancreaticoduodenectomy (Whipple procedure)

            The most commonly used operation for attempting to remove a cancer of the exocrine pancreas completely is a pancreaticoduodenectomy, sometimes called the Whipple procedure after the surgeon who first described this operation. This operation removes the head of the pancreas and sometimes the body of the pancreas as well. It also removes part of the stomach, the entire duodenum (first part of the small intestine), a small part of the jejunum (second part of the small intestine), and lymph nodes near the pancreas. The gallbladder and part of the common bile duct are removed and the remaining bile duct is attached to the small intestine so that bile from the liver can continue to enter the small intestine.

            This is a major operation that carries a relatively high risk of complications. When this operation is performed in cancer centers by surgeons experienced in the procedure, approximately 2 percent to 5 percent of patients die as a direct result of complications from surgery. When the operation is done in small hospitals or by doctors with less experience, up to 15 percent of patients may die because of surgical complications. Even with a skilled surgeon, about 30 percent to 50 percent of patients will suffer complications from the surgery. These include leaking from the various surgical connections, infections, and bleeding.

            For patients to have the most successful outcome, they must be treated by a specialized surgeon who has performed many of these operations at a referral center with extensive experience in pancreatic surgery.

            Only about 10 percent of cancers of the pancreas appear to be contained entirely within the pancreas at the time of diagnosis. Attempts to remove the entire cancer by surgery may be successful in some of these patients. But even when there appears to be no spread beyond the pancreas at the time of surgery, cancer cells too few to detect may already have spread to other parts of the body.

            Distal Pancreatectomy

            This operation removes only the tail of the pancreas or the tail and a portion of the body of the pancreas. The spleen is usually removed as well. This operation is used more often with islet cell tumors found in the tail and body of the pancreas.

            Total Pancreatectomy

            This operation was once used for tumors in the body or head of the pancreas. It removes the entire pancreas and the spleen. It is now seldom used to treat these types of tumors. When the entire pancreas is removed, patients are left without any islet cells, the cells that produce insulin. This means that patients who have this procedure will develop hard-to-manage diabetes. It is possible to live without a pancreas, but a person without a pancreas becomes totally dependent on injected insulin. Also, there doesn't seem to be any advantage to removing the whole pancreas.

            Palliative Procedures

            Palliative surgery may be performed if diagnostic tests indicate that the tumor is too widespread to be completely removed. This is done to relieve symptoms or prevent certain complications such as blockage of the bile ducts or the intestine by the cancer. If the cancer has spread too far to be removed completely by surgery, the doctors will focus on palliative treatments intended to relieve or prevent symptoms.

            Cancers growing in the head of the pancreas can block the common bile duct as it passes through this part of the pancreas. This may cause pain and digestive problems because the bile can't get into the intestine. The bile chemicals will accumulate in the bloodstream. There are two options for relieving bile duct blockage.

            One option is an operation that reroutes the flow of bile from the common bile duct directly into the small intestine and bypasses the pancreas. This operation requires an incision in the abdomen, and it may take several weeks to recover completely. One advantage is that during this procedure, the surgeon may be able to cut the nerves leading to the pancreas. This will reduce or relieve any pain that may be caused by the cancer.

            Another part of the palliative operation that can be performed is to reroute the stomach connection to the duodenum (the first part of the small intestine). Often, late in the course of pancreatic cancer, the duodenum becomes blocked by cancer. This will cause pain and vomiting that requires surgery. Bypassing the duodenum when the other palliative procedure is done can often avoid a second operation.

            A second option is to place stents (tubes) through an endoscope. In this procedure a doctor views the intestine through a long, lighted tube placed down the patient's throat, through the esophagus, through the stomach, and into the small intestine. The doctor can then insert a small length of tubing (the stent) through the endoscope. This tube helps keep the duodenum open and resists compression from the surrounding cancer. Stents can also be inserted into the bile duct, which is often blocked by the cancer in the pancreas. This is performed with an ERCP described above.

            In general, a surgical operation to relieve bile obstruction is considered when the cancer is too widespread to be removed completely by surgery but is still localized enough that the patient has a life expectancy longer than six months. If the cancer is more widespread or the patient is in a weakened condition, stent placement may be recommended.

            Treatment for Jaundice

            Jaundice is a condition in which a person's skin or whites of the eyes have a yellow discoloration. A person with jaundice may also have dark urine and light stool. Jaundice occurs when bilirubin, a substance produced by the liver, builds up in the blood. Normally, bilirubin travels from the liver down the bile duct and passes through the pancreas just before emptying into the first section of the small intestine, called the duodenum. If a tumor blocks the bile duct, bilirubin backs up into the liver, then spills into the blood. This causes a person to become noticeably yellow, or jaundiced.

            Jaundice can usually be relieved by placing a small tube called a biliary stent into the bile duct to hold it open. The stent is placed using endoscopic retrograde cholangiopancreatography (ERCP), a procedure in which a flexible telescope called an endoscope is inserted in the mouth, through the stomach, and into the first part of the small intestine. There, tiny tools are passed through the endoscope to deploy the stent.

            Jaundiced patients who have a biliary stent placed in their bile duct are at risk for an infection if the stent becomes blocked. A patient who has a biliary stent needs emergency treatment if he or she develops a fever (100°F or greater) or a return of jaundice.

            Treating Pain Caused by Pancreatic Cancer

            Pancreatic cancer can cause pain when the tumor presses on nerves or other organs near the pancreas. Many patients can manage this pain with medicines such as opioids. Opioids are a group of medicines that have been used to relieve pain for more than 100 years. When pain medicine is not enough, there are treatments that act on nerves in the abdomen to relieve the pain. The doctor may inject medicine into the area around affected nerves, or cut the nerves to block the feeling of pain. Radiation therapy or chemotherapy can also help relieve pain by shrinking the tumor.

            Chemotherapy and Radiation Treatment

            Chemotherapy uses drugs to stop the growth of cancer cells either by killing the cells or by stopping them from dividing. These drugs are given intravenously (through a vein) or by mouth. The frequency and duration of the chemotherapy schedule will depend on the particular type of drug that your doctor prescribes. Patients with potentially resectable pancreatic cancer may receive chemotherapy before or after surgery. Chemotherapy is often used to treat pancreas cancer that has metastasized. The kind of chemotherapy you receive and the length of your treatment will be determined by your doctor.

            Radiation treatment is a localized therapy that uses high-energy X-rays to destroy cancer cells. Patients receive a prescribed amount of radiation that is directed to the tumor and local lymph nodes. Often, patients receive low doses of chemotherapy along with radiation to increase the effectiveness of the treatment. Patients with resectable pancreas cancer may receive radiation therapy before or after surgery. The type of radiation used depends on the stage of the cancer. A radiation oncologist, a doctor who specializes in radiation therapy, will plan your radiation treatments. The length of your radiation treatment will be determined by your radiation oncologist.

            Patients usually receive chemotherapy and radiation on an outpatient basis, which does not require admission to the hospital.

            Chemotherapy and radiation therapy are powerful treatments that affect normal cells as well as cancer cells and may cause side effects. Common side effects include fatigue, decreased appetite, occasional nausea, abdominal cramping, and diarrhea. Ask your doctor, nurse, or other member of your healthcare team for information about which side effects you may experience and how to manage them.

            Palliative Care

            Palliative care is a special type of medical care that focuses on treating symptoms people may have when they are living with a chronic (long-lasting) illness such as cancer.

            In palliative care, the goal is to provide the best quality of life possible—even before someone becomes terminally ill. Palliative care can be used when a person is receiving treatment for a disease as well as when there is no useful treatment for the disease.

            Palliative care focuses on treating problems from the illness including pain, nausea, loss of appetite, depression, and fatigue. All symptoms are addressed, including physical, emotional, and spiritual problems. Another key feature of palliative care is its focus on not only the patient but the family as well. Chronic illness puts special stress on families, and having support can be very helpful. Talking about and planning for the future can help prepare a person and the person's family to make the best choices for everyone involved.

            Last reviewed on 10/13/09

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