Pancreatic Cancer – Treatment Options

In cancer care, different types of doctors and other health care professionals often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. Cancer care teams include a variety of other health care professionals, such as physician assistants, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.

Descriptions of the common types of treatments used for pancreatic cancer are listed below, followed by an outline of treatments by stage. The current treatment options for pancreatic cancer are surgery, radiation therapy, chemotherapy, targeted therapy, and immunotherapy. Your care plan also includes treatment for symptoms and side effects, an important part of cancer care.

Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment.

When detected at an early stage, pancreatic cancer has a much higher chance of being successfully treated. However, there are also treatments that can help control the disease for patients with later stage pancreatic cancer to help them live longer.

The current treatment options for pancreatic cancer are surgery, radiation therapy, chemotherapy, and targeted therapy. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.

Surgery

Surgery for pancreatic cancer includes removing all or part of the pancreas, depending on the location and size of the tumor in the pancreas. An area of healthy tissue around the tumor is also often removed. This is called a margin. A goal of surgery is to have “clear margins” or “negative margins,” which means that there are no cancer cells in the edges of the healthy tissue removed.

A surgical oncologist is a doctor who specializes in treating cancer using surgery.

Only about 20% of patients with pancreatic cancer are able to have surgery because most pancreatic cancers are first diagnosed when the disease has already spread. If surgery is not an option, you and your doctor will talk about other treatment options.

Surgery for pancreatic cancer may be combined with systemic therapy and/or radiation therapy (see below). Typically, these additional treatments are given after surgery, called adjuvant therapy. However, systemic therapy and/or radiation therapy may sometimes be used before surgery to shrink a tumor. This is called neoadjuvant therapy or pre-operative therapy. After neoadjuvant therapy, the tumor is re-staged before planning surgery. Re-staging is usually done with another CT scan to look at the change in tumor size and what nearby structures and blood vessels it is affecting.

Different types of surgery are performed depending on the purpose of the surgery.

Laparoscopy. Sometimes, the surgeon may choose to start with a laparoscopy. During a laparoscopy, several small holes are made in the abdomen and a tiny camera is passed into the body while a patient receives anesthesia. Anesthesia is medication to help block the awareness of pain. During this surgery, the surgeon can find out if the cancer has spread to other parts of the abdomen. If it has, surgery to remove the primary tumor is generally not recommended.

Surgery to remove the tumor. Different types of surgery are used depending on where the tumor is located in the pancreas. In all of the surgeries discussed below, nearby lymph nodes are removed as part of the operation. More than 1 type of surgeon, as well as other specialists, will usually be involved in your surgery.

If the cancer is located only in the head of the pancreas, the surgeon may do a Whipple procedure. This is an extensive surgery in which the surgeon removes the head of the pancreas and the part of the small intestine called the duodenum, as well as the bile duct and stomach. Then, the surgeon reconnects the digestive tract and biliary system. An experienced pancreatic cancer surgeon should perform this procedure.
If the cancer is located in the tail of the pancreas, the common operation is a distal pancreatectomy. In this surgery, the surgeon removes the tail and body of the pancreas, as well as the spleen.
If the cancer has spread throughout the pancreas or is located in many areas in the pancreas, a total pancreatectomy may be needed. A total pancreatectomy is the removal of the entire pancreas, part of the small intestine, a portion of the stomach, the common bile duct, the gallbladder, and the spleen.

After surgery, you will need to stay in the hospital for several days and will probably need to rest at home for about a month.

Side effects of surgery include weakness, tiredness, and pain for the first few days after the procedure. Other side effects caused by the removal of the pancreas include difficulty digesting food and diabetes from the loss of insulin produced by the pancreas. Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have and how they can be managed.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy 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.

External-beam radiation therapy is the type of radiation therapy used most often for pancreatic cancer. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time. There are different ways that radiation therapy can be given:

Traditional radiation therapy is also called conventional or standard fraction radiation therapy. It is made up of daily treatments of lower doses of radiation per fraction or day. It is given over 5 to 6 weeks in total.
Shorter treatments of higher doses of radiation therapy given over as few as 5 days is called stereotactic body radiation (SBRT) or Cyberknife. This is a newer type of radiation therapy that can provide more localized treatment in fewer treatment sessions. Whether this approach works as well as traditional radiation therapy is not yet known, and it may not be appropriate for every person. It should only be given in specialized centers with experience and expertise in using this technology for pancreatic cancer and identifying who it will work best for.
Proton beam therapy is a type of external-beam radiation therapy that uses protons rather than x-rays. At high energy, protons can destroy cancer cells. It also lessens the amount of healthy tissue that receives radiation. Proton beam therapy may be given for a standard amount of time or for a shorter time like SBRT. It is not yet known whether it works better than standard radiation therapy, and it may not be an option for every person. It should be given in treatment centers that have the experience and skills needed to use this treatment for pancreatic cancer, which may only be available through a clinical trial.

Often, chemotherapy (see below) will be given at the same time as radiation therapy because it can enhance the effects of the radiation therapy, which is called radiosensitization. Combining chemotherapy and radiation therapy may occasionally help shrink the tumor enough so it can be removed by surgery. However, chemotherapy given at the same time as radiation therapy often has to be given at lower doses than when given alone.

Radiation therapy may be helpful for decreasing the likelihood of a pancreatic cancer returning or re-growing in the original location, but there remains much uncertainty as to how much, if at all, it lengthens a person’s life.

Side effects from radiation therapy may include fatigue, mild skin reactions, nausea, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished. Talk with your health care team about what you can expect and how side effects will be managed.

Therapies using medication

Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given through the bloodstream to reach cancer cells throughout the body. Systemic therapies are generally prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication.

Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

Chemotherapy is the main type of systemic therapy used for pancreatic cancer. However, targeted therapy and immunotherapy are occasionally used and are being studied as potential treatments.

Each of these types of therapies are discussed below in more detail. A person may receive only 1 type of systemic therapy at a time or a combination of systemic therapies given at the same time. They can also be given as part of a treatment plan that includes surgery and/or radiation therapy.

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.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by ending the cancer cells’ ability to grow and divide. A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time. There is usually a rest period in between cycles. A patient may receive 1 drug at a time or a combination of different drugs given at the same time. The following drugs are approved by the US Food and Drug Administration (FDA) for pancreatic cancer:

Capecitabine (Xeloda)
Erlotinib (Tarceva), a type of Targeted therapy (see below)
Fluorouracil (5-FU)
Gemcitabine (Gemzar)
Irinotecan (Camptosar)
Leucovorin (Wellcovorin)
Nab-paclitaxel (Abraxane)
Nanoliposomal irinotecan (Onivyde)
Oxaliplatin (Eloxatin)

There are generally more side effects when 2 or more drugs are used together. Combination treatments are usually best for patients who are able to carry out their usual activities of daily living without help.

The choice of which combination to use varies depending on the cancer center and often depends on the oncologist’s experience with the drugs, as well as the different side effects and a patient’s overall health. For pancreatic cancer, chemotherapy may be described by when and how it is given:

First-line chemotherapy. This is generally the first treatment used for people with either locally advanced or metastatic pancreatic cancer (see Stages).
Second-line chemotherapy. When treatment does not work or stops working to control cancer growth, the cancer is called refractory. Sometimes, first-line treatment does not work at all, which is called primary resistance. Or, treatment may work well for a while and then stop being effective later, which is sometimes called secondary or acquired resistance. In these situations, patients may benefit from additional treatment with different drugs if the patient’s overall health is good. There is significant ongoing research focused on developing other new treatments for second-line, as well as third-line treatment and beyond. Some of these have shown considerable promise.
Off-label use. This refers to a drug being given for a condition not listed on its label. This means that it is not being given for the condition(s) that the drug is specifically approved for by the FDA. It can also mean that the drug is being given differently than the instructions on the label. An example of this is if your doctor wants to use a drug only approved for breast cancer to treat pancreatic cancer. Using a drug off-label is only recommended when there is solid evidence that the drug may work for another disease not included on the label. This evidence may include previously published research, promising results from ongoing research, or results from molecular tumor testing that suggest that the drug may work. However, off-label use of drugs may not be covered by your health insurance provider. Exceptions are possible, but it is important that you and/or your health care team talk with your insurance provider before this type of treatment begins.

Side effects of chemotherapy

The side effects of chemotherapy depend on which drugs the you receive. In addition, not all patients have the same side effects. Side effects can include poor appetite, nausea, vomiting, diarrhea, gastrointestinal problems, rash, mouth sores, hair loss, and a lack of energy. People receiving chemotherapy also are more likely to have low levels of white blood cells, red blood cells, and platelets, which give them a higher risk of anemia, infections, and bruising and bleeding easily.

Certain drugs used in pancreatic cancer are also linked with specific side effects. For example, 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. Oxaliplatin can cause cold sensitivity and numbness and tingling in the fingers and toes, called peripheral neuropathy. Peripheral neuropathy is a side effect of nab-paclitaxel as well. These side effects typically go away between treatments and after the treatments have ended, but some can be longer-lasting and can worsen as treatment continues. Your doctor can suggest ways to relieve these side effects. If the side effects are severe, your doctor may reduce the chemotherapy dose or pause chemotherapy for a short time.

Targeted therapy

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.

Not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. This helps doctors better match each patient with the most effective treatment whenever possible. In addition, research studies continue to find out more about specific molecular targets and new treatments directed at them.

The targeted therapy erlotinib is approved by the FDA for patients with advanced pancreatic cancer in combination with gemcitabine. Erlotinib blocks the effect of the epidermal growth factor receptor (EGFR), a protein that can become abnormal and help cancer grow and spread. Side effects of erlotinib include a skin rash similar to acne, diarrhea, and fatigue. Talk with your doctor about possible side effects for a specific medication and how they can be managed.

Immunotherapy

Immunotherapy, also called biologic therapy, is designed to boost the body’s natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.

Immune checkpoint inhibitors, which include PD-1 antibodies, may be an option for treating pancreatic cancer. The immune checkpoint inhibitor pembrolizumab (Keytruda) may be an option for pancreatic cancers that are MSI-high.

Different types of immunotherapy can cause different side effects. Talk with your doctor about possible side effects of the immunotherapy recommended for you.

Care for symptoms and side effects

Cancer and its treatment often cause side effects. In addition to treatments intended to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care is any treatment that focuses on reducing symptoms, improving quality of life, and supporting patients and their families. Any person, regardless of age or type and stage of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process. People often receive treatment for the cancer at the same time that they receive treatment to ease side effects. In fact, people who receive both at the same time often have less severe symptoms, better quality of life, and report they are more satisfied with treatment. Palliative care should not be confused with hospice care, which is discussed further below.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional support, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, or radiation therapy. Talk with your doctor about the goals of each treatment in the treatment plan.

Before treatment begins, talk with your health care team about the possible side effects of the specific treatment plan and palliative care options. During and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it can be addressed as quickly as possible.

Supportive care for people with pancreatic cancer includes:

Palliative chemotherapy. Any chemotherapy regimen discussed above may help relieve the symptoms of pancreatic cancer, such as lessening pain, improving a patient’s energy and appetite, and stopping or slowing weight loss. This approach is used when the cancer has spread and cannot be cured, but the symptoms of the cancer can be improved with chemotherapy. When making decisions about palliative chemotherapy, it is important that you and your doctor weigh the benefits with the possible side effects and consider how each treatment might affect your quality of life.
Relieving bile duct or small intestine blockage. If the tumor is blocking the common bile duct or small intestine, placing a tiny tube called a stent can help keep the blocked area open. This procedure can be performed using nonsurgical approaches, such as ERCP, PTC, or endoscopy (see the Diagnosis section for more information). A stent can be either plastic or metal. The type used depends on the availability, cost, a person’s expected lifespan, and whether the cancer will eventually be removed with surgery. In general, plastic stents are less expensive and are easier to insert and remove, but need to be replaced every few months, are associated with more infections, and more likely to move out of place. Stents are typically placed inside the body, but sometimes, a tube may need to be placed through a hole in the skin of the abdomen to drain fluid, such as bile. This is called percutaneous drainage. Sometimes, a patient may need surgery to create a bypass, even if the tumor itself cannot be completely removed.
Improving digestion and appetite. A special diet, medications, and specially prescribed enzymes may help a person digest food better if their pancreas is not working well or has been partially or entirely removed. Meeting with a nutritionist is recommended for most patients, especially those who are losing weight and have a poor appetite because of the disease.
Controlling diabetes. Insulin will usually be recommended if a person develops diabetes due to the loss of insulin produced by the pancreas, which is more common after a total pancreatectomy.
Relieving pain and other side effects. Morphine-like drugs called opioid analgesics are often needed to help reduce pain. Special types of nerve blocks done by pain specialists may also be used. A type of nerve block is a celiac plexus block, which helps relieve abdominal or back pain. During a nerve block, the nerves are injected with either an anesthetic to stop pain for a short time or a medication that destroys the nerves and can relieve pain for a longer time. A nerve block can be performed either percutaneously (through the skin) or with an endoscopic ultrasound (see above). Depending on where the tumor is located, radiation therapy can sometimes be used to relieve pain.

Recommended supportive care may also include complementary therapies. It is important that you talk with your doctor before trying any complementary therapies to make sure they do not interfere with your other cancer treatments.

Palliative and supportive care is not limited to managing a patient’s physical symptoms. There are also emotional and psychological issues patients experience that can be managed with professional help and support, such as anxiety, depression, help with coping skills, and the overall difficulty of dealing with cancer. Cancer also affects caregivers and loved ones, and they are encouraged to develop support networks as well.

Treatment options by stage

Below are some of the possible treatments based on the stage of the cancer. The information below is based on ASCO guidelines for the treatment of pancreatic cancer. Your care plan may also include treatment for symptoms and side effects, an important part of pancreatic cancer care. Also, patients with any stage of pancreatic cancer are encouraged to consider clinical trials as a treatment option. Talk with your doctor about all of your treatment options. Your doctor will have the best information about which treatment plan is recommended for you.

Potentially curable pancreatic cancer (also called resectable and borderline resectable pancreatic cancer)

Surgery. Removal of the tumor and nearby lymph nodes if there are no signs that the disease has grown beyond the pancreas or spread to other parts of the body.

Treatment before surgery, also called neoadjuvant therapy or pre-operative therapy. Chemotherapy, with or without radiation therapy, is regularly used for patients with borderline resectable pancreatic cancer. It is done to try to shrink the tumor and increase the chance that the surgeon can remove the tumor with clear margins. Even for patients with resectable pancreatic cancer, neoadjuvant therapy is also sometimes recommended.

Treatment after surgery, also called adjuvant therapy or post-operative therapy.

Adjuvant chemotherapy usually starts within 8 to 12 weeks after surgery depending on how quickly a patient recovers. It is typically given for a total of 6 months. Chemotherapy is usually gemcitabine, either as a single drug or in combination with a second drug called capecitabine. Recent research shows that the combination of gemcitabine and capecitabine is more effective than just gemcitabine. But it has been linked with more side effects, including diarrhea, low levels of white blood cells, and hand-foot syndrome. Talk with your doctor about the best chemotherapy options for you.
The role of radiation therapy after surgery remains controversial. The option to use radiation therapy after surgery depends on each patient’s situation. For example, it may be an option for when there were not clear margins after surgery.
For patients who received treatment before surgery, the need for additional treatment after surgery depends on each patient’s situation and overall health.

Locally advanced pancreatic cancer

First-line therapy. Chemotherapy with a combination of drugs depending on each patient’s situation and overall health (see options listed under Metastatic pancreatic cancer, below)

Radiation therapy may also be an option. It is used most often after chemotherapy when the cancer has not spread beyond the pancreas. The choice of type of radiation therapy, such as standard external beam or SBRT (see Radiation therapy above), depends on several factors, including the size and location of the tumor.

Second-line therapy. If the disease worsens during or after first-line treatment, options may include trying different chemotherapy. Or, it may be possible to use radiation therapy if the tumor has not spread beyond the pancreas and the patient has not already received it.

Clinical trials. If standard treatment options are not working, patients may want to consider a clinical trial. Talk with your doctor about clinical trials that may be open to you.

Metastatic pancreatic cancer

If cancer spreads to another part in the body from where it started, doctors call it metastatic cancer. If this happens, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Clinical trials might also be an option. Consider getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan.

Your treatment plan may include a combination of the treatments discussed above. Treatment options for patients with metastatic pancreatic cancer depend heavily on a patient’s overall health and preferences.

First-line options include:

Chemotherapy with a combination of fluorouracil, leucovorin, irinotecan, and oxaliplatin, called FOLFIRINOX.
Gemcitabine plus nab-paclitaxel.
Gemcitabine only for patients who are not healthy enough for the 2 combinations above, due to the side effects.
Occasionally, another gemcitabine- or fluorouracil-based combination may be used.

Second-line options include those listed below. These are generally for when the disease worsens or patients experienced severe side effects during first-line therapy.

For patients who have already received gemcitabine and nab-paclitaxel, a combination of fluorouracil and leucovorin with either nanoliposomal irinotecan, irinotecan, or oxaliplatin are possible options. For patients who are not healthy enough to receive multiple drugs, capecitabine only could be an option that is easier for these patients to cope with.
For patients who have already received FOLFIRINOX, a regimen using gemcitabine, such as gemcitabine alone or in combination with nab-paclitaxel, is an appropriate option.
Pembrolizumab is an option for patients with pancreatic cancer that is considered MSI-high. However, less than 1% of patients with pancreatic cancer have MSI-high disease.

Palliative care will also be important to help relieve symptoms and side effects.

For most people, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. You and your family are encouraged to talk about how you feel with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED.

A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. It is important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return.

If the cancer does return after the original treatment, it is called recurrent cancer. Pancreatic cancer may come back in or near the pancreas (called a local or regional recurrence), or elsewhere in the body (distant recurrence, which is similar to metastatic disease).

When this occurs, a new cycle of diagnostic testing will begin again to learn as much as possible about the extent and location of the recurrence. After this testing is done, you and your doctor will talk about the treatment options. The treatment of recurrent pancreatic cancer is similar to the treatments described above and usually involves chemotherapy. Radiation therapy or surgery may also be used to help relieve symptoms. Your doctor may suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

People with recurrent cancer often experience emotions such as disbelief or fear. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope.

If treatment does not work

Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.

This diagnosis is stressful, and for many people, advanced cancer is difficult to discuss. However, it is important to have open and honest conversations with your health care team and family and friends to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option for many families.