Treatment options

Treatment and care of people with cancer is usually provided by a team of health professionals, both medical and allied health, called a multidisciplinary team.

Treatment for pancreatic cancer depends on:

the type of cancer (exocrine or endocrine)
the stage of the disease
the location of the cancer
the severity of symptoms
your general health and wishes.

Treatment may involve the following.

Surgery

Surgery may be used to remove all the cancer (curative surgery), if it appears possible. If the cancer has spread too far to be removed completely, surgery may be used to relieve symptoms or prevent complications (palliative surgery).

Endocrine cancers are more likely to be successfully removed by surgery (resectable) compared to exocrine cancers.

Cancers in the widest part of the pancreas (head) are also more likely to be successfully removed by surgery. This is because these cancers are usually detected early (they often cause jaundice in the early stages, making it easier to diagnose in the early stages).

Most pancreatic cancers have spread beyond the pancreas by the time they are diagnosed. These cancers are not able to be fully removed by surgery.

A staging laparoscopy can be performed initially to accurately determine the extent of the cancer and if it can be successfully resected. This is done by performing keyhole surgery with a small camera so the surgeon can see inside the abdomen and visualise the organs. A sample of the abnormal areas (biopsy) may also be done at the same time.

Surgery for pancreatic cancer may remove all or part of the pancreas, and sometimes parts of surrounding tissues:

A pancreaticoduodenectomy (Whipple procedure) is a complex surgery to remove the head of the pancreas, and possibly the body of the pancreas, part of the small intestine, part of the bile duct, the gallbladder, lymph nodes near the pancreas and part of the stomach. The remaining parts of the bile duct, pancreas, small intestine and stomach are connected so that digestion of food can continue. This operation usually requires a large cut down the middle of the abdomen, although keyhole (laparoscopic) surgery may be possible in some cases, especially for endocrine cancers. This type of surgery is a complex surgery and can have a long recovery period and complications. These complications can include leakage from the surgical connections, infections, bleeding, problems with the stomach emptying after eating, weight loss, changes in bowel habits and diabetes.
A distal pancreatectomy removes the thinnest part (tail) of the pancreas and the spleen.
A total pancreatectomy removes the whole pancreas, the spleen, part of the small intestine, the bile duct, the gallbladder, lymph nodes near the pancreas and part of the stomach. This surgery is not common. It causes diabetes because it removes the cells that produce insulin to maintain blood sugar levels.

If the cancer has spread and cannot be removed, palliative surgery may be done to relieve the symptoms:

if cancer is blocking the common bile duct, a small tube (stent) may be inserted inside the duct to keep it open^[16]
if the cancer is blocking the flow of food from the stomach, surgery may be done to bypass the blockage^[17]^[18]
if the whole cancer can’t be removed, surgery may aim to remove part of it – this is called debulking.^[19]

Ablation and embolisation

Ablation and embolisation are unlikely to cure pancreatic cancer. They are most often used to relieve symptoms.

Ablation uses treatment with heat (radiowaves or microwaves that heat the cancer) or cold (cold gases that freeze the cancer) to destroy tumours. These treatments are delivered using thin probes that are guided into the cancer tissue.

Embolisation involves injecting a substance into an artery to block the flow of blood to the cancer tissue, causing it to die.

Radiation therapy

Along with surgery, some people may receive radiation therapy.

Usually, the radiation for pancreatic cancer is delivered to the cancer from a machine outside the body. Radiation therapy is more helpful for exocrine pancreatic cancer than for endocrine cancers, which do not respond well to standard radiation.

Peptide receptor radionuclide therapy^[20] may be used to treat endocrine cancers. This is a different type of radiation therapy which is injected by a specialist such as nuclear physician.

Chemotherapy

Along with surgery, some people may receive chemotherapy.. Chemotherapy may be offered prior to surgery (neoadjuvant therapy) to reduce the size of the tumour. This can allow the surgeon to remove the tumour with greater success. Chemotherapy may also be offered after the surgery. This is called adjuvant treatment and may be offered to reduce the risk of the cancer growing again in the future after resection.

Targeted therapy

Targeted therapy refers to treatment with medicines that are designed to specifically attack cancer cells without harming normal cells. These types of medicines affect the way that cancer cells grow, divide, repair themselves or interact with other cells.

People with advanced endocrine cancers may be offered targeted therapy drugs such as sunitinib and everolimus to slow the growth of the cancer.^[21]

Other treatments

Other treatments that may be used for functional endocrine cancers include hormone therapy (to block the action of the excess hormones) and specific medicines to relieve the symptoms caused by the excess hormones.

Follow-up

After treatment, you might need regular physical examinations and other tests to check whether the cancer has come back (recurred) or spread to other parts of the body (metastasised), or to check for side effects of treatment. You might also need help to ensure that your nutritional needs are being met, as pancreatic cancer and its treatment can cause weight loss and poor nutrition.

Advanced disease

In stage III or stage IV pancreatic cancer, the cancer has spread too far to be removed by surgery. However, surgery may be used to relieve symptoms, or problems such as blockage of the bile duct or the intestine..

In locally advanced disease, chemotherapy is sometimes given in combination with radiation therapy (chemoradiotherapy) to reduce the risk of further spread of the cancer.

Chemotherapy, with or without radiation therapy, is the main treatment for advanced forms of exocrine pancreatic cancer. This may shrink the tumours or slow their growth and provide improvement in symptoms. They can, possibly help people to live longer. Targeted therapy and immunotherapy may also be offered to slow the growth of advanced disease and improve survival.

Endocrine cancers are often slow growing. If they have spread so that they cannot be removed by surgery, medicines may be given to relieve symptoms such as diarrhoea or hormone problems. Chemotherapy or targeted therapy may be used, and surgery or ablation may be used to treat spots of cancer that have spread (metastatised) to the liver.

Recurrent and secondary cancer

Pancreatic cancer can come back (recur) after treatment. Secondary cancer is when the cancer spreads to another part of the body. Secondary cancers from pancreatic cancer often develop in the liver, but they may occur in the lungs, bone or other organs. Recurrent pancreatic cancer is treated in the same way as stage IV (metastatic) cancer. This includes chemotherapy, radiation treatment, and possibly other treatments to relieve symptoms.

Supportive Care

Supportive care forms an important component of managing advanced pancreatic cancer. The aim of supportive care is to improve the quality of life of patients, by preventing or treating symptoms caused by the cancer or it’s treatment.  Supportive care includes physical, psychological, social, and spiritual support for patients and their families. Symptoms arising from pancreatic cancer and its treatment including pain, nausea and weight loss, can be managed in conjunction with a pain specialist or palliative care specialist to provide improved quality of life.