Pancreatic Cancer: Treatment

Options for treating pancreatic cancer include surgery, chemotherapy, radiation therapy, and palliative care, depending on the specific characteristics of the cancer.

Surgery

Surgery offers the best chance for a cure and long-term management of pancreatic cancer. However not every patient is eligible for surgical intervention. Factors such as the stage of the disease, personal health, and the ability to tolerate a major operation—including prolonged anesthesia—all must be considered.

Pancreatic cancers are divided into four surgical categories.

  • Resectable This type of cancer can be surgically removed. These tumors may lie within the pancreas or extend to nearby organs, but do not involve local blood vessels. When cancer is resectable, there is no evidence of any spread outside the tissue removed during surgery.
  • Borderline Resectable This type of cancer is also limited to the pancreas but may be close to major blood vessels in the pancreas. Often these tumors can be removed and the vein can be reconstructed but the surgical procedures are more complicated.
  • Locally Advanced This type of cancer cannot be surgically removed with traditional methods because it has invaded nearby blood vessels or nearby organs. However, there is no evidence of spread to distant parts of the body.
  • Metastatic This type of cancer cannot be surgically removed because the cancer has spread to other parts of the body.

While there have been significant improvements in pancreatic operations, surgical procedures remain complex and can be difficult for some patients to undergo. It is thus important to choose an experienced surgeon and a facility that has performed a very high number of pancreatic operations, often referred to as a “high-volume” center.

Studies have shown that patients who undergo pancreatic surgery at a high-volume center experience fewer operative complications and better outcomes.

At the Pancreas Center our commitment to our patients and our time-tested surgical expertise has led to high success rates. Our surgeons perform specialized operations to remove cancerous tissue while preserving as much healthy tissue as possible.

Pancreaticoduodenectomy, often referred to as the Whipple procedure, is the most common operation to treat tumors located in the head of the pancreas where about 75 percent of pancreatic cancers occur. This famous procedure was developed in our own Department of Surgery by Dr. Allen O. Whipple, the former Chair of Surgery, in 1935.

There are two types of Whipple procedures—the conventional Whipple and the pylorus-sparing Whipple. The conventional Whipple involves removal of the head of the pancreas, the duodenum, and a portion of the stomach, as well as the gallbladder and a portion of the bile duct. The remaining stomach, bile duct and pancreas are then reconnected to the digestive tract to restore flow of food that’s been ingested along with digestive enzymes and bile. In a pylorus-sparing Whipple, a section of stomach is not removed during the operation.

A Whipple procedure typically requires 4 to 6 hours depending on the exact location and pathology of the tumor.

Distal Pancreatectomy removes the tail and body of the pancreas while preserving the head of the pancreas. Since the spleen is so close to the tail of the pancreas, sometimes the spleen is also removed during the procedure. A distal pancreatectomy can sometimes be performed laparoscopically resulting in shorter hospital stays, less blood loss, and fewer complication rates.

A typical distal pancreatectomy procedure requires about 2 to 4 hours, depending on the exact location and pathology of the tumor.

Central Pancreatectomy removes a tumor in the neck or body of the pancreas while preserving the healthy head and tail of the pancreas. This highly specialized procedure is performed at only a handful of centers in the United States, including The Pancreas Center at New York-Presbyterian/Columbia University Medical Center. A central pancreatectomy leaves exocrine and endocrine functions intact and usually decreases the patient’s chance of developing insulin-dependent diabetes.

A typical central pancreatectomy procedure requires between 2 and 4 hours, depending on the exact location and pathology of the tumor.

Total Pancreatectomy removes the entire pancreas and is similar to a Whipple procedure, in that a portion of the stomach, duodenum, gallbladder, and local lymph nodes are also removed. The spleen may be removed as well. This procedure was developed to deal with malignant cells that have invaded most of the pancreatic tissue. Because the entire pancreas is removed, however, the patient becomes an insulin-dependent diabetic for life. For this reason, the procedure is not used when a more limited pancreatectomy is possible. Total pancreatectomy typically requires 5 to 7 hours.

Surgery for neuroendocrine tumors is often less extensive than the surgery for adenocarcinoma but this depends on the location of the tumor.
More information on these procedures can be found here.

Radiation Therapy

Radiation therapy may be prescribed for patients with exocrine tumors but it is rarely used to treat neuroendocrine tumors.

Radiation therapy uses high frequency X-rays to shrink or slow the growth of cancerous tumors. It is a local treatment meant to destroy only tumor cells. A beam of radiation is directed through the abdomen to the cancerous area. The radiation is similar to that used for diagnostic X-rays, only in a higher dose.

Like chemotherapy, radiation therapy can be given before surgery, after surgery, or both. Before surgery, the goal is to shrink the tumor making it easier for the surgeon to remove. After surgery, the goal is to destroy any remaining cancer cells.

External Beam Radiation Therapy (EBRT) is most often used in treating exocrine tumors. Radiation is focused on the cancer from a machine outside the body. This type of radiation therapy is usually an outpatient procedure. Treatments are usually given five continuous days each week for between five and six weeks.

Stereotactic Body Radiation Therapy (SBRT) is a kind of radiation therapy in which very high doses of radiation are given with the help of internal markers to concentrate a high dose of radiation at the tumor site. Treatments are usually given over 2 weeks.

Chemoradiation—radiation therapy combined with chemotherapy—may be prescribed when exocrine tumors are too widespread to be removed by surgery in order to control tumor growth or prior to surgery to increase the chances of achieving a complete surgical removal of the tumor. It may also be given after surgery, to help keep the cancer from coming back.

More information can be found here.

Chemotherapy

While surgery is the only treatment that can cure pancreatic cancer, many patients are inoperable initially because their cancer has invaded blood vessels. At the Pancreas Center, we often utilize chemotherapy and radiation therapy to shrink tumors and are able to offer surgery to the patients with locally inoperable pancreatic cancer who would otherwise never have a chance for cure. The decision to use chemotherapy prior to surgery is complex and each patient is discussed in a multidisciplinary meeting by the surgeons, medical oncologists, radiation oncologists, radiologists, gastroenterologists and others.

Chemotherapy drugs are designed to kill cancer, and are generally given in cycles, with a period of treatment followed by a period of rest.
These drugs can be administered before surgery, after surgery, or both. When given before surgery, chemotherapy is called neoadjuvant. When given after surgery, chemotherapy is called adjuvant. Chemotherapy can be administered orally, by injection, or intravenously depending on the regimen and the drug.

The best course of therapy is selected after considering the specific characteristics of the patient's cancer to maximize the results of the treatment and increase survival.

The most commonly used drugs used for treating pancreatic adenocarcinoma are gemcitabine (Gemzar®), nab-paclitaxel (Abraxane), oxaliplatin, irinotecan, docetaxel (Taxotere®), cis-platinum (Platinol®), and 5-fluorouracil (5-FU) or capecitabine. These drugs are sometimes used alone or in combination.

For neuroendocrine tumors, we typically use sunitnib, everolimus, or chemotherapy. Locoregional treatments and sometimes liver transplantation are also considered.

More information can be found here

Palliative Therapy

When the cancer has spread and cannot be completely removed by surgery, the priority is to alleviate the patient’s symptoms including jaundice, pain, nausea, and poor digestion. The following techniques improve the patient’s comfort level and quality of life.

More information can be found here.