There are 2 types of surgery for pancreatic cancer, depending on the goal of the treatment. If the tumor is small enough or had not spread into the circulatory system, there’s a chance it can all be removed. The goal of the surgery is to remove or resect the cancer tumor and cells.
If the cancer is too widespread to be completely removed, then the goal might be to relieve symptoms or to prevent other future problems. This type of surgery is known as palliative since the goal is to promote comfort. Due to the nature of cancer being able to spread palliative surgery is not the preferred treatment.
Radiation therapy is treatment with high energy rays (such as x-rays) to kill or shrink cancer cells. Treatment is usually given 5 times a week for several weeks or months. Sometimes the radiation is given before surgery, sometimes after.
Radiation is often combined with chemotherapy to target tumors that are too widespread to be removed by surgery.
Side effects of radiation therapy could include mild skin changes that look like sunburn or suntan, upset stomach, loose bowels, or tiredness. Often these go away after a short while.
Chemotherapy is the use of drugs to kill cancer cells. Usually, the drugs are given into a vein or are taken as a pill. Once the drugs enter the bloodstream, they reach throughout the body, making this treatment useful for cancer that has spread beyond the place where it started.
Gemcitabine is most often used to treat pancreatic cancer that has spread. Studies are ongoing to see if it can be used to treat early stage cancers.
Chemotherapy can have negative side effects. These side effects will depend on the type of drugs given, the amount taken, and how long treatment lasts.
Temporary side effects might include nausea and vomiting, loss of appetite, hair loss, and mouth sores. Low blood cell counts from treatment can cause an increased risk of infection, bleeding or bruising after minor cuts, and fatigue. Most side effects stop once treatment is over. Side effect relief from chemotherapy or radiation is the common target of complementary therapies.
Treating Resectable Cancer
Surgeons usually consider pancreatic cancer to be resectable if it looks like it is contained only in the pancreas and has not grown into nearby large blood vessels.
If imaging tests show a reasonable chance of removing the cancer tumors completely, surgery is the preferred treatment. Removal of affected tissues offers the only realistic chance for cure. Based on the starting point of cancer growth, a Whipple procedure (pancreaticoduodenectomy) or a distal pancreatectomy is performed.
For people who have surgery to try to completely remove cancer of the exocrine pancreas, the 5-year survival rate is about 20%.
Treating Non-resectable Pancreatic cancer
Sometimes it becomes clear during the surgery that not all of it can be removed. If this happens, the surgery might be stopped, or the surgeon might continue with a smaller operation with the goal of relieving or preventing problems called palliative care.
For example, surgery can be used to relieve a blockage of the bile duct. When this duct is blocked, the result can be pain and problems with digestion.
There are 2 options for relieving a bile duct blockage. One is to re-route the flow of bile. An advantage is that during the surgery, the nerves leading to the pancreas can be cut. This can help reduce pain.
A second approach to bile duct blockage is to use tubes called stents to keep the bile duct open. The surgeon inserts the stents through an endoscope. After several months the stents may become clogged and need to be replaced. Newer stents may be used to keep the small intestine open as well.
Because pancreatic cancer can progress so quickly, palliative surgery by itself is not recommended.
Adjuvant Treatment for Pancreatic Cancer
Giving chemotherapy, either alone or with radiation therapy, after surgery is called adjuvant treatment.
Sometimes, if the tumor is thought to be removable but is very large, or has many nearby large lymph nodes, chemotherapy or chemoradiation may be given before surgery. Neoadjuvant treatment is used to shrink the tumor first. This may make it easier to remove all of the cancer tissue at the time of surgery. Additional chemotherapy may still be recommended after surgery.
Treating Borderline Resectable pancreatic cancer
A small number of pancreatic cancers have reached nearby blood vessels. If the cancer tumor has not grown deeply into these blood vessels it may be considered removable by surgery. The odds of removing all of the cancer are lower, so they are considered borderline resectable.
Borderline resectable cancers are often treated first with neoadjuvant chemotherapy to try to shrink them to aid in removal. Imaging tests are done to make sure cancer is still considered removable by surgery. This might be followed by more chemotherapy.
Treating locally advanced cancer
Locally advanced cancers have grown too far into nearby blood vessels or other tissues to be removed completely by surgery. These types of cancer are considered unresectable. They may have not spread to the liver or distant organs and tissues yet.
Surgery to remove these cancers does not help people live longer as cancer cells have already entered the circulatory system (blood and lymph vessels). If surgery is done, it is palliative.
Chemotherapy, sometimes followed by chemoradiation, is the standard treatment option for locally advanced cancers. This may help some people live longer even if the cancer tumor doesn’t shrink.
Giving chemo and radiation therapy together may work better to shrink the cancer tumor, but this combination has more side effects. The side effects of chemotherapy and radiation can be harder on patients than either treatment alone.
Treating metastatic cancer
Pancreatic cancers often first spread within the abdomen (belly) and to the liver. They can also spread to the lungs, bone, brain, and other organs.
These cancers have spread too much to be removed by surgery. If imaging tests show cancer tumors have spread to other parts of the body, it is often assumed that cancer is metastatic.
Chemotherapy is the main treatment for these cancers. It can sometimes shrink or slow the growth of cancer for a time. Chemotherapy may help people live longer, but it is not expected to be a cure.
In certain cases, immunotherapy or targeted therapy may be options for people whose cancer cells have specific genetic markers.
Treating cancer that recurs
If cancer continues to grow during treatment or comes back treatment options will depend on:
- Where and how much cancer has spread
- What treatments you have already had
- Your health and desire for more treatment
It’s important to understand the goal of any further treatment, as well as the benefits and risks involved.
When pancreatic cancer recurs, it most often shows up first in the liver. This is usually treated with chemotherapy if you are healthy enough to get it. If you have had chemo before and it was helpful, the same therapy may be helpful again. If pancreatic cancer progresses while you are getting chemotherapy, another type of chemotherapy might be tried if you are healthy enough.
At some point, it might become clear that standard treatments are not effective. It is your choice to continue treatment. At this point taking part in a clinical trial may be an option. While these are not proven effective, they may benefit you, as well as future patients.
Overall, about 8% of patients with cancer of the exocrine pancreas will be alive 5 years after the cancer is found. Even for those with local disease (it has not spread to other organs) the 5-year relative survival rate is 39%.
For those who are diagnosed as having regional cancer. Cancer cells and tumors have spread to nearby organs and tissues. The 5-year relative survival rate is 13%. If there is spread to distant organs or tissues, the 5-year relative survival rate is 3%.
Five-year relative survival rates don’t count people who died of other diseases. Of course, patients might live more than 5 years after diagnosis.
These numbers provide an overall picture but keep in mind that every person’s situation is unique and the statistics can’t predict exactly what will happen in any case.
It can be hard to stage pancreatic cancer accurately using imaging tests. Doctors do their best to assess the chance that the cancer is resectable – that is, if it can be removed completely. At best it’s an educated guess because we are relying upon an interpretation of an image. Sometimes it turns out that cancer has spread farther than was first thought.
Treatment and Communication
With any form of cancer treatment comes side effects. It is very important to communicate with your medical team.