Treatment of Pancreatic Cancer

Treating Pancreatic Cancer by Stage

It is hard to stage pancreatic cancer accurately by imaging tests. Doctors must do their best to decide before surgery whether there is a good chance the cancer can be completely removed. Surgeons usually consider an exocrine pancreatic cancer resectable (completely removable by surgery) if it is staged as T1, T2, or T3. That means it doesn’t extend far beyond the pancreas, especially into nearby large blood vessels (T4). There is no accurate way to assess the lymph node spread of the tumor before surgery.

Exocrine pancreatic cancer

Resectable: If imaging tests show a reasonable chance of completely removing the cancer, surgery should be done if possible, as it offers the only chance to cure this disease. Based on where the cancer started, either a pancreaticoduodenectomy (Whipple procedure) or a distal pancreatectomy is usually used.

In most but not all cases, either chemotherapy alone or chemotherapy plus radiation therapy (chemoradiation) is used as well. This treatment may be given before or after surgery. Some centers favor giving it before surgery because the recovery after surgery is often long, which can delay or even prevent its use. But it is not yet clear whether this approach is better than giving it after surgery. Many surgeons are concerned about preoperative therapy. They feel that patients may become weakened and are therefore less able to withstand the surgery.

A recent study has shown that giving gemcitabine chemotherapy after surgery can delay the average time before cancer returns by about 6 months. It also seems to help patients live longer. 5-FU was commonly used in the past after surgery, but now gemcitabine is used more often. There is currently an ongoing study comparing 5FU and gemcitabine as adjuvant therapy to see if one is better than the other. It is not yet clear whether adding radiation to chemotherapy would result in more of a benefit.

Locally advanced: Locally advanced cancers of the pancreas are those that have grown too far to be completely removed by surgery, but have not yet reached distant parts of the body. Several studies have shown that attempts to partially remove these cancers do not help patients to live longer. Therefore, surgery has a limited role in these cancers. It is used mainly to relieve bile duct blockage or to bypass a blocked intestine caused by the cancer pressing on other organs.

The standard treatment options for locally advanced cancers are chemotherapy with gemcitabine either alone or along with radiation therapy. One study showed that combining radiation with gemcitabine helped patients with locally advanced cancers live longer than giving gemcitibine by itself. Another study gave patients with locally advanced disease chemotherapy and radiation together and then rechecked the patients to see if the cancer has shrunk enough to be completely removed by surgery. Some patients were then able to have surgery.

Metastatic (widespread): Because these cancers have spread through the lymphatic system or bloodstream, they cannot be removed by surgery. These cancers have also spread too far to be treated by radiation therapy alone. Even when imaging tests show that the spread is only to one area of the body, it has to be assumed that small groups of cancer cells (too small to be seen on imaging tests) are already present in other organs of the body.