Treating Pancreatic Cancer, Based on Extent of the Cancer

Most of the time, pancreatic cancer is treated based on its resectability – whether the pancreatic tumor has spread to other parts of the body and if it can be completely removed by a surgeon.  Other factors, such as your overall health, can also affect treatment options. Talk to your doctor if you have any questions about the treatment plan they recommend.

This information is about treating exocrine pancreatic cancer, the most common type of pancreatic cancer. See Pancreatic Neuroendocrine Tumor (NET) for information about how that type is typically treated.

Treating resectable cancer

Surgeons usually consider pancreatic cancer to be resectable if it looks like it is still just in the pancreas or doesn’t extend far beyond the pancreas, and has not grown into nearby large blood vessels. A person must also be healthy enough to withstand surgery to remove the cancer, which is a major operation.

If imaging tests show a reasonable chance of removing the cancer completely, surgery is the preferred treatment if possible, as it offers the only realistic chance for cure. Based on where the tumor is located, usually either a Whipple procedure (pancreaticoduodenectomy) or a distal pancreatectomy is performed.

Sometimes even when a cancer is thought to be resectable, it becomes clear during the surgery that not all of it can be removed. If this happens, continuing the operation might do more harm than good. The surgery might be stopped, or the surgeon might continue with a smaller operation with a goal of relieving or preventing problems such as bile duct blockage.

Neoadjuvant treatment (treatment before surgery)

People with pancreatic tumors that are resectable but have high-risk features may benefit from receiving chemo before surgery (known as neoadjuvant treatment). High-risk features include a large tumor, the presence of nearby large lymph nodes, a very high CA 19-9 tumor marker level, or significant weight loss or pain. The reason for treating with neoadjuvant chemo would be to shrink the tumor, as well as to destroy any cancer cells that may have spread beyond the pancreas but are not yet seen on imaging (known as micrometastatic disease). This may make it easier to remove all the cancer at the time of surgery and theoretically decrease the risk of the cancer coming back after surgery. Additional chemo may still be recommended after surgery.

Adjuvant treatment (treatment after surgery)

Even when the pancreatic tumor has been removed with negative margins, there is still a high risk of the pancreatic cancer coming back. Giving chemotherapy (chemo), either alone or with radiation therapy (chemoradiation), after surgery (known as adjuvant treatment) might help some patients live longer. The chemo drugs most often used are FOLFIRINOX (a combination of 5-FU, leucovorin, oxaliplatin, and irinotecan) or a combination of gemcitabine (Gemzar) and capecitabine.

Treating borderline resectable cancer

There is more than one definition for borderline resectable pancreatic cancer. In general, it describes pancreatic cancer that has not spread beyond the pancreas, and has not grown significantly around nearby blood vessels. These cancers might still be removable by surgery, but the odds of removing all the cancer are lower, so they are considered borderline resectable.

These cancers are often treated first with neoadjuvant chemotherapy (sometimes along with radiation therapy) to try to shrink the cancer and make it easier to remove. Imaging tests (and sometimes laparoscopy) are then done to make sure the cancer hasn’t grown too much to be removed. If it hasn’t, surgery is then done to remove it. This might be followed by more chemotherapy.

Treating locally advanced (unresectable) cancer

Locally advanced cancers have grown too far into nearby blood vessels or other tissues to be removed completely by surgery but have not spread to the liver or distant organs and tissues. Surgery to try to remove these cancers does not help people live longer.

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 doesn’t shrink. Giving chemo and radiation therapy together may work better to shrink the cancer, but this combination has more side effects and can be harder on patients than either treatment alone. Sometimes, targeted therapy may be a treatment option of the tumor has a certain genetic mutation.

Other times, immunotherapy given alone may also be an option.

Surgery might be done after chemo or chemoradiation, if imaging shows the cancer has become smaller and can be removed completely by surgery. However, this is not a common occurrence.

Treating metastatic (widespread) 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. Even when imaging tests show that the spread is only to one other part of the body, it is often assumed that small groups of cancer cells (too small to be seen on imaging tests, known as micrometastatic disease) have already reached other organs of the body.

Chemotherapy is typically the main treatment for these cancers. It can sometimes shrink or slow the growth of these cancers and might help people live longer, but it is not expected to cure the cancer.

Gemcitabine is one of the drugs used most often. It can be used alone (especially for people in poor health), or it can be combined with other drugs like albumin-bound paclitaxel (Abraxane), capecitabine (Xeloda), cisplatin, or the targeted drug erlotinib (Tarceva).

Another option, especially for people who are otherwise in good health, is a combination of chemo drugs called FOLFIRINOX. This consists of 4 drugs: 5-FU, leucovorin, irinotecan (Camptosar), and oxaliplatin (Eloxatin). This treatment might help people live longer than getting gemcitabine alone, but it can also have more side effects.

In certain cases, immunotherapy or targeted therapy may be options for people whose cancer cells have certain gene changes.

Other treatments might also be used to help prevent or relieve symptoms from these cancers. For example, radiation therapy or some type of nerve block might be used to help relieve cancer pain, or a stent might be placed during an endoscopy to help keep the bile duct open.

You may also want to think about taking part in a clinical trial of new drugs or combinations of drugs.

Treating pancreatic cancer that progresses or recurs

If cancer continues to grow during treatment (progresses) or comes back (recurs), your treatment options will depend on:

• Where and how much the cancer has spread
• What treatments you have already had
• Your health and desire for more treatment

It’s important that you understand the goal of any further treatment, as well as the benefits and risks of treatment.

When pancreatic cancer recurs, it most often shows up first in the liver, but it may also spread to the lungs, bone, or other organs. This is usually treated with chemotherapy if you are healthy enough to get it. If you have had chemo before and it kept the cancer away for some time, the same chemo might be helpful again. If the cancer progresses while you are getting chemo, another type of chemo might be tried if you are healthy enough.

Otherwise, different drugs might be tried, such as targeted therapy or immunotherapy. Other treatments, such as radiation therapy or stent placement, might be used to help prevent or relieve symptoms from the cancer.

At some point, it might become clear that standard treatments are no longer controlling the cancer. If you want to continue getting treatment, you might think about taking part in a clinical trial of a newer pancreatic cancer treatment. While these are not always the best option for everyone, they may benefit you, as well as future patients.

Treating cancer of the ampulla of Vater

The ampulla of Vater is the area where the pancreatic duct and the common bile duct empty into the duodenum (the first part of the small intestine). Cancer at this site (known as ampullary cancer) can start in the pancreatic duct, the duodenum, or the common bile duct. In many patients, ampullary cancer can’t be distinguished from pancreatic cancer until surgery has been done.

These cancers often cause early symptoms such as jaundice, so they are often found while they are still resectable. Ampullary cancer is treated very similarly to pancreatic cancer. If the ampullary cancer has not spread and is felt to be resectable, a Whipple procedure is typically done..  After surgery, patients are usually treated with adjuvant chemotherapy, followed by chemoradiotherapy. If the ampullary cancer is found to be unresectable at the time of diagnosis, treatment is very similar to that of unresectable pancreatic cancer. Specifically, a combination of the chemo drugs gemcitabine and cisplatin are commonly given.