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Treatment for pancreatic cancer
Treatment for early pancreatic cancer
This page gives an overview of treatments used for early-stage adenocarcinomas and other exocrine tumours of the pancreas, generally referred to as early pancreatic cancer. The treatment options described below will only be suitable for 15–20% of people with pancreatic cancer, as most people are diagnosed at a later stage.
Surgery to remove the cancer, in combination with chemotherapy and possibly radiation therapy, is generally the most effective treatment for early pancreatic cancer. It is important that a surgeon who specialises in pancreatic cancer does the surgery.
Treatments before or after surgery
Your surgeon may recommend you have other treatments before surgery to shrink the tumour, or after surgery to destroy any remaining cancer cells. These treatments are known as neoadjuvant (before) and adjuvant (after) therapies, and may include:
- chemotherapy – the use of drugs to kill or slow the growth of cancer cells
- chemoradiation – chemotherapy combined with radiation therapy.
Surgical removal (resection) of the tumour is the most common treatment for people with early-stage disease who are in good health. Before the surgery, your treatment team may recommend that you have chemotherapy, with or without radiation therapy, to shrink the tumour.
The aim of surgery for early pancreatic cancer is to remove all the tumour from the pancreas, as well as a margin of healthy tissue. The type of surgery you have will depend on the size and location of the tumour, your general health and your preferences. Your surgeon will talk to you about the most appropriate surgery for you, as well as the risks and any possible complications. Types of surgery include:
Whipple procedure – This treats tumours in the head of the pancreas. Also known as pancreaticoduodenectomy, it is the most common surgery for pancreatic tumours.
Distal pancreatectomy – The surgeon removes only the tail of the pancreas, or the tail and a portion of the body of the pancreas. The spleen is usually removed as well. The spleen helps the body fight infections, so if it is removed you are at higher risk of some types of bacterial infection. Your doctor may recommend vaccinations before and after a distal pancreatectomy.
Total pancreatectomy – When cancer is large or there are many tumours, the entire pancreas and spleen may be removed, along with the gall bladder, common bile duct, part of the stomach and small bowel, and nearby lymph nodes. It is possible to live without a pancreas. As the body will no longer produce insulin, you will have insulin-dependent diabetes and need regular insulin injections. You will also need to take pancreatic enzyme supplements to help digest certain foods. It is important that an endocrinologist is part of your treatment team. They can help you adapt to life without a pancreas.
Having a Whipple procedure
The Whipple procedure (pancreaticoduodenectomy) is a major operation that is done by a specialised pancreatic or hepato-pancreato-biliary (HPB) surgeon.
The surgeon removes the part of the pancreas with the cancer (usually the head); the first part of the small bowel (duodenum); part of the stomach; the gall bladder; and part of the common bile duct. Then the surgeon reconnects the remaining part of the pancreas, common bile duct and stomach (or duodenum) to different sections of the small bowel to keep the digestive tract working. This allows food, pancreatic juices and bile to continue to flow into the small bowel for the next stage of digestion. Many people need to change their diet after a Whipple procedure.
A Whipple procedure is extensive surgery and usually lasts 5–8 hours. As your surgeon will explain, there is a small chance of serious complications, such as major bleeding or leaking from one of the joins between the removed parts. Most people stay in hospital for 1–2 weeks after surgery, and full recovery takes at least 8–12 weeks.
Surgery to relieve symptoms
During surgery to remove the cancer, the surgeon may find that the cancer has spread (metastasised) into one or more of the major blood vessels in the area. This may occur even if you had several scans and tests beforehand. If this happens, the surgeon will not be able to remove the tumour. However, they may be able to perform procedures (such as a double bypass) that will relieve some of the symptoms caused by the cancer.
How the surgery is done
Surgery for pancreatic cancer is carried out in hospital under a general anaesthetic. There are three main approaches:
Open surgery involves one larger cut in the abdomen.
Laparoscopic surgery involves several small cuts in the abdomen. The surgeon inserts a light and camera (laparoscope) into one of the cuts and performs the surgery using images from the camera for guidance.
Robotic-assisted surgery uses a robotic device to help the surgeon perform laparoscopic surgery.
Compared to open surgery, laparoscopic surgery and robotic-assisted surgery usually mean a shorter hospital stay, less bleeding, a smaller scar and a faster recovery time. However, open surgery may be the best option in some situations.
Talk to your surgeon about what options are available to you and check if there are any extra costs.
What to expect after surgery
While you are recovering after surgery, your health care team will check your progress and help you with the following:
Pain control – You will have some pain and discomfort for several days after surgery. You will be given pain-relieving medicines to manage this. If you are in pain when you return home, talk to your medical team about prescribing pain medicine.
Surgical drain – You may have a thin tube placed in the wound to drain excess fluid into a small bag. The tube is usually removed after a few days, but may be left in for longer. Surgical drains are never permanent.
Drips and tubes – While in hospital, you will have a drip (intravenous infusion) to replace your body’s fluids. At first you won’t be able to eat or drink (nil by mouth). You’ll then be on a liquid diet before gradually returning to normal food. A temporary feeding tube may be placed into the small bowel during the operation. This tube provides extra nutrition until you can eat and drink normally again. The hospital dietitian can help you manage changes to eating.
Enzyme supplements – Some people will need to take tablets known as pancreatic enzymes after surgery. These are taken with each meal to help digest fat and protein.
Insulin therapy – Because the pancreas produces insulin, people who have had all or some of their pancreas removed often develop diabetes after surgery. They may need regular insulin injections (up to four times per day). See page 60 for tips on coping with diabetes.
Moving around – Your health care team will probably encourage you to walk the day after surgery. They will also provide advice about when you can get back to your usual activity levels.
Length of hospital stay – Most people go home within two weeks, but if you have complications, you may need to stay in hospital longer. You may need rehabilitation to help you regain physical strength. This may be as an inpatient in a rehabilitation centre or through a home-based rehabilitation program.
What if the cancer returns?
If the surgery successfully removes all of the cancer, you will have regular appointments to monitor your health, manage any long-term side effects and check that the cancer hasn’t come back or spread. Check-ups will become less frequent if you have no further problems. Between appointments, let your doctor know immediately of any symptoms or health problems.
Unfortunately, pancreatic cancer is difficult to treat and it does often come back after treatment. This is known as a recurrence.
Most of the time, surgery is not an option if you have a recurrence. Your doctors may recommend other types of treatment with the aim of reducing symptoms and improving quality of life.
You may also be able to get new treatments by joining a clinical trial.
Treatment for advanced pancreatic cancer
Pancreatic cancer usually has no symptoms in its early stages, so many people are diagnosed when the cancer is advanced. If the cancer is in nearby organs or blood vessels (locally advanced), or has spread (metastasised) to other parts of the body, surgery to remove the cancer may not be possible. Instead treatments will focus on relieving symptoms without trying to cure the disease. This is called palliative treatment.
Some people think that palliative treatment is only for people at the end of life. However, it can help at any stage of a pancreatic cancer diagnosis. It does not mean giving up hope – rather, it is about managing symptoms as they occur, and living as fully and comfortably as possible.
Palliative treatments may include surgery, chemotherapy and radiation therapy, either on their own or in combination. This page describes how cancer treatments are used to relieve some common symptoms of advanced pancreatic cancer, such as:
- jaundice caused by narrowing of the common bile duct
- ongoing vomiting and weight loss caused by a blockage in the stomach or small bowel
- pain in the abdomen and middle back.
Many people with advanced pancreatic cancer have digestive problems – for example, a blockage in the pancreatic duct can stop the flow of the digestive enzymes required to break down food. This can be treated with pancreatic enzyme supplements.
If the tumour is pressing on the common bile duct, it can cause a blockage and prevent bile from passing into the bowel. Bile builds up in the blood, causing symptoms of jaundice, such as yellowing of the skin and whites of the eyes; itchy skin; reduced appetite, poor digestion and weight loss; dark urine; and pale stools (poo).
If cancer blocks the duodenum (first part of the small bowel), food cannot pass into the bowel and builds up in your stomach, causing nausea and vomiting.
Blockages of the common bile duct or duodenum are known as obstructions. Surgical options for managing these may include:
stenting – inserting a small tube into the bile duct or duodenum (this is the most common method)
double bypass surgery – connecting the small bowel to the bile duct or gall bladder to redirect the bile around the blockage, and connecting a part of the bowel to the stomach to bypass the duodenum so the stomach can empty properly
gastroenterostomy – connecting the stomach to the jejunum (middle section of the small bowel)
venting gastrostomy – connecting the stomach to an artificial opening on the abdomen so waste can be collected in a small bag on the outside the body.
Sometimes a surgeon may have planned to remove a pancreatic tumour during an operation but discovers the cancer has spread. If the tumour cannot be removed, the surgeon may perform one of the operations listed above to relieve symptoms.
Inserting a stent
If the cancer cannot be removed and is pressing on the common bile duct or duodenum, you may need a stent. A stent is a small tube made of either plastic or metal. It holds the bile duct or duodenum open, allowing the bile or food to flow into the bowel again.
A bile duct stent is usually inserted during a procedure known as an ERCP (endoscopic retrograde cholangiopancreatography). In an ERCP, an endoscope is passed into the bile duct through your mouth, stomach and duodenum. With the help of x-rays, the doctor places the stent across the blockage to keep the bile duct open. You may have the ERCP as an outpatient or stay in hospital for 1–2 days.
A duodenum stent is usually inserted through the mouth using an endoscope.
Jaundice symptoms usually go away over 2–3 weeks. Your appetite is likely to improve and you may gain some weight.
Chemotherapy uses drugs to kill or slow the growth of cancer cells. It is sometimes used in combination with radiation therapy (chemoradiation) to slow the growth of locally advanced cancer that has spread beyond the pancreas and cannot be removed with surgery. Chemotherapy is also used palliatively to relieve symptoms.
Chemotherapy is usually given as a liquid through a drip inserted into a vein in the arm or as tablets you swallow. To avoid damaging the veins in your arm, it may also be given through a tube implanted into a vein (called a port, catheter, central line or vascular access device). This will stay in place until all your chemotherapy treatment is over.
You will usually receive treatment as an outpatient. Typically, you will have several courses of treatment, and there will be a rest period of a few weeks between each course. Your medical oncologist will assess how the treatment is working based on your symptoms and wellbeing, as well as scans and blood tests. They will talk to you about how long your treatment will last.
Tell your doctors about any prescription, over-the-counter or natural medicines you are taking or planning to take, as these may affect how the chemotherapy works in your body.
Side effects of chemotherapy
Chemotherapy can affect healthy cells in the body, which may cause side effects. Some people have few side effects, while others have many. The side effects will depend on the drugs used and the dose. Most side effects are temporary and can be managed, so discuss how you are feeling with your medical oncologist and chemotherapy nurses.
Side effects may include fatigue and tiredness; feeling sick (nausea); vomiting; mouth ulcers and skin rashes; hair loss; diarrhoea or constipation; flu-like symptoms such as fever, headache and muscle soreness; and poor appetite. Chemotherapy can also affect your blood count. Fewer white blood cells can mean you are more likely to catch infections. Fewer red blood cells (anaemia) can leave you weak and breathless.
Also known as radiotherapy, radiation therapy uses a controlled dose of radiation to kill cancer cells or injure them so they cannot multiply. The radiation is usually in the form of focused x-ray beams targeted at the cancer. Treatment is painless and carefully planned to do as little harm as possible to healthy body tissue near the cancer.
For locally advanced pancreatic cancer, radiation therapy is usually given with chemotherapy (chemoradiation). The chemotherapy drugs make the cancer cells more sensitive to radiation therapy. Chemoradiation may also be used before or after surgery for early pancreatic cancer.
Radiation therapy is delivered over a number of treatments known as fractions. Each fraction delivers a small dose of radiation that adds up to the total treatment dose. You will usually have treatment as an outpatient once a day, Monday to Friday, for up to five or six weeks. Each session takes 10–15 minutes. You will lie on a table under a machine that delivers radiation to the affected parts of your body. Your radiation oncologist will advise you about your treatment schedule.
Radiation therapy may also be used on its own over shorter periods to relieve symptoms such as pain caused by tumours pressing on a nerve or another organ.
A newer radiation technique called stereotactic body radiation therapy (SBRT) delivers a higher dose of radiation per treatment session over a shorter period of time. SBRT is not currently standard practice for pancreatic cancer but is being investigated in clinical trials. SBRT may be a treatment option at some cancer centres.
Side effects of radiation therapy
Radiation therapy can cause both short-term side effects and late side effects, which are mainly related to the area treated. For pancreatic cancer, the treatment is targeted at the abdomen. Side effects may include tiredness; nausea and vomiting; diarrhoea; poor appetite; and skin irritation. Late side effects are uncommon, but may include damage to the liver, kidneys, stomach or small intestine. Talk to your radiation oncologist or radiation oncology nurse about ways to manage these side effects.
Treatments for advanced pancreatic cancer are generally considered palliative treatment. Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, emotional, cultural, social and spiritual needs. The team also provides support to families and carers.
Specialist palliative care services see people with more complex needs and can also advise other health care professionals. Contacting a specialist palliative care service soon after diagnosis gives them the opportunity to get to know you, your family and your circumstances. You can ask your treating doctor for a referral.
This information is reviewed by
This information was last reviewed February 2020 by the following expert content reviewers: Dr Lorraine Chantrill, Head of Department, Medical Oncology, Illawarra Shoalhaven Local Health District, NSW; Marion Bamblett, Nurse Unit Manager, Cancer Centre, Fiona Stanley Hospital, WA; Prof Katherine Clark, Clinical Director of Palliative Care, Northern Sydney Local Health District Cancer and Palliative Care Network, and Conjoint Professor, Northern Clinical School, The University of Sydney, NSW; Lynda Dunstone, Consumer; Kate Graham, Accredited Practising Dietitian – Upper GI Dietitian, Peter MacCallum Cancer Centre, VIC; Dr Gina Hesselberg, Radiation Oncologist, St George Hospital Cancer Centre, NSW; Dr Marni Nenke, Endocrinologist and Mary Overton Early Career Research Fellow, Royal Adelaide Hospital, SA; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council WA; A/Prof Nicholas O’Rourke, Head of Hepatobiliary Surgery, Royal Brisbane Hospital and The University of Queensland, QLD; Rose Rocca, Senior Clinical Dietitian – Upper GI, Peter MacCallum Cancer Centre, VIC; Gail Smith, Consumer.