Pancreatic Cancer
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Pancreatic Cancer
Treatment to manage cancer and symptoms
Pancreatic cancer usually has no symptoms in its early stages, so many people are diagnosed when the cancer is advanced. If the cancer involves nearby organs or blood vessels (locally advanced – some stage 3 cancers) or has spread to other parts of the body (metastasised – all stage 4 cancers), surgery to remove the cancer may not be possible. Instead, treatments will focus on shrinking or slowing the growth of the cancer and 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. Some studies show that if the palliative team is seen early and symptoms are controlled, people will feel better and may live longer.
Palliative treatments may include surgery, chemotherapy and radiation therapy, either on their own or in combination. This section describes how cancer treatments are used to manage the cancer and 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. 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)
- 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 opening on the abdomen so waste can be collected in a small bag outside the body.
Sometimes the surgeon may have planned to remove a pancreatic tumour but discovers during the surgery that 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, letting the bile or food to flow into the bowel again.
A bile duct stent is also known as a biliary stent. It is usually inserted using an endoscope passed through the mouth, stomach and duodenum until it reaches the bile duct. You may have this procedure as an outpatient or stay in hospital for 1–2 days. Sometimes the stent needs to be inserted directly through the skin and liver into the bile duct.
A duodenum stent is also known as a duodenal stent. It is usually inserted through the mouth using an endoscope.
Symptoms caused by the blockage usually go away over 2–3 weeks. Your appetite is likely to improve and you may gain some weight.
Click on image to enlarge
Chemotherapy uses drugs to kill or slow the growth of cancer cells. It is used for pancreatic cancer for various reasons. If the cancer is at a stage where it can be removed with surgery, chemotherapy is often used before or after the surgery. When surgery cannot remove the cancer, chemotherapy can be used as a palliative treatment to slow the growth of the cancer and relieve symptoms. For some stage 3 cancers, chemotherapy may be combined with radiation therapy. This is known as chemoradiation.
The chemotherapy drugs are usually given as a liquid through a drip inserted into a vein in the arm (intravenous infusion) or as tablets that 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 PICC line). 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, with rest periods of a few weeks in between. Your medical oncologist will assess how the treatment is working based on your symptoms and wellbeing, as well as scans and blood tests. The blood tests will help show if your body is able to cope with the chemotherapy. Tell your team 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. Your medical oncologist and chemotherapy nurses will explain the possible side effects to you, the best ways to manage them and who to contact if you need support.
Side effects of chemotherapy may include feeling very tired (fatigue); 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 the number of cells in your blood. Fewer white blood cells can mean you are more likely to catch infections. Fewer red blood cells (anaemia) can leave you weak and breathless.
Most chemotherapy side effects are temporary and can be managed, so discuss how you are feeling with your treatment team. If you are having chemotherapy as a palliative treatment, they will help you weigh up the benefits of improving your cancer symptoms against any side effects it is causing.
Other cancer drug treatments include targeted therapy and immunotherapy. Targeted therapy targets specific features of cancer cells to stop the cancer growing and spreading, while immunotherapy uses the body’s own immune system to fight cancer.
The targeted therapy drug called olaparib has been shown to provide some benefit for people with metastatic pancreatic cancer who have the BRCA gene changes. This is only a small number of people with pancreatic cancer. Olaparib is approved for use in Australia but the cost is not yet covered by the government through the Pharmaceutical Benefits Scheme (PBS) for pancreatic cancer (as at January 2022). Your doctors will be able to provide the latest information about its availability.
So far, other targeted therapy and immunotherapy drugs have had disappointing results for pancreatic cancer, but research is continuing and there are new clinical trials underway. Talk to your treatment team about whether a clinical trial is an option for you.
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.
Chemoradiation – For stage 3 cancers that cannot be removed with surgery (locally advanced cancers), radiation therapy may be given with chemotherapy to slow the growth of the cancer. This is known as chemoradiation. The chemotherapy drugs make the cancer cells more sensitive to radiation therapy. For cancers that are at a stage where they can be removed by surgery, chemoradiation may also be used before or after the surgery.
For a course of chemoradiation, the 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. Your radiation oncologist will let you know your treatment schedule. Many people have treatment as an outpatient once a day, Monday to Friday, for up to six weeks.
Each radiation therapy session takes 10–15 minutes. You will lie on a table under a machine called a linear accelerator that delivers radiation to the affected parts of your body. The machine does not touch you, but it may rotate around you to deliver radiation to the area with cancer from different angles. This allows the radiation to target the cancer more precisely and limits the radiation given to surrounding tissues.
This is a general illustration of a linear accelerator (LINAC). It’s large and often kept in a separate room. A CT scan machine is usually attached to the linear accelerator. The machine used for your treatment may look different. There may also be imaging devices on or near the linear accelerator, which help position you accurately on the couch.
Radiation therapy on its own – Radiation therapy may also be used on its own over shorter periods to relieve symptoms. For example, if a tumour is pressing on a nerve or another organ and causing pain or bleeding, a few doses of radiation therapy may shrink the tumour enough to relieve the symptoms.
SBRT – 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 standard practice for pancreatic cancer but is being investigated in clinical trials. SBRT may be a treatment option as part of a clinical trial at some cancer centres.
Side effects of radiation therapy
Radiation therapy can cause side effects, which are mainly related to the area treated. For pancreatic cancer, the treatment is targeted at the abdomen.
Side effects of radiation therapy to the abdomen may include:
- tiredness
- nausea and vomiting
- diarrhoea
- poor appetite
- reflux (when stomach acid flows up into the oesophagus)
- skin irritation.
Most side effects start to improve a few weeks after treatment, but some can last longer or appear later. 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.
If pain becomes an issue, you may need a combination of treatments to achieve good pain control. Options for relieving pain may include:
- strong pain medicines such as opioids
- nerve blocks – injecting anaesthetic or alcohol into nerves
- anticonvulsant medicines to help control nerve pain
- chemotherapy and/or radiation therapy to shrink cancer pressing on nerves
- complementary therapies such as acupuncture, massage and relaxation techniques.
Tell your treatment team if you have any pain, as it is easier to control if treated early. Don’t wait until the pain is severe.
Your team can also refer you to a pain specialist if needed.
The treatment options described above are generally part of palliative treatment. Palliative treatment is one aspect of palliative care, in which a team of health professionals work together 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 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. The palliative care team also provides support to families and carers.
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This information is reviewed by
This information was last reviewed February 2022 by the following expert content reviewers: Dr Benjamin Loveday, Hepato-Pancreato-Biliary (HPB) Surgeon, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, VIC; Dr Katherine Allsopp, Palliative Medicine Physician, Crown Princess Mary Cancer Centre, Westmead Hospital, NSW; Hollie Bevans, Senior Dietitian, Radiotherapy and Oncology, Western Health, VIC; Dr Lorraine Chantrill, Head of Department Medical Oncology, Illawarra Shoalhaven Local Health District, NSW; Amanda Maxwell, Consumer; Prof Michael Michael, Medical Oncologist, Lower and Upper GI Oncology Service, Co-Chair Neuroendocrine Unit, Peter MacCallum Cancer Centre and University of Melbourne, VIC; Dr Andrew Oar, Radiation Oncologist, Icon Cancer Centre, Gold Coast University Hospital, QLD; Meg Rogers, Nurse Consultant Upper GI/NET Service, Peter MacCallum Cancer Centre, VIC; Ady Sipthorpe, 13 11 20 Consultant, Cancer Council WA.