At MD Anderson, pancreatic cancer treatment plans are based on whether or not a tumor can be surgically removed or resected. Most pancreatic cancers are diagnosed after they’ve already spread beyond the pancreas, but about 20% of pancreatic tumors are localized to the pancreas and are resectable. Whether or not a tumor is resectable, patients’ treatment plans usually vary. Typically, patients require more than one type of therapy provided by a multidisciplinary team of doctors.
Some therapies are the current standard-of-care, while others are being tested in clinical trials. Clinical trials are critical for advancing pancreatic cancer care and improving survival outcomes. They are supported by our pancreatic cancer research.
One or more of the following therapies may be recommended to treat the cancer or help relieve symptoms.
The main surgical approaches used to treat pancreatic cancer are:
- Potentially curative: Attempt to treat pancreatic cancer by removing it.
- Palliative: Attempt to relieve symptoms, like a blocked bile duct or bowel.
Potentially curative surgical techniques
When pancreatic cancer is confined to the pancreas, and sometimes when it has spread only to nearby areas, the tumor can be removed with surgery. Complete removal of the tumor with surgery is often the best chance at curing pancreatic cancer. Partial removal of tumors doesn’t help patients live longer, so surgery is only done if the cancer can be removed entirely.
The most common technique used to remove a pancreatic tumor is called a pancreatoduodenectomy, or, more commonly, the Whipple procedure. This operation removes parts of the pancreas, intestine, nearby lymph nodes, gallbladder, bile duct and sometimes parts of the stomach.
The pancreas is located next to important blood vessels that supply blood to the liver and drain blood from the intestine. Often, cancer in the pancreas spreads into these vessels. If the pancreatic tumor cannot be completely separated from these blood vessels, many surgeons considered it unresectable. However, at MD Anderson the surgeon will often remove the tumor and reroute the affected vessels. This is called vascular resection and reconstruction and is performed during the Whipple procedure. These complex operations are potentially curative and are performed in about half of patients with localized pancreatic cancer who undergo surgery at MD Anderson.
Whether or not vascular resection and reconstruction is necessary, the Whipple procedure is a major operation that carries a high risk of complications, even when it is performed by experienced surgeons. Studies have shown this procedure is more successful and has less risk when it’s performed at a major cancer center by doctors with extensive experience in the procedures. Learn more about what makes MD Anderson surgeons some of the most experienced and skilled in the nation.
Palliative surgical operations
In many cases, cancer cannot be completely removed because it has spread too far beyond the pancreas or into major blood vessels. For these patients, surgery is sometimes used to help relieve symptoms of pancreatic cancer. Blockage of the bile duct is the most common symptom of pancreatic cancer that is treated with surgery. Blockages can cause bile to leak into surrounding organs, leading to pain and digestive problems. There are two techniques used to relieve this symptom:
- Stent placement: An endoscope is used to insert metal tubes (called stents) that help keep the bile duct open. This is often done during endoscopic retrograde cholangiopancreatography (ECRP).
- Bypass operations: The flow of bile is re-routed from the bile duct directly to the intestine, bypassing the pancreas. Bypass operations can provide longer-lasting relief, but have longer recovery periods than stent replacements.
Chemotherapy uses cancer drugs to slow or shrink pancreatic tumors. These drugs are either given intravenously (IV) or taken by mouth, and spread throughout the body through the bloodstream. Depending on the resectability (likelihood that the tumor can be completely removed by surgery) of the pancreatic cancer, chemotherapy can be given:
- Prior to surgery, to try to reduce the size of the pancreatic tumor that needs to be removed. This is called neoadjuvant therapy.
- After surgery, to destroy any cancer that may not have been completely removed. This can reduce the chance that the cancer returns and is called adjuvant therapy.
- Along with radiation, which is called chemoradiation. This is sometimes used for localized pancreatic cancer.
There are many chemotherapy drugs used to treat pancreatic cancer, including:
- 5-fluorouracil (F-5U)
- Liposomal Irinotecan
Based on the patient’s ability to tolerate therapy, two or more chemotherapy drugs are typically given in combination to treat patients.
Two chemotherapy combinations have been approved for the initial treatment of pancreatic cancer, including:
- Gemcitabine + nab-paclitaxel
- FOLFIRINOX (5-flurouracil, irinotecan and oxaliplatin)
Radiation therapy uses high-energy photon beams (x-rays) to slow or shrink pancreatic tumors. Due to the level of precision of some types of radiation therapy, higher than normal doses of radiation (dose-escalation) can be considered and used without damaging normal tissues. MD Anderson uses several different types of radiation therapy to treat pancreatic cancers.
- Intensity-modulated radiation therapy (IMRT): Delivers radiation beams from several different angles using advanced imaging and computational techniques. Because of the extreme precision associated with this therapy, higher-than-normal doses of radiation (dose-escalation) can be used. This type of therapy is usually administered between 3-6 weeks and is sometimes given in addition to chemotherapy.
- Stereotactic body radiation therapy (SBRT): Delivers radiation beams of different intensity from several angles. Because of the extreme precision associated with this therapy, large doses can be given every day, and higher-than-normal doses of radiation (dose-escalation) can be considered if needed. Treatment usually lasts less than a week.
- 3D conformal radiation therapy: The traditional method that uses three-dimensional scans to image the tumor prior to delivering radiation beams. This type of therapy is usually administered for about 2-6 weeks.
- Proton therapy: Delivers proton beams, rather than photon beams. In some situations, protons cause less radiation exposure to surrounding tissue than photons. This type of therapy may be used for pancreatic cancer patients whose disease has recurred in the same area, despite prior radiation therapy.
At MD Anderson, our radiation oncologists use a special machine called a CT on rails to deliver higher than normal doses of radiation (dose-escalation) with extreme precision. This technique is typically used during IMRT and SBRT.
Surgery is the only potentially curative treatment option for pancreatic cancer, but is an only option for about 20% of cases. This means that it’s important to define whether a patient may benefit from surgery at the time of pancreatic cancer diagnosis, and reserve surgery only for when it may provide clinical benefit.
Because of this, MD Anderson doctors use a contemporary staging system, called resectability staging, to plan a patient’s treatment. This type of staging classifies pancreatic cancers into three groups, based on whether or not they can be removed with surgery. A patient’s potential treatment plan varies depending on the resectability staging of their pancreatic cancer.
The cancer is confined to the pancreas, or has only spread to immediately nearby tissue, and the tumor can be removed entirely with surgery. This typically includes pancreatic cancers that are stage I and II. Patients with resectable pancreatic cancer may:
- Go straight to surgery.
- Receive chemotherapy prior to surgery.
- Receive radiation and chemotherapy prior to surgery.
The cancer has reached nearby blood vessels, but it has the potential to be removed with surgery. This typically includes some stage II and III cancers. Patients with borderline resectable pancreatic cancer often receive chemotherapy and may subsequently receive radiation. After these initial therapies, patients are then evaluated to determine whether their tumor can be completely removed with surgery.
The cancer cannot be removed by surgery. This stage is divided into locally advanced and metastatic.
- Locally-advanced: The cancer is still largely confined to the pancreas and surrounding organs, but has grown into or is surrounding major blood vessels. This typically includes many stage III cancers. Patients with locally-advanced, unresectable pancreatic cancer always receive chemotherapy first and then are considered for radiation therapy. Depending on the size and placement of the tumor, higher than normal doses of radiation (dose-escalation) may be used during treatment.
- Metastatic: The cancer has spread to distant organs and can’t be completely removed. Patients with metastatic pancreatic cancer are treated with chemotherapy if it can be given safely based on patient’s tolerance. Radiation therapy is sometimes used to relieve symptoms associated with their cancer.
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