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.
Treatment at MD Anderson
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If you or someone you know has been diagnosed with pancreatic cancer, you may have heard of the Whipple procedure. This complex surgery is often used to treat pancreatic cancer, but it’s not an option for everyone.
To help patients learn more about the Whipple procedure and how it can impact quality of life, we spoke with pancreatic cancer surgeon Matthew H.G. Katz, M.D.
What is the Whipple procedure?
The Whipple procedure is a surgery that removes the head of the pancreas, the distal bile duct, the gallbladder, regional lymph nodes, and the duodenum — the first part of the small intestine that connects to the stomach.
For some patients, it may also include partial removal of the stomach, as well as nearby veins and/or arteries. The surgery is typically conducted through a single incision in the upper belly, although sometimes it may be conducted through several smaller incisions.
What types of cancer can the Whipple procedure treat?
About 70% of patients who get a Whipple procedure at MD Anderson have been diagnosed with pancreatic cancer. But it’s also used to treat:
- neuroendocrine tumors of the pancreas
- pancreatic cysts
- bile duct cancer
- duodenal cancer
- ampullary cancer
- cancers that originated elsewhere but spread to the pancreas
How do you determine whether someone is a good candidate for the Whipple procedure?
Typically, the Whipple procedure is a good option for patients whose cancer is confined to the pancreas or the small area adjacent to it, and who are in good enough health to reasonably anticipate that they will fully recover.
The Whipple procedure is generally not a good option for patients whose cancers have spread to other sites. Also, because it’s a complex operation, it’s not usually recommended if a patient is frail or not strong enough to make a full recovery.
What are the benefits of a Whipple procedure?
Generally, the goal of a Whipple procedure is to prolong a patient’s life, or even potentially cure them of cancer. For some patients, the goal might be to prevent or relieve symptoms such as pain or blockage of the bile duct or stomach.
Are there any alternatives to a Whipple procedure?
Yes. They may not do the exact same thing or yield the same results, but chemotherapy, radiation therapy or even a clinical trial are alternatives that might sometimes be preferable to a Whipple procedure.
As with any treatment, it’s important for patients to weigh the risks and benefits of a Whipple procedure and find the treatment option that meets their goals — whether that’s extending life, improving quality of life, or something else.
How long does it take to recover from a Whipple procedure?
Patients typically leave the hospital and go home within a week. But, for most people, it takes as long as 2 to 6 months to fully get back to a normal quality of life. Ultimately, patients should be able to do anything after surgery that they could do before. Some patients get back to running marathons after a Whipple procedure. But it really depends on the individual.
Some patients might be older and have an underlying disease that makes them a little sicker to start with. They also might be receiving other types of treatment — such as chemotherapy or radiation therapy — before or after the operation. All of these factors can impact recovery time.
If a Whipple procedure is done on the right patient for the right reason at the right time by the right surgeon, patients can expect a full return to the quality of life they had before cancer.
What are the potential side effects of a Whipple procedure?
Patients might need to eat smaller meals more frequently throughout the day, instead of three larger meals a day. But mostly, that’s just because it feels better. So, I look at that more as a lifestyle change, not necessarily a problem.
Some patients might need enzyme replacements and antacids. So, their medications may change. Patients may also see changes in their bowel habits, because we’re completely rerouting their gastrointestinal tract.
There could be long-term nutritional deficiencies as well. Fat-soluble vitamins like A, D, E and K might not be absorbed as efficiently. The duodenum is involved with absorbing minerals like calcium, too. When you take that out, it can cause a calcium deficiency over time.
The pancreas helps regulate glucose, so when you take out a piece of that, diabetes can sometimes occur. It’s a fairly uncommon side effect, but still one we look out for.
If a doctor recommends a Whipple procedure, what questions should patients ask before deciding whether to move forward?
There are several questions patients should ask to determine whether a Whipple procedure is the best option for them – and whether this is the best team to perform that surgery. These are the questions I recommend asking:
- What other treatment options are available?
- How will this benefit me, specifically?
- What will my recovery be like?
- How many Whipple procedures do you perform a year?
- What are your outcomes?
- What kind of team do you have in place to support me, not just during surgery, but afterward?
- How closely do you work with medical and radiation oncologists to develop patients’ treatment plans?
Why is it important to get your Whipple procedure done at a place like MD Anderson?
For one thing, at a high-volume cancer center like MD Anderson, we do more than 150 of these procedures a year, and most of our patients go on to make a full recovery.
But it’s also about your life afterward. We have an entire team of specialists to help patients manage any long-term issues that may occur after a Whipple procedure.
Nutritional deficiencies can occur after a Whipple procedure without proper management, so patients will need a dietitian. Some patients’ cancer could be linked to a genetic mutation, so they might need genetic counseling and testing. If complications occur, patients might need interventional gastrointestinal services.
Timing is also critical. To get the best results, patients need to balance the timing of the surgery with all the other treatments they might be receiving. It’s not enough to say that it’s possible to perform a Whipple procedure on a certain patient. You also have to do it at the right time. And our specialists routinely work together to give our patients the best results.
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