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PANCREATIC CANCER
( By JASCAP )

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Treatment for Pancreatic Cancer

Types of treatment
Benefits and disadvantages
Treatment decisions
Giving your consent
Second opinion

Types of treatment

The type of treatment you will be offered depends on the particular type of cancer of the pancreas you have, the stage of the cancer, its size, and your general health. The treatment will be planned by a team of specialist doctors and other healthcare professionals. This is known as a multidisciplinary team (MDT), and may include:

a surgeon who specialises in treating cancer of the pancreas
a clinical oncologist – a doctor who treats cancer with radiotherapy
a medical oncologist – a doctor who treats cancer with chemotherapy
a pathologist – a doctor who specialises in how disease affects the body a radiologist – a doctor who analyses x-rays and scans
a specialist nurse who gives information and support to people with pancreatic cancer.

The MDT may also include other healthcare professionals, such as:

a dietitian
a physiotherapist
an occupational therapist
a psychologist or counsellor.

Many pancreatic cancers are not diagnosed until the cancer is quite advanced. Cancer of the pancreas can be very difficult to treat. It may not be possible to cure it, although early-stage cancer can sometimes be cured with surgery.

The most effective treatment for early-stage cancer of the pancreas is surgery to remove part, or all, of the pancreas. This is a major operation and is only suitable for people whose cancers are small and have not spread, and who are fit. If the cancer is too large, or has already spread beyond the pancreas when it's diagnosed, this kind of surgery is not possible. Learning that your cancer has spread, and therefore that certain treatments are not suitable for you, is distressing news to cope with. Your doctor will advise you about the treatments that are most likely to help in your situation.

If the cancer has spread and is causing a blockage of the bile duct or the bowel, surgery can sometimes be used to relieve the blockage and ease the symptoms.

Chemotherapy can be used in a number of different ways. It may be used after surgery for early-stage pancreatic cancer to try to reduce the chances of the cancer coming back. It can also be used to shrink cancers that have spread into the area around the pancreas, or to treat cancers that have spread to other parts of the body, such as the liver. For cancers that have not spread beyond the pancreas but can't be removed by an operation, chemotherapy and radiotherapy may be given separately or together. Sometimes you may be asked to take part in a clinical trial of a new drug or treatment.

Chemotherapy may also be given to help reduce some of the symptoms of pancreatic cancer. Radiotherapy can be helpful in controlling pain.

An important part of the care of all people with pancreatic cancer is the use of treatments to control symptoms and make you feel more comfortable, known as supportive care.

Benefits and disadvantages

Many people are frightened at the idea of having cancer treatments, because of the side effects that can occur. Some people ask what would happen if they did not have any treatment.

Although many of the treatments can cause side effects, these can usually be well controlled with medicines. Treatment can be given for different reasons, and the potential benefits will vary depending upon each person's situation.

Early-stage pancreatic cancer

In people with early-stage pancreatic cancer, surgery is often done with the aim of curing the cancer. Additional treatments such as chemotherapy may also be given to reduce the risks of it coming back.

Advanced pancreatic cancer (metastatic)

If the cancer is at a more advanced stage, the treatment may only be able to control it, leading to an improvement in symptoms and a better quality of life. However, for some people, the treatment will have no effect upon the cancer and they will get the side effects without any of the benefits.

Treatment decisions

If you have been offered treatment with the aim of curing your cancer, deciding whether to accept the treatment may not be difficult. However, if a cure is not possible and the treatment is being given to control the cancer for a period of time, it may be more difficult to decide whether to go ahead with treatment.

Making decisions about treatment in these circumstances is always difficult, and you may need to discuss the possible treatment options in detail with your cancer specialist. Many people find it helpful to have a relative or friend with you.

Giving your consent

Before you have any treatment, your doctor will explain the aims of the treatment to you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent. Before you are asked to sign the form you should have been given full information about:

the type and extent of the treatment you are advised to have
the advantages and disadvantages of the treatment
any other types of treatments that may be appropriate
any significant risks or side effects of the treatment.

If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are very complex, so it's not unusual for people to need repeated explanations.

It's often a good idea to have a friend or relative with you when the treatment is explained, to help you remember the discussion more fully.

You may also find it useful to write down a list of questions before you go to your appointment.

Patients often feel that hospital staff are too busy to answer their questions, but it's important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions.

You can always ask for more time to decide about the treatment if you feel that you can't make a decision when it is first explained to you.

You are also free to choose not to have the treatment. The staff can explain what may happen if you don't have it. It is essential to tell a doctor, or the nurse in charge, so that they can record your decision in your medical notes. You don't have to give a reason for not wanting to have treatment, but it can help to let the staff know your concerns so that they can give you the best advice.

Second opinion

Usually a number of cancer specialists work together as a team. They will use national treatment guidelines to decide on the most suitable treatment for you. Even so, you may want to have another medical opinion. Either your specialist, or your GP, will be willing to refer you to another specialist for a second opinion, if you feel it will be helpful. The second opinion may cause a delay in the start of your treatment, so you and your doctor need to be confident that it will give you useful information.

If you do go for a second opinion, it may be a good idea to take a friend or relative with you. It can also help if you have a list of questions ready, so that you can make sure your concerns are covered during the discussion.

Surgery for pancreatic cancer

Removal of the cancer (resection)
After your operation
Bypass surgery

Removal of the cancer (resection)

Occasionally, it's possible to remove all of the cancer with surgery. This is a major operation, only suitable for people with early-stage pancreatic cancer. This type of surgery should be done by specialist surgeons who are trained and experienced in pancreatic surgery, so you may need to be referred to a specialist centre to have this type of treatment. It is important to discuss the benefits and the risks with your surgeon before making the decision to go ahead with any surgery.

Depending on where the cancer is, and how much of the pancreas is involved, all, or part of the pancreas may need to be removed during surgery.

Removal of the whole pancreas is called pancreatectomy
Removal of the lower end (body and tail) of the pancreas is called distal pancreatectomy
Removal of the head of the pancreas, the lower end of the stomach, most of the duodenum (the first part of the small bowel), the common bile duct, gall bladder and the surrounding lymph nodes is called a pancreatoduodenectomy or a Whipple's operation.
A Whipple's operation in which the lower end of the stomach is not removed is called a pylorus-preserving pancreatoduodenectomy (PPPD).

Your specialist may suggest that you have a laparoscopy to see which type of surgery is possible in your case.

Occasionally, even if the cancer can't be completely removed, the surgeon may remove some of the cancer (a partial resection) to reduce symptoms and control the cancer for a while.

After your operation

After your operation, you may stay in an intensive care ward for the first couple of days.

You will then be moved to a general ward. You'll be encouraged to start moving around as soon as possible. This is an essential part of your recovery, and even if you have to stay in bed it's important to do regular leg movements and deep breathing exercises. A physiotherapist or nurse will explain these to you.

Drips and drains

A drip into a vein in your arm (intravenous infusion) will be used to give you fluids until you are able to eat and drink again.

You may have a fine tube that passes down your nose, into your stomach or small intestine. This is called a nasogastric tube and it allows any fluids in the stomach to be removed so that you don't feel sick. You may need this for up to five days.

Often a small tube (catheter) is put into the bladder, and urine is drained into a collecting bag. This will save you having to get up to pass urine and is usually taken out after a couple of days.

You may also have one or more drainage tubes in your wound, to collect any extra fluid or blood, or to drain bile or pancreatic fluid. These will be removed when the amount of fluid draining has reduced.

Pain

After your operation, you'll probably have some pain and discomfort for a few days.

Pain can usually be controlled effectively with painkillers.

It's important to let your doctor or the nurses on the ward know if you are in pain, or if your drugs are not completely relieving your pain, so that the dose can be increased or the painkillers changed as soon as possible.

Insulin and enzyme replacement

People who have had their whole pancreas removed will need to either take tablets to regulate their blood sugar, or have daily insulin injections to replace the insulin normally produced by the pancreas. They will need this for the rest of their life. They may also need to take capsules containing the special proteins (enzymes) normally produced by the pancreas, to help with digestion.

If you've had a part of your pancreas removed, immediately after the operation the remaining pancreas may not be able to produce enough enzymes to help with digestion, or enough insulin to control your blood sugar. You may need to have insulin given by injection into a vein (intravenously). This is usually only until the remaining pancreas recovers and starts to produce insulin again. You may also need to take capsules containing digestive enzymes normally made by the pancreas.

Bypass surgery

Sometimes, surgery is carried out to treat a blockage in the first part of the small bowel (duodenum), if the blockage is causing vomiting. During the operation, a piece of the small bowel (the jejunum) is connected to the stomach, to bypass the duodenum. This is called a gastrojejunostomy. It is often done at the same time as a bile duct bypass.

Chemotherapy for pancreatic cancer

Why chemotherapy is given
How it is given
Side effects

Why chemotherapy is given

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells.

If a pancreatic cancer has been completely removed with surgery, chemotherapy may be given afterwards to try to reduce the chance of the cancer coming back. This is known as adjuvant chemotherapy. If the cancer can only be partially removed you may still be given chemotherapy, to shrink the remaining tumour.

If the cancer can't be removed at all but has not spread beyond the pancreas, chemotherapy can't cure the cancer, but may shrink it down and control it for a time.

If the cancer has spread, chemotherapy may be used to try and shrink the cancer and relieve symptoms.

Chemotherapy may be given together with radiotherapy to increase its effectiveness. This is known as chemoradiation.

How it is given

Chemotherapy drugs are usually given by injection into a vein (intravenously) either in your arm or through a plastic tube (a central line), into your chest.

The chemotherapy drugs used to treat pancreatic cancer include gemcitabine (Gemzar®), 5-flourouracil (5FU), cisplatin, mitomycin, oxaliplatin (Eloxatin®) and capecitabine (Xeloda®).

It's unusual for more than one chemotherapy drug to be given at the same time in the treatment of pancreatic cancer. Combinations of drugs are sometimes used as part of research trials. Sometimes gemcitabine is given in combination with a drug called erlotinib (Tarceva®). Erlotinib is a biological therapy that works by interfering with the way that cancer cells grow and divide.

The length of time that chemotherapy is given for will depend on the drugs that are used, and how well the treatment is working. This will be monitored by your doctor at regular appointments, and you will have regular blood tests and occasional scans. Any decision to use chemotherapy will be reached after a discussion between you and your doctor.

After you have had your chemotherapy there is usually a rest period of a few weeks, which allows your body to recover from the side effects of the treatment. Chemotherapy is usually given to you as an outpatient, but occasionally it may mean spending a few days in hospital.

Our chemotherapy booklet discusses the treatment and its side effects in more detail.

A number of research trials are being carried out to try to improve the results of treatment for pancreatic cancer. You may be asked to take part in a trial.

Side effects

Chemotherapy can sometimes cause unpleasant side effects, but it can also make you feel better by relieving the symptoms of the cancer. Most people have some side effects, but these can often be well controlled with medicines. Some of the possible side effects are described here, along with some of the ways in which they can be reduced.

Reduced resistance to infection

While the chemotherapy is acting on the cancer cells in your body, it also temporarily reduces the number of white blood cells. When these cells are reduced you are more likely to get an infection. During chemotherapy, your blood will be tested regularly and, if necessary, you will be given antibiotics to treat any infection.

Sore mouth

Some chemotherapy drugs can make your mouth sore and cause small ulcers. Regular mouthwashes are important and your nurses will show you how to use these properly. If you don't feel like eating during treatment, you could try replacing some meals with nutritious drinks or a soft diet. Our booklet on eating well has some useful tips on coping with eating problems.

Diarrhoea

Some drugs used to treat cancer of the pancreas can irritate the lining of the digestive system and cause diarrhoea for a few days. Your doctor can give you medicine to slow down your bowel, and reduce the diarrhoea. You may also be able to help to control it by eating a low-fibre diet. This means avoiding wholemeal bread and pasta, raw fruit, cereals and vegetables for a few days after each treatment.

Feeling sick

Some of the drugs may make you feel sick (nauseated) and you may sometimes be sick. There are now very effective anti-sickness drugs (anti-emetics) to prevent or reduce nausea and vomiting. Your doctor can prescribe these for you. Let your doctor or nurse know if your anti-sickness drugs are not helping you, as different types can be used.

Some anti-emetics can cause constipation. Let your doctor or nurse know if this is a problem.

Hair loss

Ask your doctor whether the drugs you are taking are likely to make your hair fall out. Not all drugs cause hair loss and certain drugs are more likely to make your hair thin. If your hair does fall out, it will start to grow back once your treatment is over.

Skin

Chemotherapy can affect the skin and nails, causing dryness and flaking. Some drugs make your skin more sensitive to the sun, so it is important to cover up and use a high- factor sun cream (SPF 15 or greater).

Although these side effects may be hard to bear at the time, they will gradually disappear over a few weeks once your treatment has finished.

Radiotherapy for pancreatic cancer

Radiotherapy treats cancer by using high-energy x-rays to destroy as many cancer cells as possible, while doing as little harm as possible to normal cells.

Radiotherapy is used less often than surgery or chemotherapy. It is sometimes used to treat cancer of the pancreas which has not spread but can't be removed by surgery. In this situation it may be used together with chemotherapy (known as chemoradiation) to shrink the cancer and keep it under control for as long as possible.

Radiotherapy is also sometimes given to relieve symptoms such as pain. The radiotherapy can shrink the tumour and so relieve pressure which may be causing pain.

The dose of radiotherapy used to relieve symptoms is usually lower so you may have a shorter course of treatment and less chance of side effects.

Radiotherapy is given in the hospital radiotherapy department. How the treatment is given can vary a lot, depending on your particular needs. Sometimes a single treatment is all that is needed, but usually a course of therapy is given in daily sessions from Monday–Friday, with a rest at the weekends. Each session lasts only a few minutes. The course of treatment may last for a number of weeks. Your doctor will discuss your treatment with you in detail beforehand.

Planning your treatment
Having treatment
Side effects

Planning your treatment

To ensure that you receive maximum benefit from your radiotherapy, it has to be carefully planned. This is done using a CT scanner, which takes x-rays of the area to be treated. Treatment planning is a very important part of radiotherapy and it may take a few visits to complete.

Marks may be drawn on your skin to help the radiographer, who gives you your treatment, to position you accurately and to show where the rays are to be directed. These marks must stay visible throughout your treatment, but they can be washed off once it is over. At the beginning of your radiotherapy you will be told how to look after the skin in the area to be treated.

Having treatment

Before each session of radiotherapy the radiographer will position you carefully on the couch, either sitting or lying, and make sure that you are comfortable. During your treatment, which only takes a few minutes, you will be left alone in the room, but you will be able to talk to the radiographer, who will be watching you carefully from the next room. Radiotherapy is not painful but you have to be still for a few minutes while your treatment is being given.

The radiographer watches on a monitor while treatment is given

Side effects

Radiotherapy for cancer of the pancreas can cause side effects such as feeling sick (nausea), vomiting, diarrhoea and tiredness. These side effects can be mild, or more troublesome, depending on how much treatment you are having. Your cancer specialist will be able to advise you what to expect.

Our radiotherapy booklet tells you more about this treatment and its side effects.

Supportive care (controlling symptoms) for pancreatic cancer

Your doctor may suggest certain treatments or procedures to relieve any uncomfortable symptoms caused by the cancer. Treating symptoms is known as supportive care.

Our booklet on controlling the symptoms of cancer gives information about the methods of treating different symptoms.

Treating jaundice
Bypass surgery
Nerve block (coeliac plexus)

Treating jaundice

If the tumour blocks the bile duct, causing jaundice (see symptoms), and it's not possible to remove it, your doctors may suggest you have a procedure to relieve the blockage and allow bile to flow into the small bowel again. The jaundice will then clear up. There are three ways of doing this. These are ERCP, PTC (percutaneous transhepatic cholangiography) and bypass surgery.

ERCP and PTC

In ERCP and PTC, a tube called a stent is placed into the inside of the blocked bile duct to hold it open. The ERCP method is often used when ERCP is first carried out as an investigation (see further tests).

You'll be asked not to eat or drink anything for six hours before the procedure, so that the stomach and duodenum are empty. You will be given a sedative by injection, and the endoscope will be passed through your mouth (as described on the further tests page).

A dye will be used, as before. X-rays are taken, and by looking at the x-ray picture the doctor will be able to see the narrowing in the bile duct. The narrowing can be stretched and a tube put in through the endoscope, allowing the bile to drain.

The tube may need to be replaced later if the jaundice comes back or if an infection occurs.

The PTC method is similar to ERCP in that a dye is used to show up the blockage on x- ray. Instead of the tube being inserted through an endoscope, a needle is inserted through the skin just below your rib cage and a fine guide wire passed through the liver and into the blockage in the bile duct. The tube is then passed along this wire.

As with ERCP, you will be asked not to eat or drink for at least six hours beforehand, and you will then be given a sedative. You will also have a local anaesthetic so you should not feel pain as the needle or wire is passed through your skin, although moving the wire into the correct position in the bile duct can be painful. To help prevent any infection you will be given antibiotics before and after the procedure. It is likely that you will stay in hospital for a few days afterwards.

Sometimes, if the tube can't be passed into the bile duct from the duodenum during

ERCP, a combination of ERCP and PTC is carried out.

Bypass surgery

Surgery is sometimes recommended to deal with a blockage of the bile duct. This involves joining the gall bladder or bile duct to the small bowel (see diagram of the pancreas). This bypasses the blocked part of the bile duct and allows the bile to flow from the liver into the bowel. This operation is called a cholecystoenterostomy. In some hospitals, it's possible to do this procedure during laparoscopy.

Nerve block (coeliac plexus)

If the pain caused by cancer of the pancreas can't be properly controlled with painkilling drugs, your doctor may suggest that you have a nerve block. A nerve block stops pain messages from getting to the brain by blocking the nerves themselves. There are different ways in which this can be done – injecting an anaesthetic such as alcohol into the nerve or, occasionally, cutting the nerve.

In people with cancer of the pancreas, persistent pain in the abdomen and back can be caused by the tumour pressing on the coeliac plexus (a complicated web of nerves at the back of the abdomen). A coeliac plexus nerve block is usually a very effective way of treating this type of pain.

Before the procedure you'll be given a sedative to help you relax, usually by injection into a vein in your arm (intravenously). The nerve block may be carried out with a CT scan to help the doctor to put the needle into the right place. You will be given an injection of local anaesthetic to numb the skin beforehand. A long, fine needle is inserted through your back and into the nerve, which is then injected with alcohol.

Afterwards, for a day or two, your blood pressure may be low, making you feel light- headed and dizzy, particularly when you stand up. Sometimes the nerve can be cut rather than injected, but for this you will need a general anaesthetic. For this reason, a block involving cutting the nerve is usually carried out when a person is having other surgery, such as bypass surgery.

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