New treatment combinations are improving the outlook for people with pancreatic cancer.

Each year in the United States, more than 40,000 people are diagnosed with pancreatic cancer. The pancreas gland is an oblong organ that sits behind the stomach that helps the digestive system break down and absorb fats and proteins in foods. The pancreas also produces hormones such as insulin, which control blood sugar.

The treatment for pancreatic cancer is usually based on where the cancer is located in the pancreas and whether the tumor can be removed by a surgeon. Treatment varies depending on whether the tumor:

is confined to the pancreas and can be removed by surgery (stage I-IIB);
is confined to the pancreas and cannot be removed by surgery (stage III);
has spread (or metastasized) beyond the pancreas into other areas of the body (stage IV).

In this e-booklet we discuss the most common type of pancreatic cancer, called ductal adenocarcinoma, which begins in the duct cells.

Treatments for Pancreatic Cancer

Pancreatic cancer is best treated by doctors who specialize in this disease. If you and your doctor decide that surgery is your best treatment option, be sure to find a surgeon who performs pancreatic surgery often. This may require traveling to a different city or state. Ideally, the surgeon should work at a large cancer center that treats many patients with pancreatic cancer.

Surgery for Cancer Confined to the Pancreas

Surgery is the preferred treatment for pancreatic cancer located in an area of the pancreas that can be completely removed without harming nearby nerves and blood vessels. Findings from several clinical trials indicate that postoperative (or adjuvant) chemotherapy benefits people who have had surgery, in terms of increasing the cure rate and delaying the time to which the cancer may return.

In one clinical trial, people with pancreatic cancer were divided into two groups. One group of patients received gemcitabine (Gemzar), a type of chemotherapy, for six months after surgical removal of their tumor. The other group did not receive any chemotherapy after surgery. Cancer was controlled better in the people who received gemcitabine than in those who did not receive it. Patients who received gemcitabine went longer before their cancer returned and lived longer.

Gemcitabine did cause side effects, such as lower levels of infection-fighting blood cells, swelling in the legs and arms, rash, flu-like symptoms, nausea, and—rarely—vomiting. However, these side effects are typically manageable. It’s important to know that doctors can control and reduce such side effects so that people can stick to their treatment. In this clinical trial, the average patient finished all six months of treatment and reported feeling good about his or her quality of life during treatment.

Radiation and chemotherapy is sometimes considered as an adjunct to surgery. Radiation tends to cause side effects such as upper abdominal discomfort, fatigue, nausea, vomiting, and diarrhea. More study needs to be done to determine whether radiation should be routinely administered as a post-operative therapy for pancreas cancer. A major study in the US is underway to try and answer this important question.

Talk with your doctor about the possible benefits and side effects of chemotherapy, or the combination of chemotherapy and radiation, after pancreatic cancer surgery.

Nonsurgical Treatment for Cancer Confined to the Pancreas

Sometimes pancreatic cancer remains confined to the region of the pancreas, however, as the tumor is so close to blood vessels or nerves, it’s impossible for a surgeon to remove it all. In this case, surgery is not an option. However, there are two other options: chemotherapy alone or chemotherapy combined with radiation. Most doctors believe that chemotherapy is important to help control cancer that may spread to other parts of the body. Often, if chemotherapy works, patients also are treated with a concurrent combination of chemotherapy and radiation, the latter directed at the tumor in the pancreas.

Pancreatic Cancer That Has Spread Beyond the Pancreas

For pancreas cancer that is non-operable, treatment is generally chemotherapy-based. Depending on a person’s medical level of well-being and the stage of their cancer, one, two or three drug options may be considered. Gemcitabine is often combined with either erlotinib, capecitabine or a platinum drug, e.g., cisplatin or oxaliplatin.

Gemcitabine can also be combined with the drug erlotinib (Tarceva). Erlotinib is a type of targeted treatment that blocks the function of receptors on the surface of cells. Receptors take in messages ordering the cells to grow and divide. When they are blocked, cancer-cell growth slows or stops. Erlotinib is a pill taken once daily, every day, throughout treatment.

In a large clinical trial, the combination of erlotinib and gemcitabine worked better than gemcitabine alone in people with metastatic pancreatic cancer. Side effects of erlotinib include fatigue, nausea, and diarrhea. Talk to your doctor about medications that may help manage these side effects. In addition, erlotinib often causes a skin rash. The skin can feel dry or itchy. Research suggests that the rash may be a good sign that erlotinib is working properly. Doctors prescribe moisturizing creams, antibiotics (if the skin becomes infected), and anti-inflammatory medications to treat skin changes.

The findings from another large clinical trial suggest that combining gemcitabine with the chemotherapy capecitabine (Xeloda) is also more beneficial to people with metastatic pancreatic cancer than gemcitabine alone. Like erlotinib, capecitabine can be taken as a pill, making it much more convenient than other types of chemotherapy, which must be given intravenously (through a vein). The most common side effects of capecitabine are diarrhea, nausea, and vomiting; mouth and throat sores; stomach pain and upset; dry, itchy skin; pain, swelling, or redness of the hands and feet; and rash.

A recent clinical trial showed that FOLFIRINOX (5-Fluoruracil, irinotecan leucovorin and oxaliplatin), a non-gemcitabine based treatment, compared to gemcitabine alone, is more effective in shrinking pancreatic cancer, controlling disease and extending life. However, the combination of FOLFIRINOX did result in an increase in side effects such as nausea, diarrhea, fatigue, low blood counts and the risk of infection and other things, compared to gemcitabine.

Pancreatic cancer usually causes a number of side effects, but there are many ways that your health care team can manage them. If side effects happen, tell your doctor or nurse about them. Together, you can make the best decisions for your care.

Pain

Many people with pancreatic cancer experience pain. How strong the pain is, and how often it happens, depends on several factors: the position of the tumor, how much the cancer has grown, and the location of any tumors that have spread outside of the pancreas. Pain affects everyone differently. Depression, poor sleep, fatigue, and anxiety can all make pain more difficult to tolerate.

Pain is treatable, and getting help for it can greatly improve your quality of life. People who are pain-free eat better, sleep better, and cope with chemotherapy better than those in severe pain.

Depending on the level of pain, doctors prescribe various medications. Even the most severe pain can be managed effectively with opioids, such as morphine. Although opioids can cause constipation, there are drugs that can ease this side effect. Pain medications may also cause mild nausea, sleepiness, difficulty urinating, and itching. These side effects can be managed as well.

Some people with cancer worry about becoming addicted to pain medicines. Don’t let this fear keep you from getting help. Addiction among drug abusers is a psychological dependence on a drug. That’s different from needing drugs to relieve physical pain when you have cancer. With long-term use of an opioid pain reliever, a person can sometimes build up a tolerance to it. Tolerance means that you may need more of a medicine to get the same pain relief. If this happens, doctors can prescribe other medicines or drug delivery methods to relieve pain.

Another effective pain relief method for selected people with pancreatic cancer is the celiac plexus block. This is a procedure in which the celiac plexus (a group of nerves near the pancreas) is numbed with medication, often alcohol injected with a needle. For many patients who have celiac plexus infiltration with cancer, this reduces pain and the need for other pain medications.

If pain comes from the pancreatic tumor itself or from tumors that have spread to the bone, radiation may be an option. For some people, relaxation exercises and mind/body techniques, such as deep breathing and meditation, may also help manage pain. Some cancer treatment centers have programs to teach people with cancer and their caregivers the basics of these techniques. There are also a number of easy-to-follow educational books on this subject. CancerCare’s professional oncology social workers can help you learn these techniques as well.

Jaundice

In this condition, bile—a substance involved in digestion that is produced by the liver—builds up to unsafe levels. Jaundice is common in people with pancreatic cancer that begins in the head of the pancreas. It is caused by blockage of the bile duct, a small tube that carries bile out of the liver. Jaundice can cause loss of appetite, weight loss, nausea, and itching, as well as yellowing of the skin and eyes. If the bile duct is obstructed, as noted on imaging tests, the standard treatment for jaundice in people with pancreatic cancer is the insertion of a tube, called a stent, into the bile duct. The tube helps bile drain into the intestine.

If you have fever, chills, abdominal pain, or any recurrence of jaundice after receiving a stent, let your health care team know right away. These symptoms can be signs of an infection or a problem with the stent.

Intestinal blockages

Some people with advanced pancreatic cancer may develop blockages in the intestines. This can happen if the tumor itself blocks the intestines or if nerve damage prevents the intestines from working properly. Intestinal blockages can cause eating difficulties and repeated vomiting. For people using opioids for pain relief, changing the dosage often helps relieve blockages. Sometimes, surgery or medicines are used to treat intestinal blockages. Another option is a gastrostomy tube inserted into the stomach to allow fluids to drain. This can help relieve vomiting.

Doctors can also drain fluids called ascites from the abdomen with a hollow needle inserted through the skin. If the fluid quickly builds up again, a permanent tube called an intraperitoneal catheter may be needed to drain fluid continually.

There’s no question that clinical trials have led to advances in cancer treatment, creating a brighter future for people with cancer. Clinical trials are the standard by which we measure the worth of new treatments and quality of life as patients go through those treatments. For this reason, doctors and researchers urge people with cancer to take part.

This is especially important for people with pancreatic cancer as doctors search for newer and more effective ways to treat the disease. A major focus of the treatment of advanced pancreatic cancer is the use of new drugs as part of clinical trials. Most trials are conducted in the setting of previously untreated pancreatic cancer, and a smaller number of trials are focused on patients who have received prior therapies.

Currently, most clinical trials for people with pancreatic cancer are phase I and phase II trials. People take part in these studies for a number of reasons, including the hope that the treatment will work for them and the desire to help future patients.

What You Should Know About Clinical Trials

Your doctor can guide you in making a decision about whether a clinical trial is right for you. Here are a few things to keep in mind:

• Often, patients who take part in clinical trials gain access to and benefit from new treatments. • Before you participate in a trial, you will be fully informed as to the risks and benefits of the trial. • No patient receives a placebo (a look-alike pill or liquid with no active ingredient) if there is a standard treatment available for the disease. Most clinical trials are designed to test a new treatment against a standard treatment to find out whether the new treatment has any added benefit. • You can stop taking part in a clinical trial at any time for any reason.

The Phases of Clinical Trials

There are four phases of clinical trials:

In phase I trials, researchers test for the first time the safety of a new drug or dosage in people. Only a small group of 20 to 40 people, usually with advanced cancer, is included in phase I trials. Although these clinical trials focus on the safest dose of a new drug, doctors and patients also hope to see benefits from the treatment as well. Phase I trials usually take place in special research institutions, where patients can be closely monitored.

In phase II trials, the new drug or treatment is given to a larger group of people (100 to 300) to see if it is effective, to further evaluate its safety, to learn more about the side effects that might occur and how to manage them, and to find the best dose. Some phase II trials in pancreatic cancer are being randomized— that is, the patients taking part are randomly chosen to be in one of two groups. One group gets the new treatment, and the other gets standard treatment. Like phase I studies, phase II clinical trials usually take place at special research institutions.

In phase III trials, the study drug or treatment is given to even larger groups of people, usually many hundreds to thousands. In the case of pancreatic cancer, generally hundreds of patients take part. During this phase, researchers are able to confirm the treatment’s effectiveness; observe side effects that might not have occurred during earlier phases in smaller groups; compare the new treatment with currently used standard treatments; and collect information that will allow the new drug or treatment to be used safely.

In phase IV trials, researchers study drugs after they have been approved by the U. S. Food and Drug Administration and marketed to the public. These trials gather additional information on safety and effectiveness.

Because the pancreas plays a key role in digestion, pancreatic cancer can cause a number of nutrition-related side effects. These side effects may be a result of the cancer itself or treatment. The right nutrition can help you maintain your weight, strength, and quality of life as you go through treatment for pancreatic cancer.

The most common nutrition-related side effects people with pancreatic cancer experience are malabsorption (difficulty digesting or absorbing nutrients from food), nausea and vomiting, loss of appetite, taste changes, feeling full early, pain with eating, fatigue, and changes in bowel movements. If eating poses a challenge, let your health care team know and ask to see a registered dietitian.

The following tips can help you cope with nutrition-related side effects of pancreatic cancer:

Eat small, frequent meals. Try to eat about six to eight times a day.

Plan meals and snacks. Each day, take time to plan what and when you will be eating the next day. This will help you cope with times when you don’t feel hungry or don’t know what to eat.

Drink plenty of fluids. Most people need to drink at least six to eight cups of water or other fluid every day. Don’t include beer, wine, or other alcoholic drinks in the daily tally.

Limit the amount of fat in your diet. High-fat foods can contribute to changes in bowel habits or to feeling full quickly.

Eat high-protein foods. Pancreatic cancer and its treatment increase a person’s protein needs. To meet these needs, include a protein-rich food with each meal or snack. Good sources of protein include:

• Lean cuts of meat, poultry, or fish
• Beans, peas, or lentils
• Low-fat or fat-free dairy products
• Eggs
• Milk alternatives such as soy milk, rice milk, and hemp milk
• Meat alternatives such as tofu or veggie burgers
• Protein powders, including dry milk powder
• Nuts and seeds
• Meal-replacement drinks such as homemade smoothies or commercial liquid nutritional supplements

Choose foods that are dense in nutrients. Milk and dairy products, high-protein foods (such as lean meat), fortified cereals, and fruits and vegetables all pack in healthy amounts of vitamins and minerals.

Stay as active as possible. Physical activity helps stimulate the appetite and preserve muscle mass. Talk with your doctor about what level of exercise is right for you.

Use anti-nausea medications if you need them. Nausea can interfere with eating and quality of life.

Q. During the past decade, what progress has been made in extending survival for people with pancreatic cancer?

A. Improving pancreatic cancer survival rates has been particularly challenging. This is because the cancer tends to be detected late, the symptoms may not be very specific, the cancer tends to resist the best available thearpies, and the biology and genetics of the cancer are extremely complex. However, researchers are making strides in treating pancreatic cancer. They are continually developing better ways to study pancreatic cancer, and many people are working on new treatments. Researchers are hopeful that there will be significant changes in survival for people with pancreatic cancer during the next five years, and there have been incremental gains in recent years.

Q. I recently read that turmeric is being studied as a possible treatment for pancreatic cancer. Is there any evidence that the active ingredient in the spice is useful, and is it safe to take?

A. Studies suggest that the spice may have a role in treating cancer, but this has not yet been proved. Researchers are trying to pinpoint the best dose to take. The amount of turmeric a person would have to take by mouth is quite large, and not all of it seems to get into the bloodstream. Researchers are trying to create a drug form of the active ingredient in turmeric, called curcumin, which could be given to patients intravenously (through a blood vein). As of now, there is no evidence to prove that curcumin is helpful or whether it is safe. Researchers hope to know more about it soon.

Q. What is the treatment and prognosis for a neuroendocrine tumor that begins in the pancreas?

A. Neuroendocrine tumors that start in the pancreas are quite different from the pancreatic cancer tumors (adenocarcinomas) discussed in this booklet. Neuroendocrine tumors affect cells in the pancreas that produce hormones, including insulin. The pancreatic cancer we have been discussing affects duct cells—pancreatic cells that drain substances called enzymes from the pancreas into the bowel.

Neuroendocrine tumors appear to grow more slowly and in a different way than other pancreatic tumors. They are often removed surgically and then treated with different therapies than are used for standard pancreatic cancer. Also, neuroendocrine tumors are often treated with hormones for gastrointestinal and respiratory symptoms.

Q. For a person with pancreatic cancer who has already been treated with surgery and chemotherapy, what is the current standard of care?

A. The standard procedure is to have CT scans of the abdomen and pelvis every four to six months. In addition, blood tests are used to check levels of CA19-9, a substance released by pancreatic tumors. It is used as a marker of tumor growth. If the level of CA19-9 is high before surgery and then rises after surgery, extra tests may be needed to see if a tumor has returned.

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This e-booklet was made possible by an educational grant from Astellas Oncology.

The information presented in this publication is provided for your general information only. It is not intended as medical advice and should not be relied upon as a substitute for consultations with qualified health professionals who are aware of your specific situation. We encourage you to take information and questions back to your individual health care provider as a way of creating a dialogue and partnership about your cancer and your treatment.