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

Each year in the United States, more than 46,000 people are diagnosed with pancreatic cancer. The pancreas gland is shaped like a tadpole (with a head, body and tail) and sits behind the stomach. It helps the digestive system break down and absorb fats and proteins in foods. The pancreas also produces hormones such as insulin, which controls blood sugar.

In this booklet we discuss the most common type of pancreatic cancer, called ductal adenocarcinoma.

Treatment for pancreatic cancer is based on whether or not the cancer is localized (confined to the pancreas), involves major blood vessels or has spread to other parts of the body. If the tumor has spread (metastasized) beyond the pancreas, then treatments other than surgery are used.

Doctors often prescribe chemotherapy, targeted treatments, radiation or a combination of these therapies for people with metastatic pancreatic cancer. Targeted treatments destroy cancer cells by focusing on specific cell mechanisms thought to be important for the growth and survival of tumor cells. These medications are designed to spare healthy tissues in the hope of causing less severe side effects.

Surgery

People receiving surgical treatment for their pancreatic cancer benefit most from working with a doctor who specializes in treating this cancer and performs many pancreatic surgeries.

There are different types of surgical procedures to remove pancreatic tumors:

Whipple procedure. This procedure removes a portion of the pancreas called the “head,” along with the gallbladder, part of the stomach, part of the small intestine and the bile duct. A portion of the pancreas is left in place to produce digestive juices and insulin.

Total pancreatectomy. This operation removes the entire pancreas, part of the stomach and small intestine, the bile duct, gallbladder, spleen and nearby lymph nodes.

Distal pancreatectomy. The body and tail, or distal end, of the pancreas and usually the spleen are removed in this procedure.

If the cancer has spread and cannot be removed, surgeons can perform different types of palliative surgery. These types of procedures are designed to relieve symptoms and improve quality of life. One such procedure, described on the “Managing Side Effects” page in the discussion on jaundice, relieves a blocked bile duct by inserting a tube called a stent to drain the fluid.

Chemotherapy and Targeted Treatments

One standard treatment for pancreatic cancer is a chemotherapy drug called gemcitabine (Gemzar and others). It can shrink the cancer, ease symptoms and help patients live longer. Gemcitabine is approved by the U.S. Food and Drug Administration as a first-line treatment (first treatment given) for patients whose cancer has spread and cannot be treated with surgery.

To increase survival, gemcitabine often is combined with other medications such as albumin-bound paclitaxel (Abraxane). Sometimes doctors combine gemcitabine with oxaliplatin (Eloxatin and others) or capecitabine (Xeloda and others). Gemcitabine can also be used by patients already treated with fluorouracil (5-FU), another type of chemotherapy. For certain patients, FOLFIRINOX, a combination of folinic acid (leucovorin), 5-FU, irinotecan (Camptosar and others) and oxaliplatin, is used as the first treatment for pancreatic cancer.

There is one targeted treatment called erlotinib (Tarceva and others) that is given with gemcitabine for the treatment of pancreatic cancer. This combination works by blocking processes in tumor cells that help the cancer grow and spread.

Radiation

There are two main types of radiation treatments:

External beam radiation uses a machine outside the body to send radiation toward the cancer.

Internal radiation uses a radioactive substance sealed in needles, seeds, wires or catheters that are placed directly into or near the cancer.

Whether to use internal or external radiation depends on the type and stage of the cancer being treated.

There are many ways that your health care team can manage the side effects of pancreatic cancer or its treatment. It’s important to let your doctor or nurse know if you experience any of the symptoms discussed in this section. Together, you can make the best decisions for your care.

Pain

Pain can occur if the tumor presses on nerves or other organs near the pancreas. 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, whether or not it has affected nerves or other organs and the location of any tumors that have spread outside of the pancreas.

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 who have 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 themselves can cause side effects such as constipation, sleepiness or itching, there are drugs that can ease these symptoms as well.

Another effective pain relief method for some people with pancreatic cancer is a celiac plexus block. This is a procedure in which the celiac plexus (a group of nerves near the pancreas) is numbed with medication injected with a needle. For many patients, this procedure 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. The professional oncology social workers at CancerCare can help you learn these techniques as well.

Jaundice

In this condition, bile—a substance produced by the liver that helps break down fats in the intestines—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 from the liver to the small intestine. 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 blocked, doctors insert 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 return 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 blocks the intestines or if nerve damage or opioids used for pain relief prevent the intestines from working properly. Intestinal blockages can cause eating difficulties and vomiting. For people using opioids, changing the dosage often helps relieve Intestinal blockages.

Sometimes, surgery or stents are used to treat intestinal blockages. Another option is inserting a tube into the stomach to allow fluids to drain. This can help relieve vomiting.

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

Q. Has progress been made in increasing survival for people with pancreatic cancer?

A. Improving pancreatic cancer survival has been particularly challenging. The cancer tends to be detected late, when it has already spread, and it can resist the best available treatments because of its complex biology and genetics. However, researchers are making strides in treating pancreatic cancer. Importantly, they are continually developing better ways to study pancreatic cancer through clinical trials. These carefully controlled studies are the standard by which we measure the effectiveness of new treatments and their impact on patients’ survival and quality of life. Clinical trials also offer an additional treatment option. For these reasons, doctors and researchers urge people with pancreatic cancer to take part in clinical trials.

Q. What are 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 ductal 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, followed by treatment with hormones or targeted drugs such as everolimus (Afinitor) or sunitinib (Sutent).

Q. For a person with pancreatic cancer who has already been treated with surgery and chemotherapy, what are the next steps to take?

A. The standard procedure is to have follow-up CT scans 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 the tumor has returned.

CancerCare®
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American Cancer Society
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Cancer.Net
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National Cancer Institute
800-422-6237

Hirshberg Foundation for Pancreatic Cancer Research
310-473-5121

The Lustgarten Foundation
866-789-1000

National Coalition for Cancer Survivorship
877-622-7937

Pancreatic Cancer Action Network
877-272-6226

CLINICAL TRIALS WEBSITES

Coalition of Cancer Cooperative Groups
877-227-8451

EmergingMed
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National Cancer Institute
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This booklet was made possible by Celgene.

Last updated July 10, 2014

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.