Pancreatic cancer treatment: surgery, chemotherapy, radiotherapy and more

Treatment for pancreatic cancer can be challenging depending on:

• the size and type of pancreatic cancer
• location
• spread to the surrounding area and metastasis
• the patient's overall health

Treatment includes: surgery, endoscopic treatment, chemotherapy, radiotherapy and supportive care.

Surgery

As with any cancer process, radical surgical removal of the tumour is the only treatment option that allows for long-term survival of the patient. Unfortunately, most tumours are inoperable at the time of diagnosis.

The surgeries used for patients with pancreatic cancer include:

• Surgery for tumors in the head of the pancreas - If the tumor is located in the head of the pancreas, the most commonly performed surgery is called Whipple's surgery (pancreatoduodenectomy). Whipple's surgery is a technically demanding operation that removes the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder, part of the bile duct, and nearby lymph nodes. In some cases, part of the stomach and colon may also be removed.
• Surgery for tumors in the body and tail of the pancreas - Surgery to remove the left side (body and tail) of the pancreas is called a distal pancreatectomy. Sometimes the spleen also needs to be removed.
• Surgery to remove the entire pancreas - In some people, the entire pancreas may need to be removed. This surgery is called a total pancreatectomy. The patient lives a relatively normal life without the pancreas, but needs lifelong replacement with insulin and enzymes.
• Surgery for tumors affecting nearby blood vessels - Many people with advanced pancreatic cancer are not considered suitable for the Whipple procedure or other pancreatic surgeries if their tumors affect nearby blood vessels. At highly specialized and experienced medical centers, surgeons can perform pancreatic surgeries that involve removing and reconstructing the affected blood vessels.

Each of these surgeries carries a risk of bleeding and infection. Some people experience nausea and vomiting after surgery. There is a long recovery period after each of these surgeries.

The patient spends several days in the hospital and then recovers at home for several weeks.

Pancreatic cancer surgery leads to fewer complications if it is performed by experienced surgeons in special centres that have a lot of experience in these operations. That is why patients are referred to the centres.

Endoscopic treatment

This is one of the important options for palliative (supportive) treatment of patients with jaundice, especially if the bile ducts are blocked or narrowed by a tumour. In this case, a so-called stent is inserted into the bile duct under X-ray control with an endoscope (ERCP, mentioned above) to ensure the outflow of bile through the narrowed area.

Chemotherapy

Chemotherapy uses drugs that help destroy cancer cells. These drugs can be injected into a vein or taken orally. It is usually reserved for patients for whom surgery is not possible. It does not prolong life, but it improves the quality of life.

Chemotherapy can also be combined with radiotherapy (chemoradiotherapy). Chemoradiotherapy is usually used to treat cancer that has not spread outside the pancreas to other organs. In specialised medical centres, this combination may be used before surgery to shrink the tumour (neoadjuvant treatment). It is sometimes used after surgery to reduce the risk of the pancreatic cancer coming back (adjuvant treatment).

For people with advanced pancreatic cancer and cancer that has spread to other parts of the body (metastatic spread), chemotherapy may be used. It controls the growth of the cancer, relieves symptoms and slightly prolongs survival.

Drugs used as chemotherapy drugs in the treatment of pancreatic cancer: 5-fluorouracil, gemcitabine, leucovorin, doxorubicin, mytomycin C, paclitaxel, cisplatin, erlotinib, capecitabine.

Radiotherapy

Radiation therapy uses high-energy radiation, such as X-rays and protons, to destroy cancer cells. You may have radiation therapy before or after cancer surgery, often in combination with chemotherapy. Or your doctor may recommend a combination of radiation and chemotherapy if the cancer cannot be treated with surgery.

Radiotherapy is usually done with a machine that moves around you and directs radiation to specific places on your body (external beam radiation). In specialized medical centers, radiation therapy may be given during surgery (intraoperative radiation).

Traditional radiotherapy uses X-rays to treat cancer. In some medical centres, a newer form of radiation using protons is available. In certain situations, proton therapy can be used to treat pancreatic cancer. It may have fewer side effects compared with standard radiotherapy.

Supportive (palliative) care

Palliative care is specialized medical care. It focuses on relieving pain and other symptoms of a serious, otherwise incurable disease.

• Pain - Pain relief is especially necessary for patients who are not undergoing surgery. Analgesics are used. Their effect may be enhanced by tricyclic antidepressants and antiemetics. Among non-medication treatments, the following are used:
  • neurolysis of the celiac ganglia (numbing of the nerve plexus in the abdominal cavity) for intolerable abdominal pain
  • radiotherapy for pancreatic cancer may relieve pain but has no effect on patient survival
  • endoscopic stent implantation
• Jaundice - Requires treatment if the patient has itching or pain in the right upper quadrant of the abdomen or has inflammation of the biliary tract. Here the above endoscopic treatment is used.
• Duodenal overgrowth with closure of the duodenal diameter - Occurs in about 5% of patients with pancreatic cancer. There are two options for management of this condition:
  • Surgery - gastrojejunostomy, in which the healthy part of the small intestine is connected to the stomach.
  • endoscopic surgery - in patients who fail surgery, a stent is implanted in the duodenum to ensure the passage of food