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Pancreatic Cancer Treatment

Pancreatic Cancer Surgery

There are 2 types of surgery used for pancreatic cancer:

  • Potentially curative: used when it seems possible to remove all the cancer.
  • Palliative surgery: used if tests show the tumor is too widespread to be completely removed. In this case, surgery is done to relieve symptoms or prevent problems like bile duct blockage.

If only part of the cancer can be removed, surgery may not be recommended. Removing only part of the cancer does not prolong life or cure the cancer. Pancreatic cancer surgery is a very difficult surgery and requires a long recovery period. You should talk to your doctor about whether it’s a good option for you.

Whipple Procedure: If it looks like the pancreatic cancer can be completely removed from the head of the pancreas, the Whipple procedure is the most common type of surgery.

What is a Whipple procedure? There are two types of Whipple procedures. In one, the lower part of the stomach is removed. In the more common procedure (sometimes called a pylorus-preserving Whipple procedure), the stomach is spared. In this procedure the surgeon removes:

  • Part of the pancreas
  • Part the duodenum ( the beginning of the small intestine)
  • Gallbladder
  • Part of the common bile duct
  • Nearby lymph nodes

After these are removed, the surgeon attaches the rest of the duodenum, pancreas, and bile duct to the small intestine. This way bile and pancreatic enzymes can still enter the digestive system normally. A Whipple surgery is very complex. It is advisable to have the surgery in a hospital that does at least 20 Whipple surgeries a year.

Total Pancreatectomy: This is a rare procedure that removes the entire pancreas and spleen. Without a pancreas, the body cannot make insulin that controls blood sugar levels. After a pancreatectomy, your body will be dependent on insulin injections.

Distal Pancreatectomy: In this procedure, the tail and body of the pancreas are removed. Part of the pancreas can be preserved. The spleen is also usually removed.

Palliative surgery

Pancreatic cancer can progress quickly. For this reason, many doctors do not operate just to relieve symptoms. Your doctor may recommend surgery in the hope of curing you. However, sometimes during this operation the surgeon discovers the cancer has spread, and a cure is not possible. If this happens, the surgeon will use the operation to relieve symptoms or prevent problems like blockage of the bile duct.

When the bile duct is blocked, it can cause pain and problems with digestion. There are 2 surgical approaches to relieving the blockage:

Bypass surgery: Re-route the flow of bile from your common bile duct into your small intestine. This operation requires a large incision (cut). Recovery time is several weeks. During this surgery, your doctor may be able to cut the nerves leading to your pancreas. This can reduce or eliminate your pain.

Stents: Metal stents can be inserted to keep the bile duct open. Your doctor will use a thin, flexible tube called an endoscope to put in the stent. Recently, the use of stents is more common than bypass surgery in relieving bile duct blockage.

Other types of pancreatic cancer surgery (ablative techniques)

Other types of surgery, called ablative techniques, may be used to treat areas of spread (metastases) from pancreatic cancer, usually to the liver. This is an option when only a few metastases are present. By treating the metastases, symptoms can improve and the patient may live longer.

Radiofrequency ablation (RFA): This procedure uses radio waves to heat and destroy cancerous tissues.

Microwave thermotherapy: This procedure uses microwaves to heat and destroy the cancer.

Cryosurgery (also called cryoablation): In this procedure, a probe is put directly into the tumor. Then liquid nitrogen or liquid carbon dioxide is injected to freeze the tissue. The frozen area is destroyed.

Embolization: In this procedure, a catheter is used to find the blood vessel feeding the tumor. Then tiny beads called microspheres are put into the blood vessel. Sometimes these beads are radioactive. Injecting these beads cuts off the blood supply and kills the tumor. The catheter can also be used to deliver chemo drugs. This process is called chemoembolization.

Radiation Therapy

What is radiation?

Radiation therapy is also called radiotherapy or just radiation. It is a very effective way to destroy cancer cells.

As defined by the National Cancer Institute, radiation is the use of high-energy radiation from x-rays, gamma rays, neutrons, protons, and other sources to kill and shrink tumors.

What is radiation like? What happens?

Radiation can be delivered in three ways:

  1. External-beam radiation therapy: With external-beam radiation therapy, the radiation comes from outside your body. It is targeted at a specific area of the body. This therapy usually consists of daily treatments over several weeks. A machine called a linear accelerator (LINAC) is the most common machine used to give external-beam radiation. The most common type of external-beam radiation is three-dimensional conformal radiation therapy (3D-CRT). This uses computer software to direct the radiation to a very precise area of the body. There are many other forms of external-beam radiation therapy. Your radiologist will know which is right for you.
  2. Internal radiation therapy (brachytherapy): With internal radiation therapy, a radiologist places radioactive material inside the body. These “seeds” give off radiation to destroy nearby cancer cells. The seeds may be placed inside the body with needles, catheters, or minor surgeries. Some of the seeds are permanent, and some are temporary. The permanent seeds stop giving off radiation over time. They do no damage by remaining in the body.
  3. Systemic radiation therapy: With this type of therapy, the patient swallows or receives injections of a radioactive substance. This substance helps destroy cancer cells throughout the body. Radioactive iodine, a specific type of systemic radiation, is commonly used for thyroid cancer. Other types of systemic radiation may be used for hematological cancers.

What are the possible side effects of radiation?

The goal of radiation is to kill as much cancer as possible while preserving normal tissue. However, there can still be adverse side effects.

The side effects of radiation therapy depend on:

  • The type of radiation therapy
  • The dose of radiation
  • The part of the body that is being treated

Here are a few examples of possible side effects:

  • Red, dry, and tender skin at treatment site
  • Hair loss in the treated area
  • Fatigue
  • Radiation to the abdomen may cause nausea, vomiting, and diarrhea.
  • Radiation to the pelvic region may cause infertility.
  • Radiation to the chest and neck may cause dry, sore throat, and some trouble swallowing.
  • Salivary gland damage
  • Stiff joints from fibrosis (a buildup of scar tissue at the treatment site)
  • Some types of systemic radiation cause you to emit radiation in your sweat or other bodily fluids. If this is the case, you will need to avoid children and pregnant women until the radiation has left your body. Your radiologist can give you a safe time frame.

Most of the side effects of radiation are short term, but some may be long term.

Very rarely, radiation can increase your risk for some cancers, but your radiologist will consider benefits of treatment versus risk of a secondary cancer when deciding the dosage of radiation. If you have radiation therapy and chemotherapy at the same time, your side effects may be worse.

Tell your healthcare team about any new or worsening side effects. Most side effects can be easily managed.

Chemotherapy

Chemotherapy treatment (usually called “chemo”) uses medicines that prevent cancer cells from growing and spreading. Chemotherapy medicines do this by destroying cancer cells altogether or preventing them from dividing. Chemo affects your whole body because it goes through your bloodstream. Chemo doesn’t refer to one treatment but many, because there are lots of different chemotherapy medicines.

When is chemotherapy used?

Chemotherapy may be given either alone or along with radiation therapy. When given alone, it is given in a higher dose designed to kill off cancer cells. When given along with radiation therapy, it is delivered at a lower dose. This is designed to make the cancer more sensitive to the radiation.

Chemotherapy is usually given by vein, but some can be given by mouth. Your medical oncologist will tell you how many cycles or courses of chemotherapy are best for you. The number of cycles of chemotherapy needed vary. Different oncologists use different schedules. The type of chemo drug being used is another factor. You may also want to ask your doctor if you are a good candidate for chemotherapy research trials.

What can I expect from chemotherapy?

Chemotherapy not only weakens and destroys cancer cells at the site of the tumor, but throughout the body as well. Unfortunately, this means that chemo can unintentionally harm the development of normal cells like your hair, nails, mouth, and digestive tract.

Chemo can be used at any stage of cancer. It can be used for advanced cancer. It also can be used once the cancer has been removed. It destroys any cancer cells possibly left behind. This can help prevent the cancer from coming back. If you are going to have surgery, your doctor may recommend that you have chemo and radiation before the surgery to shrink the tumor.

The side effects chemo causes depend on the type of chemotherapy you receive and how many cycles you receive. The most common side effects of chemo are:

  • Nausea and vomiting
  • Fatigue or tiredness
  • Confusion, forgetfulness (“chemo brain”)
  • Decreased blood counts, sometimes with bruising, bleeding, or infection
  • Sores inside your mouth
  • Numbness in your hands and feet
  • Diarrhea, loose stool
  • Increased urgency to have a bowel movement or urinate

When chemotherapy is given at a lower dose, these side effects are less common. This sometimes happens when radiation is necessary too. If you experience side effects, call your physician right away. It is better to address side effects right away because there are numerous drugs available to help manage side effects.

How is chemotherapy given?

Chemo medicines come in different forms and can be given in different ways:

  • Intravenously (IV): As an infusion, the medicine comes through a thin needle (IV) in a vein, such as in your hand or lower arm. An oncology nurse will insert the needle before each infusion and take it out afterwards.
  • Injection: As a single shot into a muscle in your leg, arm, hip, or under the skin in the fatty part of your stomach, leg or arm.
  • By mouth: As a pill or capsule. You may take this yourself at home.
  • Through a port: This is inserted in your chest during a short outpatient surgery. It is about the size of a quarter and sit right under your skin. A port is a small disc made of plastic or metal. A catheter (soft thin tube) connects the port to a large vein. The chemo medicines are delivered through a thin needle right into the port. You can also get your blood drawn through the port. Once you have finished chemo, the port is removed in a brief outpatient procedure.
  • Through a catheter in your chest or arm. This is a soft thin tube that is inserted into a large vein. This is done in a short outpatient surgery. The other end of the catheter stays outside your body. This is similar to having a port.

If you have a catheter or port, your medical team will tell you signs of infection to look for.

Port vs. Catheter

Many doctors recommend getting a catheter or port. It makes receiving chemotherapy easier and more comfortable each time, as you don’t have to be restuck by a needle each time, like with an IV or injection. Some cancer patients have a portable pump attached to the port or catheter. This controls how much and how fast the chemotherapy medicine goes in. The pump can either be internal (implanted under the skin during a short outpatient procedure) or external (carried with you). Once your rounds of chemo are done, the pump is taken out.

How often will I have to have chemotherapy?

Your oncologist will set your treatment regimen. Every chemo regimen is made up of cycles. This means a period of treatment followed by a period of recovery. For example, you may get chemo one day and then have a few weeks of recovery with no treatment. That would be one cycle. Or you may get chemo for several days in a row and then have a recovery period. Several cycles make up a complete chemotherapy regimen. The number of cycles in a regimen and the length of each regimen vary from patient to patient. A lot depends on the medicines used.

You can get chemotherapy in a variety of settings: at a hospital, in a doctor’s office, or in a clinic. You may even get chemo at home if you are taking chemo in a pill form or you have a portable pump.

If you take chemo in a clinic, hospital or doctor’s office, you usually go home between treatments. In some cases, you may stay in the hospital to be monitored. This is especially true if your immune system isn’t working as well as it should be. Your doctor will explain where you’ll be getting your treatment.

What should I bring to my chemotherapy appointment?

A chemotherapy treatment at a hospital or clinic can take anywhere from one to several hours. Although many chemo treatment areas have televisions and magazines, you may want to bring something to help pass the time. Ideas include:

  • A laptop
  • Knitting, needlepoint or crochet
  • A thick novel
  • Crossword or other puzzle book
  • Sketchbook and pencils
  • Cards or board games (if you have someone to play with)
  • MP3 player or portable CD player to listen to music
  • Paper and pens to keep a journal or write letters

Is there anything I should be thinking about before I start chemotherapy?

Chemotherapy is a cancer treatment that can drain most of your energy. This is a major process your body is going through. There are some things you should take care of before you start chemo:

  • Get your teeth cleaned and get a dental check-up. Chemo weakens your immune system, so you may be more vulnerable to infections caused by bacteria that are dislodged during teeth cleaning.
  • Get any heart tests (like an EKG) that your doctor recommends.
  • If you’re a woman, get a Pap smear. Chemo can alter the results of your Pap smear, so get one beforehand.
  • Find someone to help around the house. Chemo causes extreme fatigue. Line up someone to help with your daily chores: cleaning, grocery shopping, carpooling, and cooking to name a few. Don’t be too proud or stoic to ask for help. Friends and family members will be happy to do something that helps you during this treatment phase. Ask yourself: wouldn’t you be willing to do it for someone else?
  • Join a support group if that sounds helpful.
  • Find out ahead of time what you should and shouldn’t eat or drink on treatment days.
  • Tell your doctor all the vitamins, supplements, over-the-counter and prescription medicines you take.
  • Talk to your doctor about hair loss. Most chemo medicines cause some amount of hair loss. If you plan on wearing a wig, you might want to go ahead and get it so you can match it to your hair color and style.

When you first meet with your doctor, it can be helpful to bring someone else with you. That way, there’s someone else to hear what is said and to ask questions. Here are some other tips for talking with your doctor:

  • Write out your questions ahead of time.
  • Write down the answers your doctor gives you.
  • If you don’t understand something, ask your doctor to say it in a different way. It’s important that you understand, and you have a right to know.