Frequently Asked Questions
Surgery to remove the tumor as a component of the treatment is the only way to cure pancreatic cancer. Surgery is performed when the surgeon believes all of the cancer can be removed. This generally applies to patients who are in the early stages of pancreatic cancer. Other types of surgical procedures may be performed in patients who are in later stages of pancreatic cancer to relieve symptoms such as pain and obstructions of the bile or pancreatic ducts or of the intestines.1
Pancreatic surgery has improved significantly over the past two decades. Nonetheless, surgery to remove a pancreatic tumor is complex for the surgeon to perform and difficult for a patient to undergo. Recovery after surgery usually is very slow; it may take several weeks, and complications are not uncommon ( Box 7-1 ). Patients need to frankly discuss the risks and benefits of this type of surgery with their doctors before making a decision.2 In addition, patients need to find a surgeon and a facility with a great deal of experience in performing this procedure.3 It cannot be emphasized enough that, in patients with pancreatic cancer, operative complications are significantly fewer at high-volume surgical centers compared with low-volume centers.
SOME COMPLICATIONS OF SURGERY2
|HOW TO REDUCE YOUR SURGICAL RISKS||
If you are a candidate for surgery, find a surgeon and a hospital with a great deal of experience to reduce your risks and increase your chances of a successful outcome.
According to a study in the 2002 issue of The New England Journal of Medicine, the mortality rate for Whipple procedures for pancreatic cancer performed at low-volume centers was four times higher than at high-volume centers.3
In addition – and it cannot be emphasized enough for patients with pancreatic cancer – operative complications are significantly fewer at high-volume surgical centers than at low volume centers.
Procedures to Remove the Tumor
Three major procedures are used to remove pancreatic tumors: a Whipple procedure (pancreaticoduodenectomy), a total pancreatectomy, and a distal pancreatectomy.
Pancreaticoduodenectomy. A Whipple procedure, or a pancreaticoduodenectomy, is the most common surgery performed to treat pancreatic cancer ( Figures 7-1A and 7-1B ). Two basic types of Whipple procedures exist. In one, the lower part of the stomach is removed. In the other more commonly used procedure, called a pylorus-preserving Whipple procedure, the entire stomach and first portion of the duodenum are spared. The surgeon removes the following:
- Most of the duodenum (the beginning of the small intestine)
- Head, neck and uncinate process* of the pancreas
- Part of the bile duct
- Lymph nodes in the area of the pancreas
* The neck and uncinate process is not included in the original text.
After these organs are removed, the stomach (in a standard Whipple procedure) or the remaining part of the duodenum (in a pylorus-preserving Whipple procedure), pancreas, and remaining part of the bile duct are joined to the small intestine. This allows bile and pancreatic enzymes to enter the digestive system normally and mix with ingested food.2
Total Pancreatectomy. A total pancreatectomy is a seldom used procedure that removes the entire pancreas and spleen. When the entire pancreas is removed the endocrine cells in it are also removed, leaving the patient with no islet cells. Because islet cells make insulin, which controls blood sugar levels in the body, removal of the entire pancreas will result in diabetes. The patient will then be dependent on insulin injections.2
Distal Pancreatectomy. In a distal pancreatectomy, the tail and body of the pancreas are removed, usually along with the entire spleen. Sometimes part of the body of the pancreas can be preserved.2
Palliative Surgery. Sometimes the cancer has spread, and surgical removal of the tumor is not an option. Other surgical procedures may be used to help relieve symptoms such as jaundice, nausea, vomiting, and pain in order to improve the patient’s quality of life. Surgeons can bypass blockages of the pancreatic or bile ducts or gastrointestinal tract to relieve these symptoms. Surgeons can also cut nerves or perform nerve blocks to reduce pain.2,4
Radiation therapy, also called radiotherapy, uses high-energy X-rays to shrink tumors by killing cancer cells. External beam radiation therapy is the type used most often to treat pancreatic cancer. A beam of radiation from outside of the body is focused on the tumor, similar to what is done during a diagnostic X-ray only at much higher doses of radiation. To improve the results of treatment and increase survival, radiation therapy may be used before or after surgery. Some of the common side effects of radiotherapy are shown in Box 7-2 .1
SIDE EFFECTS OF RADIATION THERAPY1
Sometimes radiation therapy is combined with chemotherapy, called chemoradiation. This combination is often used when the cancer has spread and cannot be removed surgically.
|ADJUVANT THERAPY: A treatment given after surgery (radiation therapy or chemotherapy).
Making an informed decision about whether or not to undergo adjuvant therapy can be a difficult. Before you make a decision, please Read the Essential Information about Adjuvant Therapy compiled by our multidisciplinary team.
Chemotherapy is the use of drugs to kill cancer cells. It may be given orally or by injection, or may be delivered through a catheter. Chemotherapy is a systemic treatment, meaning that the drug enters the bloodstream and travels throughout the body to reach the tumor cells. Chemotherapy may be used alone or may be combined with either radiation therapy or surgery. To improve the results of treatment and increase survival, chemotherapy may be used before or after surgery. When chemotherapy is used before surgery, it is called neoadjuvant therapy; when it is used after surgery, it is called adjuvant therapy.
In the past, the most common chemotherapy drug given to patients with pancreatic cancer was single-agent fluorouracil, or 5-FU. Other drugs (cisplatin, oxaliplatin, and taxanes) are used both alone and in combination with 5-FU. The introduction of gemcitabine (Gemzar®) has changed the treatment of pancreatic cancer. Studies show that gemcitabine is better than 5-FU for treating metastatic cancer of the pancreas.1
Targeted therapy is designed to kill only cancer cells and not normal, healthy tissue. Targeted therapy is being used to treat pancreatic cancer. Erlotinib (Tarceva®) targets a protein in the cancer cell that stimulates growth.1 Erlotinib is approved by the Food and Drug Administration (FDA) when used in combination with gemcitabine for the first-line treatment of patients with pancreatic cancer that is locally advanced, is inoperable, or has metastasized.5
The side effects of chemotherapy depend on which drugs are given, the dose, and the length of treatment. Generally, the chances of side effects occurring increase with higher doses and the use of a combination of chemotherapy drugs. Some common side effects of chemotherapy are listed in Box 7-3 . Most side effects disappear once treatment is stopped.
SIDE EFFECTS OF CHEMOTHERAPY
In addition to standard treatments approved by the FDA for pancreatic cancer, patients should be offered the opportunity to participate in clinical trials.6 Many studies are investigating the use of new medications and of new combinations of standard medicines in hopes of finding better ways to treat pancreatic cancer.
1. American Cancer Society. Pancreatic cancer. http://documents.cancer.org/ 116.00. Accessed April 15, 2007.
2. American Cancer Society. Detailed guide: pancreatic cancer. Surgery. www.cancer.org/docroot/cri/content/cri_ 2_4_4x_surgery_34.asp?sitearea=cri. Accessed April 15, 2007.
3. How important is finding an experienced surgeon? http://pathology2.jhu.edu/ pancreas/surgicaltx.cfm. Accessed April 15, 2007.
4. Yang GY, Wagner TD, Fuss M, Thomas CR. Multimodality approaches for pancreatic cancer. CA Cancer J Clin. 2005;55:352-67.
5. TARCEVA® (erlotinib) Prescribing Information. OSI Pharmaceuticals, Inc.: New York; 2005.
6. Stevens T, Conwell DL. Pancreatic neoplasms. www.clevelandclinicmeded.com/diseasemanagement/gastro/pneo/pneo.htm. Accessed April 6, 2007.
Reprinted with permission from "Understanding Pancreatic Cancer", a publication of The Lustgarten Foundation for Pancreatic Cancer Research