Treatments for Pancreatic Cancer

The most common pancreatic cancer is called “pancreatic ductal adenocarcinoma” or PDAC. It is usually this type of cancer which is being described when the term “pancreatic cancer” is used. Other less common cancers of the pancreas include PNETS (pancreatic neuroendocrine tumors), SPENs (solid pseudopapillary epithelial neoplasms) and GISTs (gastrointestinal stromal tumors). These rarer tumors have a more favorable outlook than PDACs.

There are different types of treatment for patients with pancreatic cancer, depending on the stage of the cancer and the person’s overall health. At Siteman, each cancer has a wide range of treatments that can be used alone or in combination to give the best outcome for your specific cancer, including standard therapies and novel therapies only available in clinical trials. That’s why careful diagnosis is so important.

As part of a research medical center, physicians at the Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine in St. Louis have access to a wide range of clinical trials to test new therapies as they emerge. Many of our doctors are principal investigators in these trials, which cover medical, surgical, and radiation therapies. Discuss with your physician how your cancer might benefit from clinical trials.

The standard treatments for pancreatic cancer include surgery, radiation therapy, chemotherapy, chemoradiation, and targeted therapy. Clinical trials are testing many other approaches, some of which are becoming standard of care.

Surgery and Other Procedures

Surgery is the only curative treatment for pancreatic cancers. However surgery cannot be performed in all patients with pancreatic cancer. When PDAC has spread to other organs surgery is not helpful. Surgery may not be used when the cancer has spread locally to involve structures around the pancreas such as certain blood vessels, although in some cases preoperative treatment with chemotherapy and sometimes radiation may shrink the tumor so that it become operable. Chemotherapy and radiation are also frequently used as an adjunct to surgery. The most common procedures are related to different parts of the pancreas. The pancreas is an elongated organ that has a head, neck, body and tail.

The most common procedures are:

Whipple procedure (pancreatoduodenectomy): The major operation for pancreatic cancer patients is the intricate Whipple procedure, which involves removal of the head of the pancreas, the duodenum, common bile duct, gallbladder, surrounding lymph nodes and usually part of the stomach. This is a standard operation for PDAC and other cancers of the head of the pancreas. Our surgeons performed 125 Whipple procedures in 2013, making Siteman one of the highest volume centers for this type of surgery nationwide. In a recent study of 185 Whipples done by our group of Washington University physicians, not a single postoperative death was reported.

The success of our surgeons has made Siteman one of the top centers in the United States for treating pancreatic cancer and hepatobiliary cancer, which includes cancer of the liver, gallbladder and bile duct. Studies have shown that patients benefit from treatment performed in this kind of specialized, high-volume center, which produces better outcomes for patients. Siteman surgeons also have excelled at safe surgery because of the clinical innovations they have pioneered.

Total pancreatectomy: This operation removes the whole pancreas, part of the stomach, part of the small intestine, the common bile duct, the gallbladder, the spleen, and nearby lymph nodes. It is done for cancers that involve the head, neck, and body of the pancreas.

Distal pancreatectomy: This operation removers the neck, body and tail of the pancreas and usually the spleen (pancreato-splenectomy). The RAMPS procedure invented at Siteman Cancer Center is a specialized form of pancreato-splenectomy that is especially effective in PDACs of the body and tail of the pancreas.

After surgery, some patients are given chemotherapy and/or to kill any remaining cancer cells and lessen the chances the cancer will come back. If the cancer has spread and cannot be removed, some types of palliative surgery can be done to improve symptoms and quality of life:

Surgical biliary bypass: If cancer is blocking the small intestine and bile is building up in the gallbladder, a biliary bypass can create a new pathway around the blocked area.

Endoscopic stent placement: If the tumor is blocking the bile duct, a stent can be inserted to drain bile that has built up in the area.

Minimally invasive surgeries

Surgery is the only way to cure pancreatic cancer. However, because the pancreas is centrally located in the abdomen and surrounded by a complex network of organs and blood vessels, operating on it can have a major impact on the body. At Siteman Cancer Center, we are pioneering minimally invasive pancreatic surgeries to reduce the risks to our patients and improve their time to recovery.

Siteman is one of the only cancer centers nationwide, and the only institution in Missouri, to offer a minimally invasive Whipple procedure at this time. Using laparoscopic techniques and even robotic technology, our physicians can perform both Whipple procedures and distal pancreatectomies through smaller incisions that heal more quickly.

How are the procedures done?

Minimally invasive pancreatic surgeries are done laparoscopically. This means that instead of making one large incision, the physician will make six small incisions. Five of the incisions are about a centimeter in length, and one might be two to three centimeters long.

The physician will look inside the body with a tiny camera called a laparoscope. The laparoscope allows the physician to conduct the surgery through the incisions. Sometimes, robotic arms are used as well, which increases precision and can make the operation easier.

Patients may receive chemotherapy before the procedure to shrink tumors, which can make it more likely that minimally invasive techniques can be used. They will also undergo a course of chemotherapy after the surgery.

What are the benefits of a minimally-invasive procedure?

Minimally invasive pancreatic surgeries have a number of benefits, both short-term and long-term.

Short-term benefits include:

  • Less blood loss
  • A lower rate of complications
  • A quicker return to eating
  • A shorter recovery time

In the long term, minimally invasive surgeries may lead to better patient outcomes. Chemotherapies for pancreatic cancer have become much more effective in recent years, and the sooner a patient recovers from surgery, the sooner he or she can begin or continue chemo. By allowing patients to receive the drugs that improve survival, minimally invasive surgeries may improve their treatment results.

Which patients are good candidates for this procedure?

Patients are good candidates for minimally invasive pancreatic surgeries if their tumors do not extensively involve major blood vessels. Your doctor will carefully evaluate your tumor to decide whether a minimally invasive procedure is right for you.

What are the risks, and how do they compare to regular pancreatic surgeries?

Minimally invasive Whipple procedures and distal pancreatectomies carry the same risks as traditional, open pancreatic surgery. These include:

  • Bleeding
  • Infection
  • Leakage of digestive fluids into the abdominal cavity

However, a minimally invasive approach to pancreatic surgery may decrease the risk of some of these complications. The smaller incisions reduce the amount of bleeding and make infections less likely, and the camera that is used to visualize the inside of the body helps surgeons perform the procedure with greater accuracy. Minimally invasive pancreatic surgery is also associated with less blood loss compared to open surgery.

Does the minimally invasive procedure work as well as an open one? Is the cancer more likely to come back?

There is no data to suggest that patients who receive minimally invasive pancreatic surgeries are more likely to have their cancer return. In fact, some studies show that minimally-invasive procedures offer the potential for a greater number of lymph nodes to be removed, which can help surgeons and physicians better stage and evaluate the cancer.

Radiation Therapy

Radiation oncology has active trials for minimizing the duration and amount of radiation a patient receives to reduce long-term side effects. No one should be over or undertreated. Siteman is a leader in using shorter radiation durations than the national average with the same outcomes.

IMRT and MRI guidance: Intensity modulated radiation therapy (IMRT) under MRI guidance makes it possible to give precise doses of radiation to a target area and change it as that area changes. Only two centers have MRI-guided radiation. It is also being used in an ongoing study to add chemotherapy at the time of radiation. By careful targeting of the radiation, oncologists can increase the therapeutic amount of chemotherapy for better treatment outcomes.

Systemic Therapy

Chemotherapy: involves the administration of drugs, either orally or intravenously to kill cancer cells. Over the last five years, several new drugs have increased the options for physicians treating patients with pancreatic cancer. Therapy that falls under medical treatment has a wide range of approaches, may be used before surgery, in conjunction with radiation or by itself, including timing of treatment. It can be given before or after surgery, in conjunction with radiation (chemoradiation) or by itself.

Immunotherapy: Although not yet standard of care, immunotherapy that uses your own natural immunity to fight the cancer is showing promise in pancreatic cancer clinical trials. Given as a personalized pancreatic cancer vaccine, this approach boosts your immunity to fight the cancer cells. Ask your doctor about pertinent clinical trials.

Targeted therapy: New-generation therapies that block the key drivers of pancreatic cancer are being developed for patients in clinical trials. This medical treatment uses drugs or other substances to identify and attack specific cancer cells without harming normal cells.

Different combinations of therapies may be used depending on the stage of the cancer and the health of the patient. New combinations of therapies are always being tested in clinical trials and are available at Siteman Cancer Center before other places may have access to them.

Supportive research: Siteman has their own clinical trials of agents that target the micro-tumor environment and increase the effectiveness of systemic therapies by removing suppressive immune cells that work against the treatment.

Supportive care: Patients with pancreatic cancer may have special nutritional needs. If surgery has been done to remove the pancreas, you lose important pancreatic enzymes that help digest food and may need supplemental medications to replace those lost enzymes.

Psychologists and palliative care specialists are also available to help with fitting cancer treatment into your life and easing the burden and stress of treatment.