Treatment For Pancreatic Cancer

Treatment for pancreatic cancer
• Types of treatment
• Benefits and disadvantages
• Treatment decisions
• Giving your consent
• Second opinion
Types of treatment
The types of treatment you will be offered depends on the particular type of cancer of the pancreas you have, the stage of the cancer, its size, and your general health. The treatment will be planned by a team of specialist doctors and other healthcare professionals. This is known as a multidisciplinary team (MDT), and may include:
• a surgeon who specializes in treating cancer of the pancreas
• a clinical oncologist – a doctor who treats cancer with radiotherapy
• a medical oncologist – a doctor who treats cancer with chemotherapy
• a pathologist – a doctor who specialises in how disease affects the body
• a radiologist – a doctor who analyses x-rays and scans
• a specialist nurse who gives information and support to people with pancreatic cancer.
The MDT may also include other healthcare professionals, such as:
• a dietitian
• a physiotherapist
• an occupational therapist
• a psychologist or counsellor.
Many pancreatic cancers are not diagnosed until the cancer is quite advanced. Cancer of the pancreas can be very difficult to treat. It may not be possible to cure it, although early-stage cancer can sometimes be cured with surgery.
The most effective treatment for early-stage cancer of the pancreas is surgery to remove part, or all, of the pancreas. This is a major operation and is only suitable for people whose cancers are small and have not spread, and who are fit. If the cancer is too large, or has already spread beyond the pancreas when it’s diagnosed, this kind of surgery is not possible. Learning that your cancer has spread, and therefore that certain treatments are not suitable for you, is distressing news to cope with. Your doctor will advise you about the treatments that are most likely to help in your situation.
If the cancer has spread and is causing a blockage of the bile duct or the bowel, surgery can sometimes be used to relieve the blockage and ease the symptoms.
Chemotherapy can be used in a number of different ways. It may be used after surgery for early-stage pancreatic cancer to try to reduce the chances of the cancer coming back. It can also be used to shrink cancers that have spread into the area around the pancreas, or to treat cancers that have spread to other parts of the body, such as the liver. For cancers that have not spread beyond the pancreas but can’t be removed by an operation, chemotherapy and radiotherapy may be given separately or together. Sometimes you may be asked to take part in a clinical trial of a new drug or treatment.
Chemotherapy may also be given to help reduce some of the symptoms of pancreatic cancer. Radiotherapy can be helpful in controlling pain.
An important part of the care of all people with pancreatic cancer is the use of treatments to control symptoms and make you feel more comfortable, known as supportive care.

Benefits and disadvantages
Many people are frightened at the idea of having cancer treatments, because of the side effects that can occur. Some people ask what would happen if they did not have any treatment.
Although many of the treatments can cause side effects, these can usually be well controlled with medicines. Treatment can be given for different reasons, and the potential benefits will vary depending upon each person's situation.
Early-stage pancreatic cancer
In people with early-stage pancreatic cancer, surgery is often done with the aim of curing the cancer. Additional treatments such as chemotherapy may also be given to reduce the risks of it coming back.
Advanced pancreatic cancer (metastatic)
If the cancer is at a more advanced stage, the treatment may only be able to control it, leading to an improvement in symptoms and a better quality of life. However, for some people, the treatment will have no effect upon the cancer and they will get the side effects without any of the benefits.

Treatment decisions
If you have been offered treatment with the aim of curing your cancer, deciding whether to accept the treatment may not be difficult. However, if a cure is not possible and the treatment is being given to control the cancer for a period of time, it may be more difficult to decide whether to go ahead with treatment.
Making decisions about treatment in these circumstances is always difficult, and you may need to discuss the possible treatment options in detail with your cancer specialist. Many people find it helpful to have a relative or friend with you.
Giving your consent
Before you have any treatment, your doctor will explain the aims of the treatment to you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent. Before you are asked to sign the form you should have been given full information about:
• the type and extent of the treatment you are advised to have
• the advantages and disadvantages of the treatment
• any other types of treatments that may be appropriate
• any significant risks or side effects of the treatment.
If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are very complex, so it’s not unusual for people to need repeated explanations.
It’s often a good idea to have a friend or relative with you when the treatment is explained, to help you remember the discussion more fully.
You may also find it useful to write down a list of questions before you go to your appointment.
Patients often feel that hospital staff are too busy to answer their questions, but it’s important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions.
You can always ask for more time to decide about the treatment if you feel that you can’t make a decision when it is first explained to you.
You are also free to choose not to have the treatment. The staff can explain what may happen if you don’t have it. It is essential to tell a doctor, or the nurse in charge, so that they can record your decision in your medical notes. You don’t have to give a reason for not wanting to have treatment, but it can help to let the staff know your concerns so that they can give you the best advice.
Second opinion
Usually a number of cancer specialists work together as a team. They will use national treatment guidelines to decide on the most suitable treatment for you. Even so, you may want to have another medical opinion. Either your specialist, or your GP, will be willing to refer you to another specialist for a second opinion, if you feel it will be helpful. The second opinion may cause a delay in the start of your treatment, so you and your doctor need to be confident that it will give you useful information.
If you do go for a second opinion, it may be a good idea to take a friend or relative with you. It can also help if you have a list of questions ready, so that you can make sure your concerns are covered during the discussion.

LONG SURVIVORS AFTER PANCREATODUODENECTOMY FOR PANCREAS HEAD CARCINOMA
Koji Yamaguchi* , 2 , Kazuyoshi Nishihara†, Piotr Kolodziejczyk† Masazumi Tsuneyoshi†
*Departments of Surgery I and Kyushu University Faculty of Medicine, Fukuoka, Japan †Departments of Pathology II, Kyushu University Faculty of Medicine, Fukuoka, Japan
Correspondence to 2 Department of Surgery 1, Kyushu University Faculty of Medicine. 3-I-I Maidashi, Higashiku, Fukuoka 812, Japan.
Copyright 1992 Royal Australasian College of Surgeons
KEYWORDS
long-term survivor • pancreas carcinoma • pancreatoduodenectomy
ABSTRACT
Twelve Japanese patients with pancreas head carcinoma who survived 3 years or more after a pancreatoduodenectomy and 50 who survived less than 12 months were reviewed clinicopathologically. The 12 patients who survived for ≥ 3 years exhibited more favourable prognostic factors: a higher incidence of jaundice; a smaller mass; a higher prevalence of an earlier stage tumour and adenocarcinoma of differentiated type; and a lower incidence of venous invasion, lymph node metastasis, and cancer cells at the surgical margins. However the difference was not significant. Univariate log-rank analysis regarding 13 prognostic variables showed that histologic type was a significant factor but multivariate Cox regression analysis failed to reveal an independent significant parameter. Nine of the 12 long-term survivors showed lymph node metastasis and six of the 12 revealed cancer cells at the surgical margins. Six of the 12 long-term survivors died from local recurrence and/or distant metastasis 37–78 months after operation. Only two patients survived more than 5 years after the operation. At the time of writing, one of them was still alive and another was dead 78 months after the operation. Pancreatoduodenectomy for pancreas head carcinoma infrequently offers a permanent cure for the patients with pancreas head carcinoma but sometimes produces a worthwhile long-term survival, even if the resected margins were affected by malignant cells or the lymph node metastasis was evident.
Pancreatic carcinoma
• Pancreatic carcinoma is the second commonest tumour of the digestive system
• The incidence is increasing in the Western world
• It is uncommon less than 45 years of age
• More than 80% of cases occur between 60 and 80 years of age
• Male : female ratio is 2 : 1
• Most tumours are adenocarcinomas
• More than 80% occur in the head of the pancreas

• Overall 5-year survival less than 5%
• Prognosis of ampullary tumours is much better
Clinical features
• 30% present with obstructive jaundice
• Classically described as 'painless jaundice'
• Most develop pain at some stage - 50% present with epigastric pain
• 90% develop anorexia and weight loss
• 75% have metastases at presentation
Pancreatic imaging
Ultrasound
• Abdominal ultrasound has sensitivity of about 80% for the detection of pancreatic cancer
• Detects level of biliary obstruction, excludes gallstones and may identify pancreatic mass
• Doppler ultrasound allows assessment of vascular invasion
Computerised tomography
• Spiral CT has improved on resolution of conventional CT
• Has sensitivity of greater than 95% for detection of pancreatic tumours
• Contrast-enhanced triple-phase imaging is modality of choice
• Probably the most useful of staging investigations
• Both US and CT often fail to detect small (< 2 cms) hepatic metastases

Laparoscopy
• Laparoscopy will identify liver or peritoneal metastases in 25% of patients deemed resectable after conventional imaging
• Laparoscopic ultrasound has improved predictability of resection
• Mesenteric angiography is now considered obsolete
Resectional surgery
• Resection is the only hope of cure
• Only 15% tumours are deemed resectable
• Resectability assessed by:
o Tumour size (<4 cm)
o Invasion of SMA or portal vein
o Presence of ascites, nodal, peritoneal or liver metastases
• Pre-operative biliary drainage of unproven benefit
• Has not been shown to reduce post-operative morbidity or mortality
Whipple's operation