Pancreatic Cancer: Treatment Advances & Support

Pancreatic cancer is one of the harder diagnoses in oncology. You have probably already found the statistics, and they are not gentle. It is worth being clear about what they mean and what they do not.

Across everyone diagnosed in recent years, about 13 to 14 percent are alive five years later. When the cancer is still confined to the pancreas, that figure is around 44 percent. Only about 15 percent of cases are found at that early stage, because the pancreas sits deep in the abdomen and early disease rarely causes symptoms.

Those numbers describe large groups of people diagnosed years ago, treated with what was available then. They include people who were far older, far sicker, or who never received treatment at all. They give context. They do not tell you what will happen to you. People do live years with this disease, and some are cured.

Everything in early planning turns on one question, and it is worth knowing which category you are in.

• Resectable. The tumor can be removed surgically, with no involvement of major blood vessels.
• Borderline resectable. The tumor touches or partly wraps around nearby vessels. Complete removal would be difficult, so chemotherapy, sometimes with radiation, is usually given first to try to shrink it and pull it away from the vessels. The scans are then reassessed. Some of these tumors become removable.
• Locally advanced. The tumor involves vessels too extensively to remove, but has not spread to distant organs. Treatment is systemic, and surgery is occasionally reconsidered after a strong response.
• Metastatic. The cancer has spread, most often to the liver or lungs. Treatment aims to control it and protect how you feel.

This decision should be made by a multidisciplinary team that includes a pancreatic surgeon, not by imaging alone. If your case has not been reviewed that way, ask for it. Surgical outcomes are measurably better at hospitals that perform these operations frequently, so asking about volume is a fair question.

Surgery offers the best chance of long-term survival. Which operation depends on where the tumor sits: a Whipple procedure for tumors in the head of the pancreas, a distal pancreatectomy for the body and tail, or total pancreatectomy in some cases. Recovery is substantial, and most people also need chemotherapy afterward.

Chemotherapy is the backbone of treatment at every stage. Combinations built from fluorouracil, irinotecan, oxaliplatin, gemcitabine and paclitaxel are used before surgery, after surgery, and for advanced disease. Which combination fits depends on your fitness and other health conditions as much as on the cancer.

Radiation is used in some locally advanced and borderline situations, and to relieve pain.

Germline genetic testing is recommended for everyone with pancreatic cancer. An inherited BRCA1, BRCA2 or related mutation can point toward platinum chemotherapy or a PARP inhibitor, and gives relatives information they can use.

Tumor testing occasionally finds a rarer target, such as high microsatellite instability or an NTRK or KRAS G12C alteration, that opens another option.

Several of the hardest parts of pancreatic cancer are treatable, and often under-treated.

Blocked bile ducts cause jaundice and itching and can be relieved with a stent. Poor digestion from missing pancreatic enzymes causes weight loss, bloating and greasy stools, and enzyme replacement capsules with meals often help a great deal. Nerve pain in the upper abdomen and back can be treated with medication or a nerve block. New or worsening diabetes is common and manageable.

Ask for a dietitian and for palliative care early. Palliative care is not hospice. It is symptom specialists working alongside your oncologist, and people who receive it report better quality of life.

Hope in pancreatic cancer does not require pretending. It rests on real things: that some tumors thought inoperable become operable after chemotherapy; that treatment combinations continue to improve; that clinical trials, asked about at diagnosis rather than at the end, are one of the most concrete options available; and that good symptom care can make the time you have genuinely livable.

It also rests on your own priorities. Talking early about what matters most to you, and putting that in writing, is not giving up. It is making sure the treatment plan is actually yours.

• NCI SEER Cancer Stat Facts: Pancreatic Cancer
• NCI: Palliative Care in Cancer Fact Sheet
• NCI: Clinical Trials Information for Patients and Caregivers
• NCI: Pancreatic Cancer Treatment (PDQ®) Health Professional Version