How is pancreatic cancer treated?

Treatment Approach for Pancreatic Cancer

Surgical resection is the only potentially curative treatment for pancreatic cancer, but is only possible in 10-20% of patients with early-stage disease (stage I and some stage II), with adjuvant chemotherapy recommended following surgery. 1, 2

Diagnosis and Staging

• CT scan is the preferred imaging modality for initial staging of pancreatic cancer 1
• Endoscopic ultrasound (EUS) provides complementary information on vessel invasion and lymph node involvement 1, 2
• CA 19-9 is the most useful tumor marker in pancreatic cancer 1
• Laparoscopy may detect small peritoneal and liver metastases, changing treatment strategy in up to 25% of patients 1
• MRI should be considered, especially for cystic lesions 1

Treatment Based on Disease Stage

Resectable Disease (Stage I and some Stage II)

• Surgical resection is the only potentially curative treatment 1
• For pancreatic head tumors, pylorus-preserving pancreaticoduodenectomy (Whipple procedure) is recommended 1
• For pancreatic body/tail tumors, distal pancreatectomy with splenectomy is the standard approach 1
• Standard lymphadenectomy should involve removal of ≥15 lymph nodes for adequate pathologic staging 1
• Postoperatively, 6 months of gemcitabine or 5-fluorouracil (5-FU) adjuvant chemotherapy is recommended 1
• Five-year overall survival after resection is only 10-20% despite optimal treatment 1, 3

Borderline Resectable Disease

• Neoadjuvant chemotherapy or chemoradiotherapy may benefit patients with larger tumors and/or vessel encasement 1
• This approach may achieve downsizing of the tumor and convert it to become resectable 1, 2
• Patients should be encouraged to participate in clinical trials for neoadjuvant treatment 1

Locally Advanced Unresectable Disease (Stage IIB and III)

• Gemcitabine is the standard treatment (1000 mg/m² over 30 minutes) for patients with locally advanced pancreatic cancer 1, 4
• Chemoradiation may play a role in selected patients, particularly with the combination of capecitabine and radiotherapy 1
• Biliary obstruction should be relieved via endoscopic stent placement 1, 2

Metastatic Disease (Stage IV)

• For patients with good performance status (ECOG 0-1) and bilirubin <1.5× ULN: FOLFIRINOX regimen or gemcitabine plus nab-paclitaxel should be considered 1
• For patients with performance status 2 or bilirubin >1.5× ULN: gemcitabine monotherapy is recommended 1
• For patients with poor performance status (3-4): only symptomatic treatment should be considered 1
• Gemcitabine is FDA-approved as first-line treatment for metastatic pancreatic cancer and for patients previously treated with fluorouracil 4

Palliative Management

• Jaundice is common (70-80%) in pancreatic head cancers and requires management 1
• Endoscopic stent placement is preferred over percutaneous insertion for biliary obstruction 1, 2
• Metal prostheses should be preferred for patients with life expectancy >3 months due to fewer complications 1
• Pain control is mandatory and may require specialist involvement 1

Important Considerations

• Decisions about management and resectability should involve multidisciplinary consultation 2
• Resections should be performed at high-volume centers that perform 15-20 pancreatic resections annually 2
• Elderly patients can benefit from radical surgery, but comorbidity may be a reason to abstain from resection, especially in patients older than 75-80 years 1, 2
• The prognosis of pancreatic cancer remains poor despite advances in treatment, with median survival of only 3-5 months in advanced disease 5
• Novel therapies including targeted agents, immunotherapy, and personalized medicine approaches are under investigation but not yet standard of care 6, 7