Treatment options for pancreatic cancer
Exocrine pancreatic cancer is the most common type. This means the cancer started in cells that produce pancreatic digestive juices. The main treatments for this type include:
- chemotherapy
- radiotherapy
- surgery
- treatments to control symptoms
Some people may have a 
or . You may have treatment as part of a .
The treatment you have depends on:
- where your cancer is
- whether it has spread (the stage)
- the type of pancreatic cancer
- if they can remove the cancer
- your general health and level of fitness
Most pancreatic cancers are diagnosed when they are too advanced for surgery to be an option. The cancer is either locally advanced (stage 3) or has spread to other parts of the body (metastatic or stage 4). This is because there may not have been any symptoms when the cancer was in its early stages. Or the symptoms may have been vague and difficult to spot.
A locally advanced pancreatic cancer is when the cancer has not spread to distant parts of the body. But it is spreading in and around the pancreas. This means it may block or completely surround the nearby major blood vessels. Or it may grow into nearby organs such as the bowel or stomach.
Metastatic pancreatic cancer is when the cancer has spread to another part of the body, such as the liver or lungs. This may also be called advanced pancreatic cancer.
This page is an overview of treatment for exocrine pancreatic cancers. Cancers that start in the hormone producing cells of the pancreas are called endocrine or neuroendocrine cancers. They need different types of treatment.
Deciding which treatment you need
A team of healthcare professionals discuss the best way to treat your cancer. They are called the multidisciplinary team (MDT).
The team usually includes:
- a specialist surgeon
- cancer specialists (oncologists) who treat cancer with drugs (medical oncologist) and radiotherapy (clinical oncologist)
- a specialist cancer nurse (also called a clinical nurse specialist, or your ‘keyworker’)
- a gastroenterologist – a doctor who specialises in diseases of the digestive system
- a radiologist - a doctor who looks at your scans and x-rays
- a pathologist - a doctor who specialises in looking at cells under the microscope
- a dietitian who offers support and advice about eating and drinking
- a palliative care doctor who specialises in controlling cancer symptoms
To decide about treatment, your team first looks at your test and scan results to see if they can remove the cancer. Your cancer may be:
Resectable, which means they can remove it with surgery.
Borderline resectable, which means the cancer may be involving a main blood vessel. So it is less clear if surgery is possible. You may have chemotherapy first to try and shrink the cancer before having surgery.
Unresectable, which means that surgery to remove the cancer is not possible. The cancer may be blocking or completely surrounding the nearby major blood vessels. Or it may have spread to local organs (locally advanced cancer). Or it may have spread to more distant areas of the body (metastatic cancer).
Resectable pancreatic cancer
This means that the cancer is only in the pancreas. So it hasn’t grown outside the pancreas or into structures such as the small bowel, bile duct or stomach. And it isn't affecting any of the nearby major blood vessels. Generally, doctors consider stage 1 and 2 pancreatic cancers for surgery.
Surgery
The surgeon needs to be able to remove the cancer along with an area of tissue around it that doesn’t contain any cancer cells.
Sometimes the cancer looks resectable on scans, but when the surgeon starts the operation, they find that the cancer is bigger than they thought. And so surgery to remove the cancer is not possible.
In this case, they may consider doing a different type of operation to help relieve or prevent symptoms. For example, a bypass operation to avoid a blockage of the bile duct or stomach. When you have recovered from the operation, you might then have chemotherapy instead.
Chemotherapy
If your pancreatic cancer has been removed successfully, then you may have chemotherapy. This is to lower the chances of the cancer coming back. This is called adjuvant chemotherapy. It should start within 3 months of your surgery. You have it for up to 6 months.
Borderline resectable pancreatic cancer
This means that the cancer is in the pancreas and has started to involve the nearby blood vessels. This can make it more difficult for the surgeon to remove the cancer completely and cancer cells too small to see may be left behind.
Research shows that if the surgeon isn’t able to remove an area around the cancer without any cancer cells (a clear margin) the risk of the cancer coming back is high. And the benefits of having a very big operation are less clear.
You might have chemotherapy first to try to reduce the size of the cancer and make an operation more successful. This is called neo adjuvant chemotherapy.
After neo adjuvant treatment you have a scan. This is to help the surgeon decide if you can have surgery to remove the cancer. The surgeon needs to make sure they can remove a clear margin of tissue from around the tumour.
If surgery is not possible you might continue with chemotherapy. This is generally for up to 6 months.
Because the best treatment for borderline resectable pancreatic cancer is uncertain, your doctor might offer you treatment as part of a clinical trial.
Unresectable pancreatic cancer
An unresectable pancreatic cancer means it is not possible to remove the cancer completely with surgery. These types of cancers have spread into the blood vessels and may have spread to other parts of the body. They are called either:
- locally advanced pancreatic cancer
- metastatic or advanced pancreatic cancer
They are treated slightly differently.
Locally advanced pancreatic cancer
Most people with locally advanced pancreatic cancer will have chemotherapy to try to control the cancer for as long as possible. There is a small chance that chemotherapy might shrink the cancer enough to allow for surgery.
The chemotherapy you have depends on how well you are. If you are generally fit, you usually have a combination of chemotherapy drugs. If you are less well, you may have one chemotherapy drug. Chemotherapy treatment usually lasts up to 6 months. This depends on how well the treatment is working and what side effects you get.
During treatment you have scans so your doctor can work out if it is working. If they show the cancer has shrunk enough, you may be able to have surgery.
After 6 months of chemotherapy, if the scans show you can’t have surgery you may have radiotherapy. This completes your treatment and is called consolidation radiotherapy.
People having radiotherapy usually have a short course over 5 days. In some places you may have radiotherapy every week day over 4 to 5 weeks. This is alongside chemotherapy tablets (chemoradiotherapy).
If you’re not well enough for chemotherapy as your first treatment for locally advanced pancreatic cancer, you may have radiotherapy on its own instead.
Generally treatment for locally advanced pancreatic cancer can’t cure it. But it might keep it away for some time. So after treatment you usually have scans every 3 to 6 months. This is to try to pick the cancer up before it is causing symptoms.
If the cancer comes back your doctor will talk to you about other possible treatments
Metastatic pancreatic cancer
You usually have chemotherapy for pancreatic cancer that has spread to other parts of the body. This is to try to control the cancer for as long as possible. And to help with any symptoms you may have. The type of chemotherapy you have will depend on your fitness and how well you are. You may have a combination of chemotherapy drugs or a single drug.
Doctors looking after people with pancreatic cancer are learning more about it. They already know that not all pancreatic cancers are the same. They are carrying out tests on the cancer to look for (mutations). Knowing this might mean a different type of treatment is better than standard chemotherapy. Or it may help if chemotherapy is no longer working. A small number of people whose cancers have certain gene changes may have a targeted cancer drug or an immunotherapy drug.
You may have treatment for metastatic pancreatic cancer as part of a clinical trial.
People with pancreatic cancer may need other treatments to help with symptoms caused by the cancer. These treatments include:
- a small tube (stent) put in if the cancer is blocking your bile ducts and you are
jaundiced - medicines to help control pain
- enzyme replacements to help digest fats and protein if the pancreas is not working properly
- tablets or insulin injections to control your blood sugar levels if your pancreas is not working properly (diabetes)
It is not possible to remove these cancers completely with surgery. An operation is unlikely to be helpful and it could have major side effects.
You may have other types of surgery to help control or prevent symptoms caused by the cancer.
Clinical trials for pancreatic cancer
Your doctor might ask if you’d like to take part in a clinical trial. Doctors and researchers do trials to make existing treatments better and develop new treatments to try to improve people’s outlook (prognosis).
Other health conditions
Health problems might mean you can’t have some treatments including surgery. Before you have surgery you have tests to check how fit you are including heart and lung tests.
For people who can’t have surgery or other treatments you will have treatment to help control symptoms.
Your choices
Your doctor might offer you a choice of treatments. Discuss each treatment with them and ask how they can control any side effects. This helps you make the right decision for you. You also need to think about the other factors involved in each treatment, such as:
- whether you need extra appointments
- if you need more tests
- the distance you need to travel to and from hospital
You might have to make further choices as your situation changes. It helps to find out as much as possible each time. You can stop a treatment whenever you want to if you find it too much to cope with.
Second opinion
Some people might want to get a second opinion before starting treatment. You can ask your specialist or GP to refer you to a doctor or surgeon specialising in pancreatic cancer. It can be better to arrange a second opinion through your specialist because they can send all your notes and test results with you.
Having a second opinion doesn't usually mean that the new doctor takes over your treatment and care. They discuss with you and your current doctor which they feel is the best treatment for you.
It can take time to arrange a second opinion, which might mean that your treatment is delayed for a while. Remember also that several specialists will be involved in your care as part of your multi disciplinary team. Between them, they discuss the best way to treat your cancer.
