Treatment

Surgery is the only treatment with the potential to cure cancer that starts in the pancreas — but only if all the cancer can be removed. Taking out only part of the cancer generally does not improve treatment results for patients, and the surgery is complex with a lengthy recovery.

• If imaging studies, such as computed tomography (CT) scans, suggest that surgeons will be able to remove all of your cancer, your team may recommend surgery.
• If surgery is not a good option for you, you have other options, such as chemotherapy and radiation therapy.

Surgery for Fred Hutch patients with pancreatic cancer is performed at University of Washington Medical Center (UWMC) by expert surgeons specially trained to do your type of operation.

• Our surgeons participate in the American College of Surgeons National Surgical Quality Improvement Program for pancreatic surgery to track and improve outcomes.
• After your surgery, your care team at UWMC follows evidence-based guidelines to enhance your recovery (“early-recovery after surgery” protocols).

The main surgeries for pancreatic cancer are:

• Whipple procedure (pancreatoduodenectomy)
• Distal pancreatectomy
• Total pancreatectomy

Whipple procedure

In this complex operation, surgeons remove part of your stomach, part of your small intestine (the duodenum and part of the jejunum), your bile duct that's outside your liver, your gallbladder and the wide end of your pancreas near the center of your abdomen (called the head, neck and uncinate process).

Then they pull your remaining jejunum up and connect your remaining bile duct, pancreas and stomach to it.

• The risk of complications from this operation is significantly lower when it’s performed at an experienced cancer center by a surgeon who does the procedure frequently.^1,2
• The National Comprehensive Cancer Network recommends that pancreatic resections should be done at institutions that perform a large number of them annually (at least 15-20).²
• We have two surgeons at UWMC who perform pancreatic resections. They typically perform 70-90 of these procedures each year.

Distal pancreatectomy

If cancer is in the tail of your pancreas (the narrow end, near your side) and not in the head, your surgeon may remove the tail and body of your pancreas. Whenever possible, our surgeons try to leave your spleen, but they may have to remove it in order to get all the nearby lymph nodes.

Total pancreatectomy

In some situations, the entire pancreas is removed along with surrounding structures. Your surgeon may recommend this if your tumor is large, it involves almost your whole pancreas or it spans the central area from the neck to the body of the pancreas.

This approach may also be used for people with familial pancreatic cancer. They might have a Whipple procedure or distal pancreatectomy first. Then if follow-up care shows a lesion has developed in their remaining pancreas, the rest of the gland may be removed.

Minimally invasive surgery

Our surgeons perform minimally invasive laparoscopic surgery (through small "keyhole" incisions) whenever possible. Benefits can include less pain, less narcotic pain medicine, less time in the hospital, fewer complications and better overall recovery. 

Open surgery (through a longer incision) is necessary in some situations, such as when a pancreatic tumor involves nearby blood vessels.

Robot-assisted surgery

Your surgeon may perform laparoscopic surgery using the robotic da Vinci Surgical System. With da Vinci, your surgeon sits at a console and uses hand and foot controls to move robotic arms that hold a laparoscope (camera) and surgical instruments. The console gives your surgeon a 3D view (not a flat view, like on a monitor screen). Da Vinci allows your surgeon to make very precise, complex motions (more than traditional laparoscopic instruments do), and the ideal ergonomics help prevent fatigue during long operations.

¹ Pancreatic Cancer Surgery, American Cancer Society, 2018
² NCCN Guidelines: Pancreatic Adenocarcinoma, National Comprehensive Cancer Network, 2018

Usually chemotherapy medicines are given by infusion into a vein. Some are taken by mouth in pill form. 

• For pancreatic cancer, you are likely to have chemotherapy for one of these reasons: 
  • Before surgery to shrink your tumor so it’s easier to remove
  • After surgery to kill remaining cancer cells that couldn’t be seen
  • Instead of surgery if your cancer is too widespread to remove

Your Fred Hutch team will talk with you about the specific drugs we recommend for you, how you’ll receive them, your treatment schedule and what to expect. We’ll also explain how to take the best possible care of yourself during treatment and after, and we’ll connect you with medical and support resources throughout Fred Hutch.

Targeted therapies are newer cancer treatments that work more selectively than standard chemotherapy. They target a gene or protein responsible for allowing cancer to grow, they seek out and damage cancer cells, or they prompt your immune system to attack particular cells (also called immunotherapy). 

For pancreatic cancer, we perform molecular profiling of tumors to try to detect targets that might respond to treatment.

Radiation therapy uses high-energy X-rays or other types of radiation to kill cancer cells.

For pancreatic cancer, you may have radiation therapy or a combination of radiation and chemotherapy (chemoradiation), before or after surgery or instead of surgery if you cannot have surgery. Chemo medicines can make cancer cells more sensitive to radiation. 

Conventional external-beam radiation therapy (EBRT)

Doctors commonly recommend conventional EBRT for pancreatic cancer.

• A machine called a linear accelerator sends beams of X-ray radiation toward your tumor.
• Some patients have a type of EBRT called stereotactic body radiation therapy (SBRT), which precisely delivers high doses of radiation over just a few treatments.

Learn More

Proton therapy

In some situations, your doctor may recommend proton therapy, a unique form of EBRT that targets protons at your tumor. 

• Proton therapy may significantly limit radiation exposure to surrounding healthy tissue near the pancreas, such as the bowel, liver, kidneys and spinal cord. 
• This may reduce side effects from treatment, particularly when combined with chemotherapy.
• Proton therapy may be especially useful if you have recurrent tumors and had radiation therapy to the same area in the past.

Fred Hutch - Proton Therapy is the only proton facility in the Pacific Northwest.

Learn More

Intraoperative radiation therapy (IORT)

Another option for some pancreatic tumors is IORT, a fast and effective form of radiation therapy that uses electron-beam radiation during surgery.

• Your surgeon moves normal structures out of the way to expose the target area for this precise, high-dose treatment.
• It takes only a few minutes to deliver and uses only a fraction of the total radiation given over a traditional multi-week course of external-beam radiation. 

UWMC is the only hospital in the WAMI region (Washington, Alaska, Montana and Idaho) to offer this treatment. 

As a PCSC patient, you will be asked about your pain. Your team will ask you detailed questions in order to understand the causes of your pain, select the most appropriate treatments, and evaluate your response to these treatments.

Questions may include:

• Where is your pain located? 
• How long has it been bothering you? 
• How often does it occur? Is it constant or intermittent?
• What does it feel like (stabbing, shooting, cramping, dull, aching)? 
• How intense is the pain on scale from 0 to 10, with 0 being no pain and 10 being the worst pain imaginable? (If you have trouble using a 0-to-10 pain scale, use this scale instead: Is the pain mild, moderate or severe in intensity?)
• What seems to make the pain worse? What makes it better? 
• What medicines or other treatments have you tried for the pain? Were they helpful? 

To help ensure that you receive the best pain relief you can get, ask your doctor or nurse these questions about controlling pancreas cancer pain:

• What can be done to relieve my pain? 
• What can we do if the medicine does not work? 
• Are there non-drug options for pain control? 
• Will the pain medicines have side effects? 
• What can be done to manage the side effects?

“As needed” and around-the-clock opioids

The main treatment for pancreas cancer pain is opioids (narcotics). These are the strongest pain relievers available, and they are generally very safe if taken as directed.

• If your pain is mild to moderate or intermittent, your doctor may prescribe opioids to take only as needed (not on a regular schedule).
• If your pain is moderate to severe or constant, your doctor will prescribe opioids to take around the clock on a regular schedule.

Taking pain medicines on a regular, around-the-clock basis is a more effective way to treat constant pain, and it may actually decrease the total amount of pain medicine you need to get relief each day.

Short-acting and long-acting opioids

Opioids come in two main forms: short-acting and long-acting.

• The short-acting form is used for “as needed” management of pain. The medicine takes effect in about 40 minutes, and the effect typically lasts four hours.
• The long-acting form typically takes effect in one hour, and the effect lasts 8 to 12 hours. One form of long-acting opioid is the fentanyl (Duragesic) patch. It takes 12 hours to take effect but lasts for three days. The patch is changed every three days for a constant level of pain relief.

Commonly used opioids

These opioids are commonly used for pancreas cancer pain management:

• Morphine (Kadian, MSIR, MS Contin, Oramorph-SR)
• Oxycodone (Roxicodone, OxyIR, OxyContin)
• Hydromorphone (Dilaudid) 
• Fentanyl (Duragesic, Actiq)
• Methadone (Dolophine)

Side effects of opioids

Side effects of opioid pain medicines may include constipation, sleepiness, balance problems, difficulty urinating, itching, nausea, or vomiting. You should not drive until you know the effects the medicine has on you and whether you can drive safely. Please tell your team if you experience any side effects of your pain medicines.  

Non-opioid medicines for pain

Other prescription and over-the-counter medicines used to relieve pain include acetaminophen (Tylenol) and non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin, Advil) or naproxen (Aleve). They can be effective for mild to moderate pain. However, they may have interactions with chemotherapy or may not be advised in certain situations. It is very important to check with your doctor, nurse, or pharmacist before taking these medicines.

At times, medicines called “adjuvant analgesics” are also used for pain and symptom management. These are typically anticonvulsant (anti-seizure) or antidepressant medicines. They may help treat nerve pain, improve sleep, or improve mood. Low mood, anxiety, and lack of sleep all worsen quality of life and are important to address.

Non-opioids used for pancreas cancer pain include the following:

• Anticonvulsants: gabapentin (Neurontin), pregabalin (Lyrica)
• Antidepressants: duloxetine (Cymbalta), nortriptyline, desipramine

Intravenous infusion

Pain medicines are usually taken by mouth. For patients who cannot take pills, medicines can be given through an intravenous (IV, by vein) infusion or a subcutaneous (needle under the skin) infusion. In both cases, the medicines can be delivered by a portable pump worn in a backpack, so the patient can walk around while getting the medicine. 

Epidural and intrathecal routes

Other ways to deliver pain medicine include epidural and intrathecal routes. This involves putting a catheter (tube) into the back so a pump can deliver the medicine through this tube. Because this delivery method can cause leg weakness and problems controlling the bowels and urine, use is usually limited to patients who are in the hospital or bed bound at home.

Celiac plexus block

When pain does not respond to other measures, or when pain medicine causes unacceptable side effects, a local anesthetic or alcohol nerve block may be performed.

This procedure provides pain relief by acting directly on the bundle of nerves (celiac plexus) that carries pain signals from the pancreas to the brain. The block can be done in two ways.

• Percutaneous (through the skin) celiac plexus block. This is an invasive procedure that uses either ultrasound or CT guidance to locate the celiac plexus. Needles are placed through the skin, and alcohol is injected on each side of the aorta (large blood vessel) on either side of the celiac axis. This procedure is performed by anesthesia pain specialists in an outpatient setting. The nerve block may last for up to three to four months. It will wear off over time but can be repeated.
• Endoscopic ultrasound-guided celiac plexus nerve block. For this procedure, the doctor uses an endoscope (thin, lighted tube) to look into the stomach, where a needle is placed to inject medicine into the celiac plexus. It appears to be safe and effective but more studies are needed to compare it to other available methods.

A nerve block is performed to reduce pain, reduce the need for high doses of oral opioids, and maintain quality of life. Risks and side effects of a celiac plexus block include diarrhea, leg weakness, and problems controlling bowels or urine.

Thorascopic splanchnicectomy

Thorascopic splanchnicectomy is a minimally invasive procedure that cuts specific nerve branches. This technique is done under general anesthesia. Results are promising for significant pain relief, but the duration of pain relief remains unknown.

External-beam radiation therapy

External-beam radiation therapy is also used to reduce pain. When directed at the tumor, this method may provide fast pain relief.

Non-drug therapies may also be helpful in treating pancreas cancer pain and improving quality of life. These include techniques like relaxation, imagery, distraction, heat and cold therapy, massage, hypnosis, acupuncture, physical therapy, positioning for comfort, coping skills, emotional support, and counseling.