Pancreatic cancer

Treatment

Seattle Cancer Care Alliance (SCCA) experts offer comprehensive care for pancreatic cancer, including advanced treatments and new options available only through clinical studies.

Many patients are seen at our Pancreatic Cancer Specialty Clinic. At this clinic, all of the specialists who will be involved in your care will meet to design treatment that's tailored to you. You will receive a multidisciplinary treatment plan in a single day — truly one-stop shopping.

Some patients see a single specialist, based on their individual needs. Either way, we see you quickly so you can start your treatment quickly.

This page is about pancreatic cancer. To learn more about NETs, visit our dedicated NET section.

Pancreatic cancer expertise at SCCA

Everything you need is here

We have surgical oncologists, medical oncologists, radiation oncologists, gastroenterologists and pathologists who specialize in pancreatic cancer; the most advanced diagnostic, treatment and recovery programs; and extensive support. 

Innovative pancreatic cancer therapies

SCCA patients have access to advanced therapies being explored in clinical studies for pancreatic cancer or pancreatic NETs conducted here and at our founding organizations Fred Hutchinson Cancer Research Center and UW Medicine. We'll talk with you about any studies, as well as standard treatments, that might be relevant for you.

SCCA was among the first institutions in the Pacific Northwest region to offer peptide receptor radionuclide therapy (PRRT) as a treatment option for patients with NETs. Lutathera® (lutetium Lu 177 dotatate) uses radiation to target cancer cells while minimizing the harm to healthy tissue.

Pancreatic cancer treatment tailored to you

Your SCCA doctors will collaborate on a comprehensive treatment plan to get the best results for you based on your health and the type, stage and location of your cancer. Genomic profiling (laboratory methods to learn about the genetic make-up of your cancer cells) helps us personalize your care by targeting specific pathways, an approach known as precision medicine. 

Team-based approach

Your personal team includes more than your pancreatic cancer doctors. Additional experts who specialize in treating people with cancer will be involved if you need them — experts like a dietitian, pain specialist, social worker, palliative care professional or chaplain.

Ongoing care and support

During and after treatment, your team continues to provide follow-up care on a schedule tailored to you. The SCCA Survivorship Clinic is also here to help you live your healthiest life as a pancreatic cancer survivor.

Treatment types

Treatment looks different for different people depending on your diagnosis. We tailor your treatment plan to you. Learn more about the treatment types offered at SCCA. 

Surgery

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 SCCA 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.

 

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

Surgery

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.

Chemotherapy

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 SCCA 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 SCCA.

Chemotherapy

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

Targeted therapy

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.

Targeted therapy

Targeted therapies are newer cancer treatments that work more selectively than standard chemotherapy. 

Radiation therapy

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.

The SCCA Proton Therapy Center 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. 

Radiation therapy

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

Nutrition

Your pancreas aids in digestion and regulates your blood glucose levels, so pancreatic cancer is likely to affect the way your body uses food. 

To anticipate and prevent potential problems or to diagnose and deal with them early, it’s important to meet with a dietitian when you begin cancer treatment. You might also need enzymes, taken in pill form, to help with digestion.

Pancreatic tumors can affect digestion differently depending on their type and location. Your SCCA dietitian will evaluate your needs and create an individualized nutrition plan for you.

Pain management

Managing pain is one of the most important aspects of your care for pancreatic cancer. Pain is a common symptom: During the course of cancer care, 70 percent of patients experience some form of pain, which can affect their quality of life. Fortunately, pain can be successfully controlled.

Dermot R. Fitzgibbon, MD, and his team at the SCCA Pain Clinic work with medical oncologists in the Pancreatic Cancer Specialty Clinic (PCSC) to manage patients’ long-term pain with medicines as well as non-drug treatments. The goals of pancreatic cancer pain management are to control any pain you have, minimize any side effects you experience from pain medicines, and enhance your quality of life.

Cancer patients can experience chronic non-cancer pain, cancer-related pain, or a combination of the two. Chronic non-cancer pain tends not to change much over time. It can usually be managed by one or two doctors. In contrast, cancer pain may be complex and sometimes requires the involvement of many care professionals.

Most of the time, a patient’s oncologist can manage his or her pancreatic cancer pain. “We tend to be more involved in the more complex cases,” Dr. Fitzgibbon says about the Pain Clinic. “Cancer pain care needs to be carefully coordinated. It requires careful follow-up of issues and medications that can complicate a patient’s overall care.”

Comprehensive pain assessment

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? 
Comprehensive pain assessment

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 to ask about pain relief

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?
Questions to ask about pain relief

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.

Treatment for pancreatic cancer pain with medicines

“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
Treatment for pancreatic cancer pain with medicines

Learn about the different types of pain medicines such as commonly used opioids to non-opioid medicines. 

Advanced forms of pain management for pancreatic cancer

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.

Advanced forms of pain management for pancreatic cancer

Learn about other types of pain management that does not involve pain medicines being taken by mouth. 

 

Other pain relief methods

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.

Other pain relief methods

Learn about thorascopic splanchnicectomy, a minimally invasive procedure, and external-beam radiation therapy.