Learn

There is treatment for everyone diagnosed with pancreatic cancer.

Treatment

Access to healthcare professionals who focus on symptom management and supportive care improves patient outcomes and is critical for quality of life.

The World Pancreatic Cancer Coalition recommends that pancreatic cancer patients have their symptom management and supportive care needs addressed at all stages of treatment.

Craig’s Cause Pancreatic Cancer Society strongly recommends that all patients have their diagnosis reviewed and are supported by the following healthcare professionals and organizations:

1. Hepato- Pancreatico - Biliary (HPB) surgeon, who is trained specifically in the complex pancreas surgeries.
2. Medical oncologist, who has an interest in treating pancreatic cancer and has knowledge of clinical trial information BEFORE treatment starts.
3. Nutritionist, knowledgeable about dietary challenges of living with pancreatic cancer.
4. Psychologist knowledgeable in the treatment of a cancer diagnosis for both patients and caregivers.
5. Social worker, who can provide support and guidance to access a number of resources.
6. Palliative Care Specialist
7. Patient advocacy organizations who can provide direct support to patients.

Are Biopsies Necessary?
Yes! Pancreatic cancer is not one disease that follows one pathway. Different types of pancreatic cancer respond to different treatments. Up to 10% of pancreatic cancers are not traditional pancreatic cancer. Other types of cancer (like melanoma, ovarian cancer, renal cell carcinomas and others) can spread to the pancreas. Lymphomas and pancreatic neuroendocrine tumors also can present as a pancreatic mass. To receive the best care you must find out what type of pancreatic cancer you have, which can only be determined by a biopsy.  Additionally, to access most clinical trials, a tissue diagnosis is required.

Surgery

Although 15- 20% of pancreatic cancer patients are eligible for surgery, research indicates that patients are not always informed of this option. Surgical removal of the pancreas tumour is the only curative treatment for pancreatic cancer. It can also offer long-term control of pancreatic cancer.  

Craig’s Cause Pancreatic Cancer Society strongly recommends that patients diagnosed with pancreatic cancer are referred to a HPB (Hepato-Pancreatico-Biliary) surgeon, who is a specialist specific to treating benign and malignant diseases of the liver, pancreas and biliary tree. 

Key Points Regarding Surgical Intervention

  • Patients should be referred to a HPB Surgeon
  • Surgery is only possible when the HPB Surgeon is confident that the cancer is localized and identified in the early stages of the disease.
  • Patients should be referred to a high volume hospital
  • Research indicates that these hospitals have higher surgical success rates and fewer complications. CLICK HERE to review our HPB Surgeon referral list, at high volume hospitals.
  • A HPB pancreatic cancer surgeon should perform several pancreatic cancer surgeries a year.

Depending on the diagnosis, there are three major procedures used to remove pancreatic tumours. These are:

Whipple Procedure (pancreaticoduodenectomy)

During the operation the surgeon removes the following organs:
• Most of the duodenum (the beginning of the small intestine)
• Head of the pancreas
• Part of the bile duct
• Gallbladder
• Lymph nodes in the area of the pancreas

After these organs are removed, the stomach, or the remaining part of the duodenum, pancreas, and remaining part of the bile duct are joined to the small intestine. This allows bile and pancreatic enzymes to enter the digestive system normally and mix with ingested food.

On average, the Whipple Procedure is performed in 6-8 hours. In some cases, if the patient has had previous abdominal operations with subsequent formation of scar tissue the surgical procedure can take longer and the risks of requiring blood transfusions or developing complications increase significantly.

The Whipple Procedure, or pancreaticoduodenectomy, is the most common surgery. Patients can receive a Whipple Procedure when the tumour(s) is in the head of the pancreas, requiring removal.
Whipple Procedure Recovery
After the operation, patients are admitted to the surgical unit where the nursing staff will monitor their progress and administer painkillers. Patients are placed on intravenous and usually not allowed to eat for the first 5-6 days. 

Most patients are able to go home 7-14 days after surgery where they will most likely find movement and activity difficult for the first few weeks and require some help from family or friends. The patient's ability to eat can take up to several months to improve.

Patients may experience a low mood that usually resolves in a few weeks. Patients often return to their normal activities after 2-3 months. There are usually no restrictions on activities after that time.

Benefits of Whipple Procedure Surgery
The goal of the Whipple Procedure is to completely remove the cancerous growth. Additionally, the surgery provides the patient with the best chance of cure, which is why a wide area of tissue around the affected part is removed.

Patients often return to their normal activities after 2-3 months. There are usually no restrictions on activities after that time.

Complications and Risks of Whipple Procedure Surgery
Pancreaticoduodenectomy is considered by any standard, a major surgical procedure. The risks of complications are fewer in hospitals where this procedure is done often. Possible complications that patients may experience post-operatively include:Infections (incision, lungs, urine, in the abdominal cavity)Blood loss during surgery requiring transfusions Leaking of bile or pancreatic juicesDifficulty emptying the stomach after eatingInflammation of the pancreas (rare)Failure of other organs, such as the heart, kidneys and liver (rare)

Long-Term Challenges after Whipple Procedure Surgery

Diabetes
The pancreas produces insulin that is required for control of blood sugar. There is a risk of developing diabetes following surgery. Patients who are not diabetic before surgery are unlikely to develop diabetes afterwards. Patients who are diabetic before surgery are likely to need additional diabetic medications or insulin after the operation.

Malabsorption
Refers to the poor digestion and absorption of food, resulting in loose stools that are greasy, pale and tend to float in the water. The pancreas produces enzymes required for digestion of food. Removal of part of the pancreas decreases the production of these enzymes. Therefore, in some patients there is need for long-term treatment with pancreatic enzyme capsule supplements to be taken by mouth with each meal.

Weight loss
It is common for patients to lose weight compared to their weight before their illness. Usually by three months after surgery patients start regaining some of the lost weight.

Alteration in Diet
After the operation, there is no restriction to a patient’s diet although most individuals after the Whipple Procedure will only be able to eat small amounts of food at one time. Patients may need to have small meals with snacks between meals in order to minimize symptoms of bloating or discomfort. In general, it takes several months for digestion to improve and for the patient to eat at a normal level.

Total Pancreatectomy

The Total Pancreatectomy removes the entire pancreas, part of the small intestine, part of the stomach, the common bile duct, the gallbladder, the spleen, and nearby lymph nodes are removed.

Recovery, benefits, complications and long term challenges are similar to that of a Whipple Procedure.

Distal Pancreatectomy

When a Distal Pancreatectomy operation is performed the body and tail of the pancreas are removed, if the tumor is located in one of these two areas. The spleen is also removed at the same time.

Recovery, benefits, complications and long term challenges are similar to that of a Whipple Procedure.

Palliative Surgery

Patients who are not curable may be offered palliative surgery which removes part of the pancreas and connects the bowel around the obstruction. Additionally, some of the tumour will be removed, to relieve some pain and discomfort.

Video Resources


Chemotherapy

Pancreatic cancer patients have higher Quality of Life scores when they receive supportive care (symptom management and palliative care).

Craig’s Cause Pancreatic Cancer Society strongly recommends that every patient diagnosed with pancreatic cancer is referred to a medical oncologist, experienced in treating pancreatic cancer patients.

What is Chemotherapy?

Chemotherapies are powerful drugs which are typically given intravenously (I.V.), but can now sometimes be administered in pill form or through injections. Currently, all chemotherapies used to treat pancreatic cancer are administered by I.V. at this time.

Chemotherapy drugs disrupt the “growth program” of cancerous cells, however, they also disrupt the “growth program” of normal cells. It is important to remember that unlike our healthy cells that grow, die and rejuvenate, cancerous cells just continue to grow (they forget how to die). Cancerous cells are not reprogrammed to grow, once they die. If we can get the cancer cells to die, they will stay dead. The goal of chemotherapy is to disrupt this cancer cell growth. 

What Is a Medical Oncologist?

A medical oncologist is a physician who specializes in the diagnosis and medical treatment of cancer and its complications.

Patients are typically referred to a medical oncologist after being diagnosed with cancer but occasionally may see one before a cancer is confirmed.

What is the Role of a Medical Oncologist?

  • Explain the cancer diagnosis and the possible impact of the disease on health.
  • Explain the disease stage and the goals of treatment.
  • Explain all relevant treatment options available, including clinical trials testing new treatments.
  • Recommend the best course of treatment in the context of a patient's health history, symptoms and preferences.
  • Deliver optimal safe and supportive care.
  • Supervise and manage treatments designed to increase the chance of a cure when possible or, if a cure is not possible, controlling/improving symptoms and slowing cancer progression. This is called palliative, or symptomatic and supportive therapy.
  • Initiate and supervise treatments aimed at controlling and improving symptoms such as pain, nausea, or loss of appetite when they are a problem.

What Treatment Options are Available to Canadians?

Depending on a patient’s diagnosis and stage of disease, medical oncologists may recommend:

  • treatment before surgery (neo adjuvant therapy)
  • treatment after surgery (adjuvant therapy)
  • treatment for symptom and pain control

Neoadjuvant therapy before surgery is recommended when a cancer cannot be removed initially; however, surgery may be possible if radiation, chemotherapy or a combination of these treatments can shrink the mass. Additionally, neo adjuvant therapy is being used with the possibility of prognostic improvement, however, for resectable pancreatic cancer this remains controversial.

Adjuvant therapy after surgery may be recommended for 3 reasons: a) The surgeon may not have been able to remove the cancer completely, so treatment may be used to help shrink or control what was left behind. b) Chemotherapy may be used to reduce the risk of the cancer coming back in the future. c) The surgeon was unable to remove the tumour at all.

Palliative or symptomatic and supportive care is recommended to control the disease and prolong survival, to minimize or improve the symptoms, improve or maintain function and quality of life, and to minimize problems from the disease.

First Line Treatments for Metastatic Pancreatic Adenocarcinoma

Gemzar® (Gemcitabine) was approved in 1996. It can be used prior to surgery (neo adjuvant therapy) and after surgery (adjuvant therapy), as research supports the benefits, in terms of patient survival.

In 2011, FOLFIRINOX was approved in Canada as a first-line treatment for metastatic pancreatic cancer. FOLFIRINOX is a combination of 4 drugs including 5-FU/leucovorin, irinotecan, and oxaliplatin. Clinical trials have demonstrated positive results and, as a result, FOLFIRINOX has become a standard of care of metastatic pancreatic cancer. This treatment is often recommended only for patients who are healthy enough to tolerate the side effects.

In 2014, ABRAXANE® (Albumin-bound Paclitaxel) was approved in Canada and is used in combination with Gemzar® (Gemcitabine) as a  first-line treatment for metastatic pancreatic adenocarcinoma.

There has been no phase 3 randomized clinical trial study to date to compare which regimen FOLFIRINOX or gemcitabine + Nabpaclitaxel so superior and therefore both are used as first line treatments for metastatic pancreatic cancer.

Treatment for Pancreatic Cancer After Surgery

Patients can receive treatment after undergoing pancreas surgery however choice of treatment is based on each individual case.

There are two treatment options available for patients, but it is one or the other. FOLFIRINOX OR Capecitabine + Gemcitabine.


Second Line Treatments for Metastatic Pancreatic Adenocarcinoma

ONIVYDE® , or liposomal irinotecan, when used in combination with 5-FU (Fluoroouracil) and leucovorin, has been the only drug identified to date to have a survival benefit in the second line treatment of pancreatic cancer after progression on gemcitabine-based therapies based on the NAPOLI-1 phase 3 study (Wang-Gillam A, Li C, Bodoky G, et al. Nanoliposomal irinotecan with fluorouracil and folinic acid in metastatic pancreatic cancer after previous gemcitabine-based therapy (NAPOLI-1): a global, randomised, open-label, phase 3 trial. The Lancet 2016;387(10018):545-557.)

While it has obtained Health Canada approval in August 2017, it has not been approved for coverage of funding in Canada to date. Some private insurance plans may cover funding of this drug currently.

Symptom Control 

There are a variety of medicines which are available to treat the symptoms of pancreatic cancer and the side effects treatment. These include:

Pain Medication- Pain is a serious issue for many diagnosed with pancreatic cancer. Please see page on Pain Management

Celiac Plexus Nerve Block- The pancreas sits on a nerve bundle which can cause pain. This nerve bundle can be frozen (just like a tooth can be frozen, at a dentist's office).

Appetite/Energy Stimulants- The pancreas is involved with nutrition, so pancreatic cancer can cause weight loss and malabsorption. There are medications that can stimulate appetite and assist in the absorption of foods.

Anti-Nauseants- Patients often experience nausea and/or vomiting, making eating difficult. There are medications that can prevent feelings of nausea and may prevent vomiting.

Many medical oncologists work with a primary care nurse. If there are issues that the patient would like to resolve, they may feel more comfortable speaking with the primary care nurse.

Final Points

In closing, it is important to remember that a medical oncologist is a very important member of a patient's medical team, so it is important to find one who is willing to work with the patient and their primary caregivers. If a patient is not comfortable with their current medical oncologist, they can request a second opinion. A second opinion can be requested through the current medical oncologist or through the patient's family physician. 

This chapter was written in collaboration with Dr. Daniel Rayson MD, FRCPC and Dr. Ravi Ramjeesingh MD, PhD, FRCPC, both of whom are medical oncologists at the QEII Health Sciences Centre, in Halifax Nova Scotia.



Clinical Trials

Pancreatic cancer patients who participate in clinical research have better outcomes. Clinical trials can advance research and improve treatment options.

The World Pancreatic Cancer Coalition strongly recommends that everyone diagnosed with pancreatic cancer is given the opportunity to take part in a clinical trial. 


Clinical Trial Finder

What are Clinical Trials?

Clinical Trials (also referred to as Clinical Studies or Interventional Studies) are research studies performed on people and are aimed at evaluating new:

  • medical strategies
  • treatment
  • medical products (drugs or devices)
  • changes to procedures or to a participant’s behaviour (ie. diet) 

The outcome of the product or approach is unknown. The process has usually been designed to compare a new medical approach to:

  • a standard one that is already available
  • a placebo which contains no active ingredients
  • those receiving no intervention

The goal of a clinical trial is to produce the best data available for health care decision making through research and to advance medical knowledge and help improve patient treatment and care.


Are Clinical Trials Safe?

Before a research study meets Clinical Trial criteria, it must undergo a very long and careful research process. Before a clinical trial starts, the research must prove that the trial follows strict scientific standards and will remain safe and effective for participants.

Benefits to Clinical Trials?

All clinical trials offer patients standard of care PLUS additional care. The additional care may come in a variety of forms such as:

  • access to new drugs
  • access to a team of healthcare professionals who are required to meet with patients on a very regular basis

For an individual to be eligible for a clinical trial they must meet a set of criteria. This is why it is important to discuss the option for a clinical trial, before standard of care has started, when possible. 

What does eligible mean?

It means that patients must meet the listed standards. These standards are referred to as eligibility criteria. Participants must meet a list of standards or they will be disqualified.

In Canada, there have been minimal advancements in pancreatic cancer mortality since 1998. Clinical trials are the only way we can change this statistic. 

Finding a Clinical Trial that is right for you is very important. Use the button titled "Clinical Trial Finder" above to assist you.

Video Resources


Palliative Care

What was once referred to as Palliative Care is now often referred to as Supportive Care. Palliative care can be part of a supportive care program. For this section, we will use the term Supportive Care. 

We know that patients who have access to supportive care have improved patient outcomes, making it critical for quality of life. The World Pancreatic Cancer Coalition strongly recommends that pancreatic cancer patients should have their symptom management and supportive care needs addressed at all stages of treatment and their pancreatic cancer journey. 

One misconception about Supportive (Palliative) Care is that patients are only referred when they are nearing the end of life. This is not true. Patients can be referred to supportive care at any point during their pancreatic cancer journey. 

What is Supportive Care?

Supportive Care is specialized care which focuses on a patient's quality of life, associated with life-threatening illness. It can bring many services and healthcare professionals together for the patient and family, taking on many roles such as:

  • The early identification and assessment of pain and other health challenges.
  • Creating healthcare goals for both patients and families.
  • Management of side effects from treatment.  
  • Patient care around physical well being.
  • Patient care around nutritional support. 
  • Patient care around psychosocial well being.
  • Patient care around spiritual well being.
  • Developing a support system to help patients live as actively as possible, until death.
  • Developing a support system to help families cope during the pancreatic cancer journey, and their loved one's diagnosis. 
  • Supporting families through the end of life journey. 

In Canada, Supportive Care can be provided through a variety of programs, depending on the needs of the patient, family and services available. The following are some programs offered in Canada.

Home Care
This program enables patients to remain safely in their homes, with dignity, independence and quality of life.

Home care can include personal care, respite, essential housekeeping, transportation and nursing care.

The cost of home care can vary from province to province but is often based on your income, the service that is required and the amount of time required. Asking for a referral from your healthcare team may assist in deferring of costs. 

Residential Hospice
The goal of residential hospice is to keep the patients as comfortable as possible. Staff will also work to ensure that the patients emotional and spiritual needs are met.

This program provides full time care to patients who are making no further plans for diagnostic tests, resuscitation or other life-prolonging interventions. Patients usually must show that they have explored all appropriate and available supports, but are no longer able to be supported at home. 

The cost of residential hospice care programs are often not covered by the public health care system, so the family or patient may be required to pay an additional daily fee.

Hospital
Hospitals have staff who have received specialty training within the palliative care field. They not only work with the patient and the families but also with the patients’ health care providers.

Although hospitals vary depending on provinces and resources, most hospitals have a palliative care ward or a unit. These wards or units are often used to manage symptoms that are more complex or difficult. They often try to create a room for you or your loved one that has privacy and a “home like” feel to it.

Palliative care units may be used for a short period of time or long term support, but stays are dependent on what the patient needs in terms of support. 

Personal Care Homes

Personal care homes are also referred to as nursing homes. These personal care homes or nursing homes provide regular palliative care. It is important to understand that you do not have to be a long time resident to receive palliative care services within a nursing home. 

Once again, nursing home facilities often have access to teams who have specialized training in palliative care. They will work with the patient, the family and health care providers to ensure that symptoms are managed and that the patient is made as comfortable as possible. Many of the staff are also trained in helping families and caregivers make difficult decisions.

What is the difference between palliative care and hospice care? Palliative care can be offered at any age and stage of the disease. It can be offered along with a curative treatment. 

Hospice care offers many of the same services as palliative care, however, the services are used predominantly for patients who have only a few months left to live.

When choosing supportive care, it is important to understand:

• How each service works in the patients province

• The services provided 

• How each program is funded


Things to consider

Many families find the financial burdens difficult and challenging, during times of illness. Some hospital foundations may have financial support programs to aid patients and caregivers. Do not be embarrassed to ask about these programs, as they were developed for this very purpose. Asking for a referral to a Social Worker is often the way to start this process.

Each family and patient will have individual needs so there is never a “one fit” program. Looking into each program and deciding which program is best, is recommended. It is important to ask as many questions as you need to, to determine if the services offered match the needs of the patient. 



Video Resources