Treatment for advanced pancreatic cancer

Monday 1 February, 2016

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On this page: Surgery to relieve symptoms | Chemotherapy | Radiotherapy | Other treatments for advanced pancreatic NETs | Palliative treatment | Key points


If the cancer is locally advanced to nearby organs or blood vessels, or has spread (metastasised) to other parts of the body, surgery to remove the cancer may not be possible.

Instead your treatment team will consider treatment to relieve symptoms including jaundice, digestive problems and pain. These treatments may include surgery, chemotherapy and radiotherapy, either on their own or in combination.

Other types of treatment for advanced pancreatic NETs include radiofrequency ablation, microwave ablation and chemo-embolisation.

Surgery to relieve symptoms

If the tumour is pressing on the bile duct, it can cause a blockage and prevent bile from passing into the small bowel. Bile then builds up in the bloodstream, causing symptoms of jaundice, such as:

  • yellowing of the skin and whites of the eyes
  • itchy skin
  • reduced appetite, poor digestion and weight loss
  • dark urine and pale stools.

If cancer blocks the duodenum (upper part of the small intestine) food cannot pass into the bowel and builds up in your stomach, causing nausea and vomiting. Double bypass surgery or surgical insertion of a stent may be considered to relieve symptoms. Debulking, removing as much of the tumour as possible, may be an option for relieving symptoms of pancreatic NETs.

Double bypass surgery

A double bypass surgery may be performed to relieve symptoms such as jaundice. This surgery is often carried out when the surgeon has planned to remove the tumour, but is unable to because the cancer has spread (metastasised) or has involved one or more of the major blood vessels in the region.

During a double bypass surgery, the surgeon connects a piece of your bowel to the bile duct or gall bladder to redirect the bile around the blockage. At the same time, the surgeon also connects a part of your bowel to the stomach, in order to bypass the duodenum. This will allow your stomach to empty properly. The surgery usually requires a hospital stay of 7–10 days.

Pancreas with tumour pressing on bile duct
Inserting a stent

If the cancer cannot be removed, and is pressing on the bile duct or duodenum, a stent may be inserted. A stent holds the bile duct or duodenum open, allowing the bile or food to flow into the bowel again.

The stent is inserted during a procedure known as an endoscopic retrograde cholangiopancreatography (ERCP). An ERCP involves passing an endoscope into the bile duct via your mouth, stomach and duodenum. X-rays are used to position the stent across the blockage to keep the bile duct or duodenum open. You can have an ERCP as an outpatient or you may stay in hospital for 1–2 days. You will be sedated for the procedure.

Stent opening the blocked bile duct

A stent is a tube made of either plastic or metal.

Plastic stents

These are sometimes used to temporarily relieve symptoms before surgery, then removed as part of the operation. They are generally short term and can be replaced when they become blocked, usually after a few months.

Metal stents

These are used when the tumour cannot be surgically removed. They usually remain open from several months to over a year. If the metal stent becomes blocked, another stent will be placed inside the blocked stent to open it up.

Following the insertion of a stent, symptoms of jaundice usually disappear over 2–3 weeks, but the itchy skin often goes away in 3–4 days. Your appetite should improve and you may gain some weight.

Debulking pancreatic NETs

Debulking is used for pancreatic NETs only. If the whole tumour can’t be removed, the surgeon may still try to remove as much of it as possible. This surgery, called debulking, is not always possible and will depend on the position and size of the tumour.

Debulking may relieve some of your symptoms and, for functioning pancreatic NETs, reduce your hormone levels. If your hormone levels can be regulated, you will feel better and experience fewer side effects.

Chemotherapy

Chemotherapy is the use of drugs to kill or slow the growth of cancer cells.

Chemotherapy is sometimes used in combination with radiotherapy (chemoradiation) to treat locally advanced cancers, i.e. cancer that has spread beyond the pancreas and cannot be removed with surgery.

If you have advanced pancreatic cancer, chemotherapy may be given as palliative treatment to relieve symptoms and improve survival. Chemotherapy is not commonly used to treat pancreatic NETs.

You will probably receive chemotherapy by injection into a vein (intravenously) at treatment sessions over several weeks. In most cases you will receive the treatment as an outpatient. Most people have up to six courses of treatment. After each treatment session, you will have a break or rest period of 1–3 weeks at home. Your medical team will talk to you about how they will assess if the treatment has worked.

Tell your doctors about any prescription, over-the-counter or natural medicines you’re taking or planning to take, as these may affect how the chemotherapy works in your body. For information about natural medicines and other complementary therapies call Cancer Council 13 11 20 or see Understanding Complementary Therapies.

Side effects of chemotherapy

Chemotherapy affects fast-growing cells in the body, such as the white blood cells (which fight infections), hair cells and the cells lining the mouth and digestive system.

Chemotherapy can cause temporary side effects, which may include:

  • fatigue and tiredness
  • nausea and/or vomiting
  • a low red blood cell count (anaemia), causing weakness and breathlessness
  • a low white blood cell count, causing poor resistance to infection
  • mouth ulcers
  • diarrhoea
  • flu-like symptoms such as fever, headache and muscle soreness
  • poor appetite
  • skin rashes.

You may have none or only some of the above side effects. Discuss how you are feeling with your medical oncologist, as there are ways to reduce or manage your side effects. For more information about chemotherapy, call the Cancer Council 13 11 20 or see Understanding Chemotherapy.

"I found chemo a bit daunting – walking into the room with the chairs lined up. But the nurses were great and talked through it with me so I knew what to expect." - Cheryl

Radiotherapy

Radiotherapy treats cancer by using x-rays to kill cancer cells or injure them so they cannot multiply. These x-rays can be targeted at cancer sites in your body.

Radiotherapy is usually used in combination with chemotherapy (chemoradiation) to treat locally advanced cancers, i.e. cancer that has spread beyond the pancreas and cannot be removed with surgery. Radiotherapy may also be given after surgery for early-stage cancer to reduce the risk of cancer recurring.

Radiotherapy may also be used to relieve symptoms such as pain caused by tumours that may be pressing on a nerve or another organ. Radiotherapy is rarely used to treat pancreatic NETs.

Treatment is usually given Monday to Friday, for up to five or six weeks. Each session takes 10–15 minutes. Treatment is painless and planned to do as little harm as possible to healthy body tissue.

Side effects of radiotherapy

Radiotherapy can cause temporary side effects, including:

  • tiredness
  • nausea and vomiting
  • diarrhoea
  • poor appetite
  • skin irritation.

Ask your doctor about managing these side effects, call Cancer Council 13 11 20 or see Understanding Radiotherapy.

Other treatments for advanced pancreatic NETs

Other treatments may be used to treat advanced pancreatic NETs that have spread to the liver. These treatments include:

  • Radiofrequency ablation and microwave ablation
    Using an ultrasound or CT, a needle is inserted through the abdomen into the tumour. The needle sends out radio waves that produce heat and destroy the cancer cells. The treatment is performed under local anaesthetic.
  • Chemo-embolisation
    In this procedure, a catheter is inserted into the hepatic artery, which supplies blood to the liver. A chemotherapy drug is released into the artery, along with tiny particles called microspheres, which block the flow of blood into the tumour. This causes the tumour to shrink. The procedure is performed under local anaesthetic and you may need to stay in hospital overnight.
  • Peptide receptor radionuclide therapy (PRRT)
    This treatment is used for functioning and non-functioning pancreatic NETs that have receptors for the hormone somatostatin. You will be given amino acids to protect your kidney function. Then, a cell-targeting protein, or peptide, which is combined with a radioactive substance, is injected into the blood stream. Each session lasts around four hours and most people have a few sessions over several weeks or months.

Palliative treatment

Palliative treatment helps to improve quality of life by easing symptoms of cancer when a cure may not be possible. It is particularly important for people with advanced cancer, but it can be used during different cancer stages.

Often treatment focuses on pain relief and stopping the spread of cancer, but it can also involve the management of other physical and emotional symptoms, such as depression. Treatment may include radiotherapy, chemotherapy or other medication.

If pancreatic cancer has spread and it is not possible to treat it with surgery, your doctor may recommend treatment to relieve problems such as:

  • jaundice – caused by narrowing of the bile duct persistent vomiting and weight loss – caused by obstruction in the stomach or small bowel
  • poor digestion – caused by the blockage of the pancreatic duct, which stops the flow of the digestive enzymes required to break down food
  • pain – in the abdomen and middle back.

See information on managing dietary issues that may be caused by pancreatic cancer and its treatment.

Key points

  • When pancreatic cancer is advanced or cannot be surgically removed, treatment to relieve symptoms is still possible.
  • A double bypass surgery may be performed to relieve jaundice or a blockage in the duodenum.
  • Alternatively, a stent may be inserted to increase the flow of bile into the bile duct, or food into the bowel.
  • The procedure to insert a stent is known as an endoscopic retrograde cholangiopancreatography (ERCP).
  • Chemotherapy is the use of drugs to kill or slow the growth of cancer cells. It is sometimes used on its own, or in combination with radiotherapy (chemoradiation), to treat advanced cancer.
  • Radiotherapy, which directs x-ray beams at the cancer, is sometimes used with chemotherapy (chemoradiation) for advanced cancer, or on its own as palliative treatment.
  • Other treatments for pancreatic NETs may include radiofrequency ablation, microwave ablation and chemo-embolisation.
  • Peptide receptor radionuclide therapy (PRRT) may be used to treat advanced pancreatic NETs that have receptors for the hormone somatostatin.
  • Palliative treatment helps to improve quality of life by easing symptoms of cancer when a cure may not be possible.

Reviewed by: A/Prof Vincent Lam, Associate Professor of Surgery, Sydney Medical School & Hepatobiliary, Pancreatic and Transplant Surgeon Westmead Hospital, NSW; Dr Phillip Tran, Radiation Oncologist, Site Director, Sunshine Hospital Radiation Therapy Centre, VIC; Dr Victoria Atkinson, Senior Medical Oncologist, Division of Cancer Services, Princess Alexandra Hospital, QLD; Alison Keay, Upper GI Cancer Nurse Coordinator, WA Cancer & Palliative Care Network, WA; Belinda Steer, Clinical Lead Dietitian, Nutrition and Speech Pathology Department, Peter MacCallum Cancer Centre, VIC.
Updated: 01 Feb, 2016