DEAR MAYO CLINIC: How do doctors determine whether or not chemotherapy or surgery is appropriate for treating pancreatic cancer? Why do some people with a late-stage diagnosis have treatment, while others are told treatment will not help their situation?
ANSWER: The treatment plan for each individual with pancreatic cancer is unique to that person’s situation and the stage of the disease when it is diagnosed. But where in the past many people were advised that no treatment was available when cancer had spread outside the pancreas, today improved chemotherapy offers new treatment possibilities for this difficult cancer.
Pancreatic cancer is uncommon compared to other kinds of cancer, such as lung, colorectal and breast cancer. Symptoms of pancreatic cancer are relatively nonspecific and can include abdominal or back pain, weight loss, new onset or worsening diabetes, and jaundice or yellowing of the skin. Smoking is the only known significant risk factor, and although a small fraction of patients have a genetic predisposition, the majority of causes are unknown. The lifetime risk of developing the disease for people in the general population is about 1 percent. Unfortunately for those who do get it, pancreatic cancer is one of the hardest kinds of cancer to successfully treat. The five-year survival rate now is just over 7 percent.
The reason pancreatic cancer is so devastating is twofold. First, there’s no early screening for it. Many cases are diagnosed at an advanced stage when cancer has already spread from the pancreas to other organs. The second reason has to do with the biology of the cancer. It’s very aggressive and has a high tendency to spread to other sites, even with very small tumors in seemingly early-stage disease. That means that for many people, the disease comes back after treatment.
In people diagnosed before cancer has spread outside the pancreas, treatment may include surgery to remove the tumor, followed by chemotherapy. But that group is in the minority and only includes about 15 percent of patients at diagnosis. In up to 50 percent of patients, the cancer has spread to other sites outside the pancreas, making surgery ineffective. In about 35 percent of patients, the tumors involve vascular structures around the pancreas, so the cancer traditionally was felt to be surgically inoperable.
It’s in this second group of patients that a new approach to treatment has been helping over the last several years. With the advent of improved chemotherapy and radiation therapy, it’s now possible to give treatment to those individuals that may, in a significant number of cases, reduce the cancer to a point that surgery is a viable option for long-term survival and even cure.
The advances in chemotherapy for pancreatic cancer have been particularly positive. Whereas the response rates to traditional chemotherapy in people with pancreatic cancer used to be at about 9 percent, that rate has almost tripled with the new chemotherapy regimens available today. It’s even higher in patients whose tumors have not spread to other sites.
Additionally, the surgery used to remove pancreatic cancer has improved. First and foremost, for surgery to be successful there can’t be any cancer cells left behind. If there are, patients do not derive any benefit from the operation. Historical data suggests that about 1 in 4 patients had some cancer remaining in the pancreas after surgery. With the use of preoperative chemotherapy and subsequent radiation therapy, along with updated surgical techniques, we have improved those percentages and increased the odds that all cancer cells will be removed. This strategy and improved care after surgery have also decreased the number of complications that happen as a result of surgery, and that improves overall survival, too.
A diagnosis of pancreatic cancer can be very frightening. But for many people, modern treatment options are available. In the past, some doctors simply told people with this disease that nothing could be done, based on poor overall historical outcomes. Today that’s often not true. If you are diagnosed with pancreas cancer and you aren’t given any treatment choices, get another opinion. Talk to an oncologist or to a surgeon at a center that does a high number of surgeries who specializes in pancreatic cancer to find out what options may be possible for you. — Mark Truty, M.D., Surgery, Mayo Clinic, Rochester, Minn.