"..Expert Answers on Pancreatic Cancer Treatment.."

Pancreatic cancer will be diagnosed in about 42,000 Americans this year, and some 35,000 will die of it. What can be done to treat pancreatic cancer, or prevent recurrences after treatment? Readers recently posted questions about pancreatic cancer treatment and prevention on the Consults blog. Here, Dr. Eileen O’Reilly of Memorial Sloan-Kettering Cancer Center in New York responds.

Preventing Recurrences After Treatment for Pancreatic Cancer

Q.

"..I had a Whipple two years ago. So far the CT scans have shown no recurrence. Is there anything I can do, including clinical trials, to improve the likelihood that it will not recur?.."
Michael, Silver Spring, Md

Q.

"..My wife underwent surgery for the removal of the upper two-thirds of her pancreas and spleen, followed by six weeks of radiation treatment and chemotherapy. A small mass of pancreatic cancer was found inside the pancreas. It was discovered during the work-up before surgery for early stage ductal breast cancer..."

"..A lumpectomy was performed for the breast cancer during the surgery for the pancreatic cancer.  She has had recurring CT scans and  mammograms since. The CT scans were given every 3 months, then 6 months and now once a year. She has had three additional CT scans when she had abdominal pain that lasted more than a day. She has had no recurrence of breast or pancreatic cancer and is working full time at age 63.

Will the risk of recurring pancreatic cancer ever reach a level that is similar to someone who has not had pancreatic cancer?.."
JF, Phoenix

A.

Dr. O’Reilly responds:

"..Surgery is usually done for patients with pancreatic cancer that is localized and operable. Surgery is typically followed by chemotherapy, or sometimes chemotherapy combined with radiation.

Following completion of these therapies, as of now, there is no proven additional treatment that impacts the risk of cancer recurrence. And while we can “never say never” in this disease, one of the important statistics that we emphasize is that the risk of recurrence does fall significantly the longer one is out from surgery. Hence, each milestone that is passed in time offers some additional reassurance..."

Metastatic and Late-Stage Cancer

Q.

"..My father (76 years old) was diagnosed this past February and is currently on a regimen that includes Gemcitabine and Oxaliplatin. He was classified with stage 4 and has metastases in his lymph glands. He has responded well to the treatment, with drastically reduced tumor markers. Can someone who responds well to chemo or radiation become a candidate for surgery? If there has already been a metastisis does that automatically disqualify one for the surgical option?.."
Marc, New York City

Q.

"..My father died of pancreatic cancer when I was young. The cancer was discovered when his complexion started turning yellow due to pancreatic failure. He was given a Whipple. The operation was fairly successful, but he suffered from a hernia. He also became extremely anemic within about nine months of the operation. About two years after the operation, my father died from a blood clot. I mention this story because some in my family feel that if father had been better informed about his bleak chances of survival, he may have decided to forgo surgery and “die with dignity.” At my father’s (presumably advanced) stage of cancer, how much can a Whipple operation extend the life of the patient? That is, what are the chances of survival beyond the first year or two? Also, what are the most common proximate causes of death for people with pancreatic cancer?..":  Schakj, Kansas City, MO

Q.

"..Since pancreatic cancer is so hard to diagnose, one may have the disease for several months or a year and not know it. Question: When survival statistics for pancreatic cancer are compiled, does the survival time start from the time of diagnosis, or the initiation of treatment?

Another question: in inoperable pancreatic head cancer, if the chemotherapy is working and the tumor size and metastatic spread is shrinking, what is the limiting factor in survival — side effects of chemo, or a gradual attenuation of the response to treatment? Thanks so much!.." Bob Seurat, Chicago, IL

A.

Dr. O’Reilly responds:

"..Typically, chemotherapy-based treatments are indicated for pancreatic cancer that has spread. There is usually not a role for surgery or radiation. At the current time, there is not a consensus as to whether using one, two, three or more drugs in combination or in sequence is preferable. It depends on the specifics of the case, the patient’s level of well-being, other medical illnesses that may be present and the goals of treatment.

By consensus, survival statistics are referenced from the date of surgery for those who undergo an operation (the minority of patients) or the date of biopsy for those who have more advanced disease.

In general, outcomes in pancreatic cancer are primarily governed by the control of the cancer. About 60 percent to 70 percent of pancreatic cancers will have significant amounts of metastatic disease at the time a person succumbs. A lesser but significant percentage of patients succumb to complications of predominantly local disease related to the pancreas and surrounding structures and have a lesser burden of metastases. Researchers are studying these different clinical outcomes and behaviors in the hopes that they will have future implications for treatment selection for different groups of patients..."

Side Effects of Cancer Treatment

Q.

"..Hello — my dad is 86 and had the Whipple surgery in Jan. He recovered well and is on chemo (just over halfway through); Gemzar is the drug. His only difficult side effect is constipation. He has used all of the suggestions his MD had (suppositories, stool softeners, milk of magnesia, etc.) but bowel movements are VERY difficult for him. Do you have any suggestions please? Thank you very much.."
Art Hyman, Northampton MA

Q.

"..Do some doctors detect cancer better than others? Is it better to go a therapeutic or interventional gastroenterologist?.."
Medicare Patient, Corning

Q.

"..My mother was just diagnosed two months ago at age 64 with stage IIa pancreatic cancer; now she has just been re-staged as stage 4. She had a Whipple done, but has had trouble maintaining health from a nutrition standpoint, and was not able to tolerate the first round of chemotherapy, She stopped chemotherapy after one treatment because she was vomiting, and getting sicker, but if she is not able to tolerate the chemotherapy, is our only option to stop it until she can get healthier and risk the cancer spreading? It seems like all of her doctors have written her off, do you have any suggestions? We are grasping for hope and do not know where to turn or what to do. Any suggestions you have regarding nutrition, or anything would be greatly appreciated. Thank you!.."   KAG, Chandler, AZ

A.

Dr. O’Reilly responds:

"..A number of readers asked about symptom management. Advanced cancer of the pancreas often requires attention to multiple, interrelated and often complex symptoms that can require special expertise. Input from multiple disciplines is often needed -– for example, from gastroenterology, nutrition, interventional radiology, surgery, radiation oncology, medical oncology, pain management and supportive and palliative care services.

Typically, patients with pancreatic cancer can have multiple interrelated symptoms attributed directly to the diagnosis and often related to treatment or medications used to address symptoms. Nutritional challenges, pain management,and management of constipation are very critical issues that require ongoing attention. The nature of this blog does not lend itself to providing advice on specific circumstances. But the readers do highlight many of the day-to-day questions that pertain to the care of a patient with pancreatic cancer.

These days, there is an increasing awareness surrounding radiation exposure for routine scans. As of now, the exact risks are not known. For the most part, the risks are considered to be very small in the context of pancreatic cancer follow up, and for now, CT imaging should be guided by either the clinical situation or local guidelines..."