Pancreatic Cancer Treatment

Surgery

Surgery is used when results of tests suggest that it is possible to remove all the cancer. Only about 20% of patients with pancreatic cancer are able to have surgery because most pancreatic cancers are first diagnosed when the disease has already spread.

Types of surgery

• Whipple procedure (pancreaticoduodenectomy) is the most common operation to remove a cancer in the head of the pancreas.
• Distal pancreatectomy is a surgery that removes only the tail of the pancreas or the tail and a portion of the body of the pancreas.
• Total pancreatectomy surgery removes the entire pancreas, as well as the gallbladder, part of the stomach and small intestine, and the spleen.
• Palliative surgery may be used to relieve symptoms or to prevent certain complications like a blocked bile duct or intestine in instances where the cancer is too widespread to be removed completely. ERCP (Endoscopic Retrograde Cholangiopancreatography is a procedure where the surgeon inserts a tiny scope down the esophagus to the first part of the small intestine, known as the duodenum. The surgeon can use surgical instruments passed through the scope to relieve complications of pancreatic cancer like a blocked bile duct.

Chemotherapy

Chemotherapy uses drugs to help kill cancer cells. These drugs can be injected into a vein or taken orally. Most pancreatic cancers are treated with one or more of the following chemotherapy agents: 

• Gemcitabine (Gemzar)
• 5-fluorouracil (5-FU)
• Oxaliplatin (Eloxatin)
• Albumin-bound paclitaxel (Abraxane)
• Capecitabine (Xeloda)
• Cisplatin
• Irinotecan (Camptosar)
• Liposomal irinotecan (Onyvide)

Radiation therapy

Radiation therapy uses high-energy particles or beams, such as X-rays to destroy cancer cells. You may receive radiation treatments before or after pancreatic cancer surgery, often in combination with chemotherapy such as capecitabine or gemcitabine. In specialized medical centers, radiation therapy may be delivered during surgery (intraoperative radiation).

Radiation treatments are usually performed Monday through Fridays with weekends off for either 2, 3 or 5 weeks depending on the underlying reason for treatment. 

Targeted therapy

Targeted therapy is a type of cancer treatment designed to attack or kill cancer cells, while sparing normal cells as much as possible. They are designed to target abnormal proteins, receptors or genes that are found in cancer cells or the surrounding tissue. Often times additional testing on the cancer is used to decide if targeted therapy is the best treatment for a person with pancreatic cancer.

PARP inhibitors

PARP inhibitors work by blocking a protein used by cells to repair damaged DNA. They were initially developed to treat cancers in people with an inherited BRCA1 or BRCA2 mutation.

For people with a BRCA1 or BRCA2 mutation, the PARP inhibitor Lynparza (olaparib) has been approved as maintenance therapy in patients with advanced pancreatic cancer whose cancer did not get worse after at least four months of chemotherapy. Because PALB2 mutations act similarly to BRCA1 and BRCA2, the American College of Medical Genetics has guidelines that indicate people with PALB2 mutations may benefit from this drug, too. 

Research is ongoing to learn if PARP inhibitors are also affective for treating pancreatic cancer in other situations, including:  

• people with an inherited mutation in a different gene that repairs DNA damage.
• people who do not have an inherited gene mutation, but their tumor tested positive for an acquired mutation in a gene that repairs DNA damage.
• in combination with immunotherapy or other agents.

Other targeted therapies

Other targeted therapies used to treat pancreatic exocrine cancer include:

• Bizengri (zenocutuzumab) is a type of targeted therapy approved for treatment of advanced, unresectable, or metastatic pancreatic cancer with a biomarker known as an NRG1 gene fusion which got worse or came back on, or after prior treatment.
• Enhertu (trastuzumab deruxtecan) is a type of targeted therapy approved for treatment of advanced cancers that have a biomarker called HER2-positive. 
• Retevmo (selpercatinib) is approved for treatment of of advanced cancers that have a biomarker called a RET gene fusion. 
• Rozlytrek (entrectinib) is approved for treatment of of advanced cancers that have a biomarker called an NTRK fusion.
• Vitrakvi (larotrectinib) is approved for treatment of of advanced cancers that have a genetic change called an NTRK fusion.

Targeted therapies used to treat pancreatic neuroendocrine tumors include:

• Afinitor (everolimus) is a type of targeted therapy known as an mTOR inhibitor that is FDA approved for treating people with advanced pancreatic neuroendocrine tumors.
• Sutent (sunitinib malate) is a targeted therapy that is FDA approved to treat patients with pancreatic neuroendocrine tumors that cannot be removed by surgery or that have metastasized.

Immunotherapy

Immunotherapies are cancer treatments that help the body’s immune system detect and attack cancer cells. There are several different categories of immunotherapies. 

Immune checkpoint inhibitors

Immune checkpoint inhibitors are a type of immunotherapy used to treat several types of cancer, including some pancreatic cancers. Cancer cells can switch off the immune system. Immune checkpoint inhibitors are drugs that prevent this from happening. This allows the immune system to find, unmask and destroy cancer cells.

• Jemperli (dostarlimab) is an immunotherapy that is FDA approved to treat metastatic cancers that have progressed after prior treatment, and for which there are no other available treatment options. The approval is for cancers that have a biomarker known as dMMR. This biomarker is often seen in cancers that develop in people with Lynch syndrome.
• Keytruda (pembrolizumab) is known as an immune checkpoint inhibitor. Keytruda is approved for treatment of patients with metastatic cancer with a biomarker known as microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR). Although this biomarker is not common in pancreatic cancer, it is often seen in people with a Lynch syndrome gene mutation who develop cancer. 

Cancer vaccines

Cancer vaccines help the body's immune system recognize and attack cancer cells. Currently, there are no vaccines with FDA approval to treat pancreatic cancer, but several are being studied in clinical trials. 

Timing of treatment

• Neoadjuvant treatment is given before surgery to shrink the tumor and help the surgeon remove as much of the cancer as possible. 
• Adjuvant chemotherapy is given after surgery to prevent the cancer from spreading or coming back.
• Maintenance therapy with a PARP inhibitor is given to some people after they complete chemotherapy treatment to keep the cancer from coming back or growing. 
• If the cancer recurs, additional chemotherapy, targeted therapy or immunotherapy may be given, depending on response to initial treatment and tumor biomarker testing.

Treatment side effects

Your healthcare team should explain what you might expect from all treatments, including:

• all of the possible risks and side effects of each treatment.
• which side effects may be serious and how to tell. 
• when and who you should call if you experience a side effect.
• what can be done to treat or alleviate each side effect. 

Make sure you let your healthcare team know if you experience any side effects of your treatment. For more information about possible treatment side effects, see our section on Cancer Treatment by Treatment Type.