Article: Overview of pancreatic cancer treatment options
|How is pancreatic cancer detected or screened?||Clinical trials|
|Choosing your cancer care center wisely||Guidelines|
|Approaches for treating pancreatic cancer||Questions for your doctor|
|What does this mean for me?||Resources|
PANCREATIC CANCER AT A GLANCE
In 2020, the impact of pancreatic cancer received much-needed media attention due to the passing of U.S. Supreme Court Justice Ruth Bader Ginsberg, U.S. House of Representative member John Lewis and Jeopardy! game show host Alex Trebek—who all died from the disease that year. They were preceded by many well-known figures including Dizzy Gillespie, Sharon Jones and Alan Rickman, profiled by WebMD to highlight the impact of this disease.
Although pancreatic cancer is rare, it is the third leading cause of cancer-related death in the United States, claiming more than 47,000 lives in 2020 and is projected to be the second leading cause of cancer deaths by 2030. The American Cancer Society estimates that more than 60,000 people in the United States will be diagnosed with pancreatic cancer in 2021.
Pancreatic cancer develops in the pancreas, an organ that aids in the digestion of food and the breakdown of sugar. The pancreas is located behind the stomach and around the upper portion of the small intestine. Pancreatic cancer starts when mutated cells of the pancreas begin to grow uncontrollably and begin to form a tumor (a mass of cells).
Because the pancreas is located behind the stomach, early tumors are not easily seen or felt by healthcare providers during routine physical exams. People with pancreatic cancer usually have no symptoms until the cancer has become very large or has already spread (metastasized) to other organs. More than half (52 percent) of all pancreatic cancer cases are diagnosed as cancer and another third are found when the cancer is inoperable. In all of these situations, the cancer is diagnosed at a point where it is treatable, but incurable.
Screening for pancreatic cancer can be done using a type of known as esophageal (EUS) or a type of magnetic resonance imaging () known as magnetic resonance cholangiopancreatography (MRCP). Because pancreatic cancer is considered rare, screening is not usually recommended for the general public. Expert guidelines recommend screening only for people at high risk, including those with a strong family history of the disease or with a known inherited mutation that increases their risk of pancreatic cancer.
Pancreatic cancer tends to be aggressive—even when diagnosed at early stages—which makes it difficult to treat. Only 11 percent of people with pancreatic cancer are expected to live five years after their initial diagnosis. However, the chance of surviving up to five years is increased about fourfold with early detection, which also allows for better treatment outcomes.
Andrew M. Lowy, M.D., Chief, Division of Surgical Oncology at the Moores Cancer Center at University of California San Diego Health, spoke with CURE magazine about current pancreatic cancer treatments and drugs that are being studied in clinical trials to better treat the disease.
“Pancreatic cancer is a complex disease,” said Dr. Lowey in the interview. “Patients (with pancreatic cancer) face several issues that range from managing their therapy, whether it be chemotherapy, radiation therapy or surgery, to managing other medical aspects.”
To help address these concerns, multiple healthcare professionals need to be involved in your cancer care. These multidisciplinary teams of professionals are more likely to be found at academic cancer centers that have expertise in treating pancreatic cancer. Pancreatic patients whose care is managed by a are likely to live an average of seven months longer than pancreatic patients who are not treated this way.
A may include the following health professionals:
|Gastroenterologist||Physician who treats the digestive system.||Dietician/ nutritionist||Provides guidance on foods/diets that are suitable for your condition.|
|Medical oncologist||Physician who treats cancer using .||Pathologist||Studies the cells, tissues and organs removed during a biopsy or surgery|
|Oncology nurses||Provides hands-on care, gives and helps with side effect management.||Genetic
|Determine need for and interprets genetic testing to assess your risk for inherited cancers.|
|nurses/providers||Provides treatment for cancer-related symptoms.||Radiation oncologist||Physician who prescribes and plans radiation therapy to treat cancer or symptoms.|
|Anesthesiologist||Physician who gives anesthesia, a medicine that prevents you from feeling pain during surgery.||Surgical
|Physician who performs operations to remove cancer.|
|Diagnostic radiologist||Physician who interprets results of x-rays and other imaging tests.||Mental health professionals (e.g., psychiatrists, psychologists, social workers)||Professionals who help manage issues such as depression, anxiety, or mental health conditions that affect how you feel emotionally.|
|Clinical Research Coordinator||Expertise in clinical research and clinical trials for new therapies||Oncology pharmacist||
Pharmacist with specialty training in optimizing medications to treat cancer and minimize side effects or medication interactions.
Pancreatic cancer is treated with multiple therapies, including surgery (partial or total removal of the pancreas) or chemotherapy. “Like all cancers, the treatment selection is based on ,” Dr. Lowy says. “However, what’s different about pancreatic cancer is because it’s such an aggressive disease, every patient essentially will get chemotherapy at some point in their care.”
Chemotherapy is a drug treatment that uses chemicals to kill fast-growing cancer cells. According to Dr. Lowy, the best outcomes for treating pancreatic cancer are achieved when people receive chemotherapy in addition to surgery. Chemotherapy can be given as therapy (before surgery) or as an therapy (after surgery).
In the past, chemotherapy was often prescribed only after surgery in patients with disease to kill any remaining cancer cells. However, Dr. Lowy explains, this traditional approach has many disadvantages. “The thing to understand is that pancreas surgery is very complex. Despite the fact that we’ve gotten better at it, it is associated with a high complication rate. [It can take patients time] to recover from the operation to be able to get their chemotherapy. And so, by giving chemotherapy before the operation, when people are still in good shape before they have to undergo a surgical recovery, it ensures that we get that chemotherapy delivered.”
Dr. Lowy also notes that for people whose cancer has spread beyond the pancreas (advanced cancer), giving chemotherapy before surgery can determine if they will be a good candidate for the operation. If chemotherapy is successful in getting rid of cancer in other areas of the body, then that person would be considered a good candidate for surgery. If not, then surgery would not be considered beneficial.
Currently, three standard chemotherapy regimens are used to treat newly diagnosed pancreatic cancer. These include FOLFIRINOX (a combination of folinic acid, 5-fluorouracil, irinotecan and oxaliplatin), a combination of gemcitabine and nanoparticle albumin bound (nab)-paclitaxel (Abraxane), and Lynparza (a targeted also called olaparib). FOLFIRINOX is intravenous and usually given to people who are in good health due to its associated side effects. Gemcitabine and Abraxane is also intravenous and typically has fewer/different side effects than FOLFIRINOX so is favored if the patient who are not as healthy. Lynparza is a pill but is only offered to those people whose cancer is due to underlying , or mutations.
Targeted and immunotherapies
Although not a focus in the CURE article, it’s important to note that newer, targeted therapies and immunotherapies may be available to treat certain types of pancreatic cancer. The olaparib (Lynparza) is approved for (after chemotherapy) for people with an inherited or mutation whose cancer responded to platinum chemotherapy.
Tumor testing should also be used to try to identify other possible treatments for pancreatic cancer. For example, tumors that have the traits of deficient mismatch repair () or are high () or have a high tumor mutation burden on genomic profiling may respond to a type of known as immune checkpoint inhibitors. Pembrolizumab (Keytruda) is an drug with approval for treating cancers regardless of what organ the cancer came from.
According to Dr. Lowy, more therapies to treat pancreatic cancer are being tested in current clinical trials than any other time in history, and these therapies span different drug classes. The therapies include immunotherapies (drugs that prompt that your immune cells to fight cancer), cancer metabolism drugs (drugs that block cancer cell growth by cutting it off its energy source) and targeted therapies (drugs that target specific genes or the genetic material of certain cancer cells).
“Some of these drugs may be approved as soon as 2022 if they show effectiveness in treating pancreatic cancer,” Lowey concludes. It is also important to consider that treatment of pancreatic cancer on a clinical trial, even if the clinical trial includes standard therapies, is associated with improved survival and other important clinical outcomes for patients. This is related to the extra attention to detail, coordinated services and expertise involved in treatment delivery on a clinical trial.
Some inherited mutations increase the risk of pancreatic cancer
Some inherited mutations, including , , , CDKN2A, , , and others, have been linked to an increased risk for pancreatic cancer.
The gene has been linked to an increased risk of pancreatic cancer. However, more research is needed to confirm whether a link exists between other genes (, , , ) and pancreatic cancer.
If you have been diagnosed with pancreatic cancer, it is important to be selective about the facility you choose to receive treatment. This will ensure that you get the most effective and up-to-date treatment regimen for your disease. It is important to speak with your doctor about all options that are available to you, including a , treatments, and any clinical trials that may be beneficial for your cancer care.
If pancreatic cancer runs in your family or you have an inherited mutation linked to pancreatic cancer risk, you should speak to experts in genetics and in pancreatic cancer detection to see if you qualify for pancreatic cancer screening or a clinical research study.
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- Kahl K, Know Your Options When It Comes to Pancreatic Cancer. The Cure. February 12, 2021.
- 16 Celebrities With Pancreatic Cancer. WebMD. May 23, 2021.
- Hoehn R, Rieser C, Winters S, et al. A Pancreatic Cancer Multidisciplinary Clinic Eliminates Socioeconomic Disparities in Treatment and Improves Survival. Ann Surg Oncol. 2021 May;28(5):2438-2446. Published online February 1, 2021
FORCE receives funding from industry sponsors, including companies that manufacture cancer drugs, tests and devices. All XRAYS articles are written independently of any sponsor and are reviewed by members of our Scientific Advisory Board prior to publication to assure scientific integrity.
National Comprehenvice Cancer Network (NCCN) Guidelines
The NCCN recommends the following screening for people at increased risk for pancreatic cancer:
- Discuss the benefits and risks of screening with their doctor. Screening should be performed by a facility that is experienced with screening for pancreatic cancer. The recommended age for considering screening depends on a person’s family history of pancreatic cancer and varies by type of gene mutation.
- Consider screening with magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic (EUS)
- Consider participating in a pancreatic cancer screening study
NCCN recommends that people with inherited mutations in the following genes (with or without a family history of cancer) "consider pancreatic cancer screening" with MRCP or EUS:
- : (): Consider pancreatic cancer screening by MRCP or EUS every 1-2 years beginning at age 30-35 or 10 years younger than the earliest pancreatic cancer in the family.
- CDKN2A: Consider pancreatic cancer screening beginning at age 40 or 10 years earlier than the earliest pancreatic cancer diagnosis in the family.
NCCN guidelines recommend that people with an inherited mutation in one of the following genes and a family history of cancer "consider pancreatic cancer screening" with MRCP or EUS beginning at age 50 or 10 years earlier than the earliest pancreatic cancer diagnosis in the family: , , , , , , , , .
NCCN does not currently recommend pancreatic cancer screening for people with the above mutations who do not have a family history of cancer.
American Society for Gastrointestinal Endoscopy (ASGE) Guidelines
In February 2022, the ASGE released updated guidelines on pancreatic cancer screening for people with a or mutation. These guidelines recommended:
- All patients with a mutation regardless of family history of pancreatic cancer, should undergo annual screening for pancreatic cancer with MRI/MRCP or EUS beginning at age 50 (or 10 years earlier than the earliest pancreatic cancer in the family).
The National Comprehensive Cancer Network (NCCN) recommends the following for people diagnosed with pancreatic cancer:
- Receive treatment from a (MDT): Treatment decisions should involve an MDT that includes a team of doctors, healthcare workers, genetic counselors and mental health professionals who have expertise and experience with treating and addressing issues related to your type of cancer. MDTs are more likely to be found or affiliated with cancer centers that have experience in treating pancreatic cancer.
- Have tumors staged via imaging tests: is needed to plan and monitor your treatment. Imaging tests (e.g., tomography scans) are used to pancreatic cancer. The tests determine whether the tumor can be removed with surgery (resectable) if cancer has spread to nearby organs or (locally advanced) or has spread to other parts of the body (metastasized).
- Discuss with your healthcare team whether they recommend chemotherapy before and/or after your surgery.
- Have genetic testing, using a comprehensive gene panel for (this applies to anyone who is diagnosed with pancreatic cancer).
- Genetic testing results may be used in making treatment decisions.
- Have tumor testing (for people with locally advanced or pancreatic cancer).
- Tumor testing results can also be used in making treatment decisions.
- Keep a copy of all test results (online patient portals are a great way to access test results). This will come in handy during a second opinion, if necessary.
- Do I qualify for any pancreatic cancer clinical trials?
- How do I obtain tumor testing of my cancer to look for specific treatment options?
- Should I consider genetic testing for an inherited mutation?
- Given my family history, do I qualify for pancreatic cancer screening?
- Which healthcare professionals will be involved in my cancer care?
- Will surgery be beneficial for me?
- What side effects are associated with my cancer treatment(s)?
The following are studies looking at risk management for pancreatic cancer:
- NCT03250078: A Pancreatic Cancer Screening Study in Hereditary High-Risk Individuals. The main goal of this study is to screen and detect pancreatic cancer and precursor lesions in individuals with a strong family history or genetic predisposition to pancreatic cancer. Magnetic Resonance Imaging and Magnetic cholangiopancreatography (MRI/MRCP) will be utilized to screen for pancreatic cancer or precursor lesions.
- NCT02478892: Preliminary Evaluation of Screening for Pancreatic Cancer in Patients With Inherited Genetic Risk. The study is a , observational study evaluating the utility of endoscopic or for the identification of preneoplastic and neoplastic pancreatic lesions in patients at high risk for pancreatic cancer, specifically those with BRCA1/2, or mutations.
- NCT03568630: Blood Markers of Early Pancreas Cancer. Identifying biomarkers of early pancreatic ductal adenocarcinoma (PDAC) could facilitate screening for individuals at higher-than-average risk, expedite the diagnosis in individuals with symptoms and substantially improve an individual's chance of surviving the disease.
- NCT02206360: Pancreatic Cancer Early Detection Program (PCEDP). This is a study looking at esophageal as a screening for pancreatic cancer in high risk individuals.
- NCT03250078: A Pancreatic Cancer Screening Study in Hereditary High Risk Individuals. The goal is to screen for pancreatic cancer in individuals with a strong family history or genetic risk using Magnetic Resonance Imaging and Magnetic cholangiopancreatography (MRI/MRCP).
A number of other clinical trials for pancreatic cancer screening and prevention may be found here.
The following are studies enrolling people diagnosed with pancreatic cancer:
- NCT04229004: Precision Promise Platform Trial for Pancreatic Cancer. This study tests different treatments for pancreatic cancer.
- NCT04267939: ATR Inhibitor BAY 1895344 Plus Phase 1b Study in Advanced and Ovarian Cancer. This study will look at how well how well advanced respond to treatment with the BAY1895344 combined with the niraparib.
- NCT04493060: Treating Pancreatic Cancer with an Inherited or Tumor BRCA1/2 or Mutation with and Dostarlimab. This study looks at how well the and the drug dostarlimab work together in treating patients with pancreatic cancer, who have an inherited or tumor mutation in one of these genes: , , , , , or .
- NCT03337087: Treating Pancreatic, Colorectal, Gastroesophageal, or Biliary Cancer with Chemotherapy and This study will look at how the works with chemotherapy in treating patients with pancreatic, colorectal, gastroesophageal or biliary cancer. The study will measure the best dose and look at side effects with this combination of drugs.
- NCT04150042: A Study of Melphalan, BCNU, Vitamin B12b, Vitamin C and Stem Cell Infusion in People with Advanced Pancreatic Cancer and Mutations. This study will look at whether combining melphalan, BCNU, vitamin B12b and vitamin C, followed by autologous (self) bone marrow stem cell infusion, is safe and effective for treating people with advanced pancreatic cancer who have a or gene mutation.
- NCT04666740: Pembrolizumab and Olaparib for Pancreatic Cancer with or Exceptional Response to Platinum Chemotherapy. This is a study for people diagnosed with pancreatic cancer with a tumor test result called HRD-positive, or whose disease has responded well to first-line or second-line platinum therapy. The study will look at whether combining the drug pembrolizumab and the olaparib is a more effective treatment for this cancer than taking olaparib alone.
- NCT04858334: Olaparib or in Patients with Surgically Removed Pancreatic Cancer who have a , or Mutation (APOLLO). The purpose of EA2192 / APOLLO is to compare the usual approach (observation) to treatment for one year with a drug called olaparib, in patients with a , or mutation.
- NCT04657068: Treatment with ATR Inhibitor for Advanced or Solid Tumors. This study will look at how well a new oral known as an ATR inhibitor works on advanced or solid tumors with mutations in genes linked to damage repair. The study will look at response to treatment with the drug ART0380 in combination with the chemotherapy agent, gemcitabine.
A number of other clinical trials for people with pancreatic cancer can be found here.
The following are studies looking at treatment for people with advanced .
- NCT05169437: () in patients with inherited or tumor mutations in advanced (PAVO). PAVO is a Phase II study investigating if the study drug, a called , is safe and effective for certain people who have been diagnosed with an advanced solid tumor with either an inherited or tumor mutation.
- NCT02264678: Ascending Doses of Ceralasertib in Combination With Chemotherapy and/or Novel Anti Cancer Agents. This is a study of ceralasertib administered orally in combination with chemotherapy regimens and/or novel anti-cancer agents, to patients with advanced cancer. The study is enrolling people with inherited mutations including , , , , and people with tumors that are HRD-positive.
- NCT03162627: Selumetinib and Olaparib in . The goal of Phase 1 of this clinical research study is to find a tolerable dose combination of selumetinib and olaparib that can be given to people with advanced or recurrent . This study is open to people whose cancer stopped responding or progressed on PARP inhibitors.
- NCT04644068: Study of AZD5305 as Monotherapy and in Combination With Anti-cancer Agents in Patients With Advanced Solid Malignancies (PETRA). This research is designed to learn if treatment with a new , AZD5305, alone, or in combination with anti-cancer agents is safe, tolerable, and has anti-cancer activity in patients with advanced . The study is open to people who have previously been treated with PARP inhibitors.
- NCT04267939: ATR Inhibitor Plus Study in Advanced and Ovarian Cancer. This study will look at how well how well people with advanced respond to treatment with the BAY1895344 in combination with the . This study is open to people with inherited mutations in , , and others. Contact the study coordinator for information about eligilibity for people with mutations in other genes.
- NCT04657068: Treatment with ATR Inhibitor for Advanced or Solid Tumors. This study will look at how well a new oral known as an ATR inhibitor works on advanced or with mutations in genes linked to damage repair. This study is open to people who have an inherited or acquired or mutation or people with tumors that are HRD-positive. This study is open to people whose cancer stopped responding or progressed on PARP inhibitors.
- NCT04197713: Olaparib Combined with AZD1775, an Investigational for People with Advanced with Mutations in , , , or Others. This study is looking at how well the oral therapy AZD1775 works when combined with the Olaparib for treating advanced cancers in people with an inherited or tumor mutation in , , , or other genes or biomarkers. The study is open to people who have stopped responding or progressed after treatment with a .
The following organizations offer peer support services for people with, or at high risk for pancreatic cancer:
- FORCE peer support
- Our Message Boards allow people to connect with others who share their situation. Once you register, you can post on the Diagnosed With Cancer board to connect with other people who have been diagnosed.
- Peer Navigation Program will match you with a volunteer who shares your mutation and situation.
- Private Facebook Group
- Virtual and in-person support meetings
- Join a Zoom community group meeting.
- American Sign Language
- People of Color
- Let's Win PC
- The Healing NET Foundation is a nonprofit organization for people with neuroendocrine cancers.
- The Neuroendocrine Cancer Awareness Network (NCAN) is a non-profit organization dedicated to raising awareness of neuroendocrine cancer, providing support for caregivers and people with NETs.