Treatment

Many people with pancreatic cancer want to take an active part in making decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, the shock and stress that people may feel after a diagnosis of cancer can make it hard for them to think of everything they want to ask the doctor. Often it helps to make a list of questions before an appointment. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some patients also want to have a family member or friend with them when they talk to the doctor-to take part in the discussion, to take notes, or just to listen.

Cancer of the pancreas is very hard to control with current treatments. For that reason, many doctors encourage patients with this disease to consider taking part in a clinical trial. Clinical trials are an important option for people with all stages of pancreatic cancer. The section on "The Promise of Cancer Research" has more information about clinical trials.

At this time, pancreatic cancer can be cured only when it is found at an early stage, before it has spread. However, other treatments may be able to control the disease and help patients live longer and feel better. When a cure or control of the disease is not possible, some patients and their doctors choose palliative therapy. Palliative therapy aims to improve quality of life by controlling pain and other problems caused by this disease.

The doctor may refer patients to an oncologist, a doctor who specializes in treating cancer, or patients may ask for a referral. Specialists who treat pancreatic cancer include surgeons, medical oncologists, and radiation oncologists. Treatment generally begins within a few weeks after the diagnosis. There will be time for patients to talk with the doctor about treatment choices, get a second opinion, and learn more about the disease.
Getting a Second Opinion

Before starting treatment, a patient may want a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient requests it. Gathering medical records and arranging to see another doctor may take a little time. In most cases, a brief delay to get another opinion will not make therapy less helpful.

There are a number of ways to find a doctor for a second opinion:

• The doctor may refer patients to one or more specialists. At cancer centers, several specialists often work together as a team.

• The Cancer Information Service (1-800-4-CANCER) can tell callers about treatment facilities, including cancer centers and other programs supported by the National Cancer Institute, and can send printed information about finding a doctor.

• A local medical society, a nearby hospital, or a medical school can usually provide the name of specialists.

• The American Board of Medical Specialties (ABMS) has a list of doctors who have met certain education and training requirements and have passed specialty examinations. The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their educational background. The directory is available in most public libraries.

Preparing for Treatment The doctor can describe treatment choices and discuss the results expected with each treatment option. The doctor and patient can work together to develop a treatment plan that fits the patient's needs. Treatment depends on where in the pancreas the tumor started and whether the disease has spread. When planning treatment, the doctor also considers other factors, including the patient's age and general health. These are some questions a person may want to ask the doctor before treatment begins: What is the diagnosis? Where in the pancreas did the cancer start? Is there any evidence the cancer has spread? What is the stage of the disease? Do I need any more tests to check whether the disease has spread? What are my treatment choices? Which do you recommend for me? Why? What are the expected benefits of each kind of treatment? What are the risks and possible side effects of each treatment? What is the treatment likely to cost? Is this treatment covered by my insurance plan? How will treatment affect my normal activities? Would a clinical trial (research study) be appropriate for me? People do not need to ask all of their questions or understand all of the answers at one time. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information. Methods of Treatment People with pancreatic cancer may have several treatment options. Depending on the type and stage, pancreatic cancer may be treated with surgery, radiation therapy, or chemotherapy. Some patients have a combination of therapies. Surgery may be used alone or in combination with radiation therapy and chemotherapy. The surgeon may remove all or part of the pancreas. The extent of surgery depends on the location and size of the tumor, the stage of the disease, and the patient's general health. Whipple procedure: If the tumor is in the head (the widest part) of the pancreas, the surgeon removes the head of the pancreas and part of the small intestine, bile duct, and stomach. The surgeon may also remove other nearby tissues. Distal pancreatectomy: The surgeon removes the body and tail of the pancreas if the tumor is in either of these parts. The surgeon also removes the spleen. Total pancreatectomy: The surgeon removes the entire pancreas, part of the small intestine, a portion of the stomach, the common bile duct, the gallbladder, the spleen, and nearby lymph nodes. Sometimes the cancer cannot be completely removed. But if the tumor is blocking the common bile duct or duodenum, the surgeon can create a bypass. A bypass allows fluids to flow through the digestive tract. It can help relieve jaundice and pain resulting from a blockage. The doctor sometimes can relieve blockage without doing bypass surgery. The doctor uses an endoscope to place a stent in the blocked area. A stent is a tiny plastic or metal mesh tube that helps keep the duct or duodenum open. After surgery, some patients are fed liquids intravenously (by IV) and through feeding tubes placed into the abdomen. Patients slowly return to eating solid foods by mouth. A few weeks after surgery, the feeding tubes are removed. These are some questions a person may want to ask the doctor before having surgery: What kind of operation will I have? How will I feel after the operation? How will you treat my pain? What other treatment will I need? How long will I be in the hospital? Will I need a feeding tube after surgery? Will I need a special diet? What are the long-term effects? When can I get back to my normal activities? How often will I need checkups? Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. A large machine directs radiation at the abdomen. Radiation therapy may be given alone, or with surgery, chemotherapy, or both. Radiation therapy is local therapy. It affects cancer cells only in the treated area. For radiation therapy, patients go to the hospital or clinic, often 5 days a week for several weeks. Doctors may use radiation to destroy cancer cells that remain in the area after surgery. They also use radiation to relieve pain and other problems caused by the cancer. These are some questions a person may want to ask the doctor before having radiation therapy: Why do I need this treatment? When will the treatments begin? When will they end? How will I feel during therapy? Are there side effects? What can I do to take care of myself during therapy? Are there certain foods that I should eat or avoid? How will we know if the radiation is working? Will I be able to continue my normal activities during treatment? Chemotherapy is the use of drugs to kill cancer cells. Doctors also give chemotherapy to help reduce pain and other problems caused by pancreatic cancer. It may be given alone, with radiation, or with surgery and radiation. Chemotherapy is systemic therapy. The doctor usually gives the drugs by injection. Once in the bloodstream, the drugs travel throughout the body. Usually chemotherapy is an outpatient treatment given at the hospital, clinic, doctor's office, or home. However, depending on which drugs are given and the patient's general health, the patient may need to stay in the hospital. Patients may want to ask these questions about chemotherapy: Why do I need this treatment? What will it do? What drugs will I be taking? How will they be given? Will I need to stay in the hospital? Will the treatment cause side effects? What can I do about them? How long will I be on this treatment?

Side Effects of Treatment

Because cancer treatment may damage healthy cells and tissues, unwanted side effects are common. These side effects depend on many factors, including the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. The health care team will explain possible side effects and how they will help the patient manage them.

The NCI provides helpful booklets about cancer treatments and coping with side effects, such as Radiation Therapy and You, Chemotherapy and You, and Eating Hints for Cancer Patients. See the sections called "National Cancer Institute Information Resources" and "National Cancer Institute Booklets" for other sources of information about side effects.

Surgery Surgery for pancreatic cancer is a major operation. Patients need to stay in the hospital for several days afterward. Patients may feel weak or tired. Most need to rest at home for about a month. The length of time it takes to regain strength varies. The side effects of surgery depend on the extent of the operation, the person's general health, and other factors. Most patients have pain for the first few days after surgery. Pain can be controlled with medicine, and patients should discuss pain relief with the doctor or nurse. The section on "Pain Control" has more information. Removal of part or all of the pancreas may make it hard for a patient to digest foods. The health care team can suggest a diet plan and medicines to help relieve diarrhea, pain, cramping, or feelings of fullness. During the recovery from surgery, the doctor will carefully monitor the patient's diet and weight. At first, a patient may have only liquids and may receive extra nourishment intravenously or by feeding tube into the intestine. Solid foods are added to the diet gradually. Patients may not have enough pancreatic enzymes or hormones after surgery. Those who do not have enough insulin may develop diabetes. The doctor can give the patient insulin, other hormones, and enzymes. The section "Nutrition for Cancer Patients" has more information.

Radiation Therapy

Radiation therapy may cause patients to become very tired as treatment continues. Resting is important, but doctors usually advise patients to try to stay as active as they can. In addition, when patients receive radiation therapy, the skin in the treated area may sometimes become red, dry, and tender.

Radiation therapy to the abdomen may cause nausea, vomiting, diarrhea, or other problems with digestion. The health care team can offer medicine or suggest diet changes to control these problems. For most patients, the side effects of radiation therapy go away when treatment is over.
Chemotherapy

The side effects of chemotherapy depend mainly on the drugs and the doses the patient receives as well as how the drugs are given. In addition, as with other types of treatment, side effects vary from patient to patient.

Systemic chemotherapy affects rapidly dividing cells throughout the body, including blood cells. Blood cells fight infection, help the blood to clot, and carry oxygen to all parts of the body. When anticancer drugs damage healthy blood cells, patients are more likely to get infections, may bruise or bleed easily, and may have less energy. Cells in hair roots and cells that line the digestive tract also divide rapidly. As a result, patients may lose their hair and may have other side effects such as poor appetite, nausea and vomiting, diarrhea, or mouth sores. Usually, these side effects go away gradually during the recovery periods between treatments or after treatment is over. The health care team can suggest ways to relieve side effects.
Pain Control

Pain is a common problem for people with pancreatic cancer. The tumor can cause pain by pressing against nerves and other organs.

The patient's doctor or a specialist in pain control can relieve or reduce pain in several ways:

• Pain medicine -- Medicines often can relieve pain. (These medicines may make people drowsy and constipated, but resting and taking laxatives can help.)

• Radiation -- High-energy rays can help relieve pain by shrinking the tumor.

• Nerve block -- The doctor may inject alcohol into the area around certain nerves in the abdomen to block the feeling of pain.

• Surgery -- The surgeon may cut certain nerves to block pain.

The doctor may suggest other ways to relieve or reduce pain. For example, massage, acupuncture, or acupressure may be used along with other approaches to help relieve pain. Also, the patient may learn relaxation techniques such as listening to slow music or breathing slowly and comfortably.

Nutrition

People with pancreatic cancer may not feel like eating, especially if they are uncomfortable or tired. Also, the side effects of treatment such as poor appetite, nausea, or vomiting can make eating difficult. Foods may taste different. Nevertheless, patients should try to get enough calories and protein to control weight loss, maintain strength, and promote healing. Also, eating well often helps people with cancer feel better and have more energy.

Careful planning and checkups are important. Cancer of the pancreas and its treatment may make it hard for patients to digest food and maintain the proper blood sugar level. The doctor will check the patient for weight loss, weakness, and lack of energy. Patients may need to take medicines to replace the enzymes and hormones made by the pancreas. The doctor will watch the patient closely and adjust the doses of these medicines.

The doctor, dietitian, or other health care provider can advise patients about ways to maintain a healthy diet. Patients and their families may want to read the National Cancer Institute booklet Eating Hints for Cancer Patients, which contains many useful suggestions and recipes. The "National Cancer Institute Booklets" section tells how to get this publication.