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Pancreatic Cancer - Treatment
Last reviewed: 06.07.2025
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In approximately 80–90% of patients, the tumor is inoperable due to metastases or invasion of major vessels detected during diagnosis. Depending on the location of the tumor, the surgery of choice is most often the Whipple procedure (pancreaticoduodenectomy). Additional therapy with 5-fluorouracil (5-FU) and external beam radiation therapy is usually prescribed, resulting in a survival rate of approximately 40% at 2 years and 25% at 5 years. This combination therapy for pancreatic cancer is also used in patients with limited but inoperable tumors and results in a median survival of approximately 1 year. Newer agents (eg, gemcitabine ) may be more effective than 5-FU as a baseline chemotherapy, but no agent, alone or in combination, is more effective. Patients with liver or distant metastases may be offered chemotherapy as part of a trial program, but the outlook with or without treatment remains poor and some patients may choose the inevitable.
If an inoperable tumor causing gastroduodenal or biliary tract obstruction is detected during surgery or if these complications are expected to develop rapidly, double gastric and biliary drainage is performed to relieve the obstruction. In patients with inoperable lesions and jaundice, endoscopic stenting of the biliary tract can resolve or reduce jaundice. However, in patients with inoperable lesions whose life expectancy is expected to be greater than 6-7 months, bypass anastomosis is advisable due to complications associated with stenting.
Symptomatic treatment of pancreatic cancer
Ultimately, most patients will suffer severe pain and die. Therefore, symptomatic treatment of pancreatic cancer is as important as radical treatment. Appropriate care for patients with a fatal prognosis should be considered.
Patients with moderate to severe pain should be given oral opioids in doses adequate to control pain. Concern about the development of tolerance should not be a barrier to effective pain control. In chronic pain, long-acting agents (eg, subcutaneous fentanyl, oxycodone, oxymorphone) are more effective. Percutaneous or intraoperative visceral (splanchnic) block allows effective pain control in most patients. In cases of intolerable pain, opioids are administered subcutaneously or intravenously; epidural or intrathecal administration provides additional effect.
If palliative surgery or endoscopic biliary stenting does not relieve pruritus due to mechanical jaundice, the patient should be given cholestyramine (4 g orally 1 to 4 times daily). Phenobarbital 30-60 mg orally 3-4 times daily may be effective.
In exocrine pancreatic insufficiency, porcine pancreatic enzyme tablets (pancrelipase) may be prescribed. The patient must take 16,000-20,000 units of lipase before each meal. If meals are prolonged (e.g., in a restaurant), the tablets should be taken during the meal. The optimal pH for enzymes inside the intestine is 8; for this reason, some clinicians prescribe proton pump inhibitors or H2 blockers. Monitoring for the development of diabetes mellitus and its treatment are necessary.
Forecast
The course of pancreatic cancer is progressive with increasing symptoms; if radical surgery has not been performed, the patient's life expectancy is on average 6-14 months from the moment of diagnosis.
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