There is no way to sugarcoat the fact that pancreatic cancer is very difficult to treat. Only about 20 to 30 percent of cases are found early enough to treat surgically, before the cancer has spread, and surgery gives the only chance that this cancer can be eradicated, says Dr. Elizabeth M. Jaffee, the Dana and Albert “Cubby” Broccoli professor of oncology and deputy director of the Sidney Kimmel Comprehensive Cancer Center at the Johns Hopkins University School of Medicine. Even then, only about 20 percent of those patients can be cured, she says. This is because the pancreas has “natural barriers” to chemotherapy and radiation, and Jaffee explains that “it resists chemical destruction. And genetic data suggests [the cancer] starts to metastasize before you can detect it.”
Though a pancreatic cancer diagnosis is dire, treatments are improving, she says. “I believe in the next five to 10 years we will start to turn this into a chronic disease,” she says. Now, only 5 to 10 percent of patients have a long-term response to treatment; “we hope to turn that to 50 percent,” she says.
Treatment options for pancreatic cancer patients include:
— Chemotherapy and radiation therapy.
— Targeted therapy and immunotherapy.
— Clinical trials.
Pancreatic Cancer Surgery
Pancreatic cancer surgery has improved significantly over the past two decades, according to the Lustgarten Foundation. Surgery to remove a pancreatic tumor is complex to perform and difficult to undergo, but it is the only real option for curing pancreatic cancer. It is generally performed on patients who are in the early stages of the disease, and if the surgeon believes all of the cancer can be removed safely. On occasion, surgery may help patients in later stages by relieving pain or other symptoms.
The procedures used to remove pancreatic cancer are the Whipple procedure (pancreaticoduodenectomy), a total pancreatectomy and a distal pancreatectomy. The Whipple procedure, the most common surgery performed to remove tumors in the head of the pancreas, may include removing part of the stomach, small intestine, gall bladder and other structures. In a total pancreatectomy, the entire pancreas is removed, along with the gallbladder, spleen, part of the duodenum, nearby lymph nodes and sometimes part of the stomach. A distal pancreatectomy, typically used when tumors are in the middle and tail of the pancreas, involves removing those parts of the pancreas and sometimes the spleen.
Chemotherapy and Radiation Therapy
There are several chemotherapy agents used to treat pancreatic cancer. The choice depends on overall health and the location and size of the tumor, as well as the genetic characteristics of the tumor that may make certain drugs better options. Usually, the patient receives a combination of drugs. In some cases, chemotherapy may shrink the tumor enough to give patients with locally advanced disease the option to try surgery.
Radiation therapy sends high-energy X-rays to tumors to kill cancer cells. Radiation and chemotherapy often occur at the same time, but radiation may also be used before or after completing chemotherapy.
Targeted Therapy and Immunotherapy
Targeted therapy, as its name implies, targets the genetic changes in cancer cells that cause them grow and spread. Targeted therapies typically use either small-molecule drugs or monoclonal antibodies. Small-molecule drugs are able to enter into cells and target structures inside them. Monoclonal antibodies are large molecules that attach to targets on the outside of cancer cells. These not only may directly attack the cancer cells, they can also mark the cells to trigger the patient’s immune system to join the attack.
This process is called immunotherapy. Cancer cells are often able to “hide” from the immune system. Immunotherapies try to stimulate the immune system to help the body fight cancer, along with infections and other diseases. Currently, the only immunotherapy approved for pancreatic cancer is pembrolizumab, or the drug named Keytruda. It has proved effective for about 1 in 50 advanced pancreatic cancer patients, according to the Lustgarten Foundation.
“The problem with immunotherapy is that it takes longer than chemotherapy to get a response. It can take three to six months, and advanced patients often don’t have that time,” Jaffee says. Research is underway to “accelerate the response,” she says. “We are learning how to combine radiation, chemotherapy and immunotherapy, but we don’t know how durable they are yet. In the next three to five years, we will know which work and how to make them better.”
Clinical Trials for Pancreatic Cancer
Clinical trials are leading the way to promising advances in care for pancreatic cancer patients. “We are seeing more and more clinical trials focusing on new and innovative treatments for pancreatic cancer,” says Cassadie Moravek, the Pancreatic Cancer Action Network’s associate director of clinical initiatives. Participating in a clinical trial may be the best treatment there is. “We know that pancreatic cancer patients who participate in clinical research have better outcomes,” she says.
The Pancreatic Cancer Action Network maintains a database of pancreatic cancer clinical trials and can provide information about clinical trials for patients. Still, progress is slow. Twenty years ago, the five-year survival rate was 4 percent, 10 years ago it was 5 percent, and today it is 9 percent, Moravek says. But it is progress nonetheless. “With improved treatments, we are seeing improved outcomes. Patients today not only have more standard of care treatment options available to them, but there are also many more clinical trials available to them. There has been about a 100 percent increase in median overall survival from Phase III clinical trials since 1999.”
Jaffee adds that studies are being designed with a better sense of urgency as well. “There is a new way we think about trials. We have to be quicker and more nimble, with smaller, more targeted studies so we can quickly modify it and make it better,” she says. “The technology used to study tumors has improved exponentially, and the whole culture of clinical trials for cancer patients has changed to become more patient-centric through the understanding of genetics. I am optimistic. I think we are on the verge of making a big difference in this cancer.”
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