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Pancreatic Cancer Treatment (PDQ®): Treatment - Health Professional Information [NCI]Purpose of This PDQ SummaryThis PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of pancreatic cancer. This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board. Information about the following is included in this summary:
This summary is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions. Some of the reference citations in the summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations. Based on the strength of the available evidence, treatment options are described as either "standard" or "under clinical evaluation." These classifications should not be used as a basis for reimbursement determinations. This summary is also available in a patient version, written in less technical language, and in Spanish. General InformationNote: Information on pancreatic cancer in children is available in the PDQ summary on Unusual Cancers of Childhood. Note: Estimated new cases and deaths from pancreatic cancer in the United States in 2009:[1]
Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.) Carcinoma of the pancreas has had a markedly increased incidence during the past several decades and ranks as the fourth leading cause of cancer death in the United States. Despite the high mortality rate associated with pancreatic cancer, its etiology is poorly understood.[2] Cancer of the exocrine pancreas is rarely curable and has an overall survival (OS) rate of less than 4%.[3] The highest cure rate occurs if the tumor is truly localized to the pancreas; however, this stage of the disease accounts for fewer than 20% of cases. For those patients with localized disease and small cancers (<2 cm) with no lymph node metastases and no extension beyond the capsule of the pancreas, complete surgical resection can yield actuarial 5-year survival rates of 18% to 24%.[4][Level of evidence: 3iA] Improvements in imaging technology, including spiral computed tomographic scans, magnetic resonance imaging scans, positron emission tomographic scans, endoscopic ultrasound examination, and laparoscopic staging can aid in the diagnosis and the identification of patients with disease that is not amenable to resection.[5] In a case series of 228 patients, positive peritoneal cytology had a positive predictive value of 94%, specificity of 98%, and sensitivity of 25% for determining unresectability.[6] For patients with advanced cancers, the OS rate of all stages is less than 1% at 5 years with most patients dying within 1 year.[7,8,9,10] No tumor-specific markers exist for pancreatic cancer; markers such as serum CA 19-9 have low specificity. Most patients with pancreatic cancer will have an elevated CA 19-9 at diagnosis. Following or during definitive therapy, the increase of CA 19-9 levels may identify patients with progressive tumor growth.[11][Level of evidence: 3iDiii] The presence of a normal CA 19-9, however, does not preclude recurrence. Patients with any stage of pancreatic cancer can appropriately be considered candidates for clinical trials because of the poor response to chemotherapy, radiation therapy, and surgery as conventionally used. Palliation of symptoms, however, may be achieved with conventional treatment. Symptoms caused by pancreatic cancer may depend on the site of the tumor within the pancreas and the degree of involvement. Palliative surgical or radiologic biliary decompression, relief of gastric outlet obstruction, and pain control may improve the quality of life while not affecting OS.[12,13] Palliative efforts may also be directed to the potentially disabling psychological events associated with the diagnosis and treatment of pancreatic cancer.[14] (Refer to the PDQ summary on Pain for more information.) Information about ongoing clinical trials is available from the NCI Web site. References:
Cellular ClassificationPancreatic cancer includes the following carcinomas: Malignant
Borderline Malignancies
References:
Stage InformationThe staging system for pancreatic exocrine cancer continues to evolve. The importance of staging beyond that of resectable and unresectable is uncertain since state-of-the-art treatment has demonstrated little impact on survival. To communicate a uniform definition of disease, however, knowledge of the extent of the disease is necessary. Cancers of the pancreas are commonly identified by the site of involvement within the pancreas. Surgical approaches differ for masses in the head, body, tail, or uncinate process of the pancreas. The American Joint Committee on Cancer (AJCC) has designated staging by TNM classification.[1] TNM Definitions Primary tumor (T)
Regional lymph nodes (N)
Distant metastasis (M)
AJCC Stage Groupings Stage 0
Stage IA
Stage IB
Stage IIA
Stage IIB
Stage III
Stage IV
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Treatment Option OverviewNote: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.) The survival rate of patients with any stage of pancreatic exocrine cancer is poor. Clinical trials are appropriate alternatives for treatment of patients with any stage of disease and should be considered prior to selecting palliative approaches. To provide optimal palliation, determination of resectability must be made. Staging studies for resectability include helical computed tomographic scan, magnetic resonance imaging scan, and endoscopic ultrasound. The introduction of minimally invasive techniques, such as laparoscopy and laparoscopic ultrasound, may decrease the use of laparotomy.[1,2] Surgical resection remains the primary modality when feasible since, on occasion, resection can lead to long-term survival and provides effective palliation.[3,4,5][Level of evidence: 3iA] The role of postoperative therapy (chemotherapy with or without chemoradiation therapy) in the management of this disease remains controversial because much of the randomized clinical trial data available are statistically underpowered and provide conflicting results.[6,7,8,9,10] Frequently, malabsorption caused by exocrine insufficiency contributes to malnutrition. Attention to pancreatic enzyme replacement can help alleviate this problem. (Refer to the PDQ summary on Nutrition in Cancer Care for more information.) Celiac axis (and intrapleural) nerve blocks can provide highly effective and long-lasting control of pain for some patients. (Refer to the PDQ summary on Pain for more information.) Information about ongoing clinical trials is available from the NCI Web site. References:
Stage I and II Pancreatic CancerNote: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.) Approximately 20% of patients present with pancreatic cancer amenable to local surgical resection, with operative mortality rates of approximately 1% to 16%.[1,2,3,4,5] Using information from the Medicare claims database, a national cohort study of more than 7,000 patients undergoing pancreaticoduodenectomy between 1992 and 1995 revealed higher in-hospital mortality rates at low-volume hospitals (<1 pancreaticoduodenectomy per year) versus high-volume hospitals (>5 per year) (16% vs. 4%, respectively, P < .01).[1] Complete resection can yield 5-year survival rates of 18% to 24%, but ultimate control remains poor because of the high incidence of both local and distant tumor recurrence.[6,7,8][Level of evidence: 3iA] The role of postoperative therapy (chemotherapy with or without chemoradiation therapy [CRT]) in the management of this disease remains controversial because much of the randomized clinical trial data available are statistically underpowered and provide conflicting results.[9,10,11,12,13] Three phase III trials examined the potential overall survival (OS) benefit of postoperative adjuvant 5-fluorouracil (5-FU)-based CRT. A small randomized trial conducted by the Gastrointestinal Study Group (GITSG) in 1985 demonstrated a significant but modest improvement in median-term and long-term survival over resection alone with postoperative bolus 5-FU and regional split course radiation given at a dose of 40 Gy.[9][Level of evidence: 1iiA];[10][Level of evidence: 2A] An attempt by the European Organization for the Research and Treatment of Cancer to reproduce the results of the GITSG trial failed to confirm a significant benefit for adjuvant CRT over resection alone;[11][Level of evidence: 1iiA] however, this trial treated patients with pancreatic as well as periampullary cancers (with a potential better prognosis). A subset analysis of the patients with primary pancreatic tumors indicated a trend towards improved median, 2-year, and 5-year OS with adjuvant therapy compared with surgery alone (17.1 months, 37% and 20% vs. 12.6 months, 23% and 10%, P = .09 for median survival). An updated analysis of a subsequent European Study for Pancreatic Cancer (ESPAC 1) trial examined only patients who underwent strict randomization following pancreatic resection. The patients were assigned to one of four groups (observation, bolus 5-FU chemotherapy, bolus 5-FU CRT, or CRT followed by additional chemotherapy). With a 2 × 2 factorial design reported, at a median follow-up of 47 months, a median survival benefit was observed for only the patients who received postoperative 5-FU chemotherapy. These results were difficult to interpret, however, because of a high rate of protocol nonadherence and the lack of a separate analysis for each of the four groups in the 2 x 2 design.[12,13,14][Level of evidence: 1iiA] The United States Gastrointestinal Intergroup has reported the results of a randomized phase III trial (RTOG-9704) that included 451 patients with resected pancreatic cancers who were assigned to receive either postoperative infusional 5-FU plus infusional 5-FU and concurrent radiation or adjuvant gemcitabine plus infusional 5-FU and concurrent radiation.[15] The primary endpoints were OS for all patients and OS for patients with pancreatic head cancers. The median OS for the 388 patients with pancreatic head tumors was 20.5 months in the gemcitabine arm versus 16.9 months in the 5-FU arm; 3-year survival was 31% versus 22%, respectively (P = .09; hazard ratio = 0.82; confidence interval [CI], 0.65-1.03). OS for all patients was not reported in the publication; however, median survival estimates extrapolated from the presented survival curve were approximately 19 months for the gemcitabine group and 17 months for the 5-FU group.[15][Level of evidence: 1iiA] Results have also been reported from CONKO-001, a multicenter phase III trial of 368 patients with resected pancreatic cancer who were randomly assigned to six cycles of adjuvant gemcitabine versus observation.[16] In contrast to the previous trials, the primary endpoint was disease-free survival (DFS). Median DFS was 13.4 months in the gemcitabine arm (95% CI, 11.4-15.3) and 6.9 months in the observation group (95% CI, 6.1-7.8; P < .001). However, there was no significant difference in OS between the gemcitabine arm (median 22.1 months, 95% CI, 18.4-25.8) and the control group (median 20.2 months, 95% CI, 17-23.4).[16][Level of evidence: 1iiDii] Although the available data do not resolve the controversy of the optimal adjuvant therapy strategy for patients with resected pancreatic cancer, the results of CONKO-001 and RTOG-9704 suggest that a gemcitabine-containing platform represents an appropriate choice for current management and may be considered as a building block for future clinical trials. Additional trials are still warranted to determine more effective adjuvant therapy for this disease. STANDARD TREATMENT OPTIONS:
TREATMENT OPTIONS UNDER CLINICAL EVALUATION:
Current Clinical Trials Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage I pancreatic cancer and stage II pancreatic cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria. General information about clinical trials is also available from the NCI Web site. References:
Stage III Pancreatic CancerNote: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.) Patients with stage III pancreatic cancer have tumors that are technically unresectable because of local vessel impingement or invasion by tumor. These patients may benefit from palliation of biliary obstruction by endoscopic, surgical, or radiological means.[1] Three trials attempted to look at issues of combined modality therapy versus radiation therapy alone (the Gastrointestinal Tumor Study Group's GITSG-9173 trial, the Eastern Cooperative Oncology Group's E-8282 trial, and the Federation Francophone de Cancerologie Digestive-Société Française de Radiothérapie Oncologie group's FFCD-SFRO trial ).[2,3,4] The three trials had substantial deficiencies in design or analysis. Until recently, the standard of practice has been to give chemoradiation therapy, and that was based on the first two studies; however, with the preliminary publication of the third study, standard practice has changed. Prior to the use of gemcitabine for patients with locally advanced or metastatic pancreatic cancer, investigators from the GITSG randomly assigned 106 patients with locally advanced pancreatic adenocarcinoma to receive external beam radiation therapy (EBRT) (60 Gy) alone or to receive concurrent EBRT (either 40 Gy or 60 Gy) plus bolus fluorouracil (5-FU).[2][Level of evidence: 1iiA] The study was stopped early when the chemoradiation therapy arms were found to have better efficacy. The 1-year survival was 11% for patients who received EBRT alone compared with 38% for patients who received chemoradiation with 40 Gy and 36% for patients who received chemoradiation with 60 Gy. After an additional 88 patients were enrolled in the combined modality arms, there was a trend toward improved survival with 60 Gy EBRT plus 5-FU, but the difference in time-to-progression and overall survival (OS) was not statistically significant when compared to the 40 Gy arm.[5] In contrast, investigators from the ECOG randomly assigned 114 patients to radiation therapy (59.4 Gy) alone or with concurrent infusional 5-FU (1,000 mg/m2 daily on days 2 through 5 and days 28 through 31) plus mitomycin (10 mg/m2 on day 2) and found no difference in OS between the two groups.[3] Whether chemoradiation therapy should be considered for patients with stage III pancreatic cancer is controversial. Preliminary results from a study of the FFCD-SFRO were presented in abstract form at the 2006 American Society of Clinical Oncology meeting.[4] Patients with locally advanced pancreatic cancer were randomly assigned to receive either concurrent chemoradiation therapy followed by gemcitabine or gemcitabine alone. The trial was halted because of poor accrual after 109 of the planned 176 patients were enrolled. In a preliminary report with a median 16-month follow-up, patients who received chemoradiation followed by gemcitabine had a median survival of 8.4 months versus 14.3 months for the group who received gemcitabine alone (stratified log-rank, P = .014). STANDARD TREATMENT OPTIONS:
TREATMENT OPTIONS UNDER CLINICAL EVALUATION:
Current Clinical Trials Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage III pancreatic cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria. General information about clinical trials is also available from the NCI Web site. References:
Stage IV Pancreatic CancerNote: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.) The low objective response rate and lack of survival benefit with current chemotherapy indicates clinical trials as appropriate treatment of all newly diagnosed patients. Occasional patients have palliation of symptoms when treated by chemotherapy with well-tested older drugs such as fluorouracil (5-FU). Gemcitabine has demonstrated activity in patients with pancreatic cancer and is a useful palliative agent.[1,2,3] A phase III trial of gemcitabine versus 5-FU as first-line therapy in patients with advanced or metastatic adenocarcinoma of the pancreas reported a significant improvement in survival among patients treated with gemcitabine (1-year survival was 18% with gemcitabine as compared with 2% with 5-FU, P = .003).[2][Level of evidence: 1iiA] A preliminary report, in abstract form, of a phase III trial ( CAN-NCIC-PA3) comparing gemcitabine alone versus the combination of gemcitabine and erlotinib (100 mg/day) in patients with advanced or metastatic pancreatic carcinomas showed that erlotinib modestly prolonged survival when combined with gemcitabine alone.[4] Differences in overall survival (OS) favored the erlotinib arm (hazard ratio = 0.81; 95% confidence interval, 0.67-0.97; P = .025). The corresponding median and 1-year survival rates for patients receiving erlotinib versus placebo were 6.37 months and 5.91 months, and 24% versus 17%, respectively.[4][Level of evidence: 1iiA] When 5-FU was added to gemcitabine and compared with gemcitabine alone, the median survival of patients with advanced or metastatic disease (6.7 months vs. 5.7 months, respectively, P = .09) was not significantly improved.[5][Level of evidence: 1iiA] STANDARD TREATMENT OPTIONS:
TREATMENT OPTIONS UNDER CLINICAL EVALUATION:
Current Clinical Trials Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage IV pancreatic cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria. General information about clinical trials is also available from the NCI Web site. References:
Recurrent Pancreatic CancerChemotherapy occasionally produces objective antitumor response, but the low percentage of significant responses and lack of survival advantage warrant use of therapies under evaluation.[1] STANDARD TREATMENT OPTIONS:
TREATMENT OPTIONS UNDER CLINICAL EVALUATION:
Current Clinical Trials Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with recurrent pancreatic cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria. General information about clinical trials is also available from the NCI Web site. References:
Get More Information From NCICALL 1-800-4-CANCER For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from 9:00 a.m. to 4:30 p.m. Deaf and hard-of-hearing callers with TTY equipment may call 1-800-332-8615. The call is free and a trained Cancer Information Specialist is available to answer your questions. CHAT ONLINE The NCI's LiveHelp® online chat service provides Internet users with the ability to chat online with an Information Specialist. The service is available from 9:00 a.m. to 11:00 p.m. Eastern time, Monday through Friday. Information Specialists can help Internet users find information on NCI Web sites and answer questions about cancer. WRITE TO US For more information from the NCI, please write to this address:
SEARCH THE NCI WEB SITE The NCI Web site provides online access to information on cancer, clinical trials, and other Web sites and organizations that offer support and resources for cancer patients and their families. For a quick search, use our "Best Bets" search box in the upper right hand corner of each Web page. The results that are most closely related to your search term will be listed as Best Bets at the top of the list of search results. There are also many other places to get materials and information about cancer treatment and services. Hospitals in your area may have information about local and regional agencies that have information on finances, getting to and from treatment, receiving care at home, and dealing with problems related to cancer treatment. FIND PUBLICATIONS The NCI has booklets and other materials for patients, health professionals, and the public. These publications discuss types of cancer, methods of cancer treatment, coping with cancer, and clinical trials. Some publications provide information on tests for cancer, cancer causes and prevention, cancer statistics, and NCI research activities. NCI materials on these and other topics may be ordered online or printed directly from the NCI Publications Locator. These materials can also be ordered by telephone from the Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237), TTY at 1-800-332-8615. Changes to This Summary (07 / 01 / 2009)The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above. GENERAL INFORMATION Updated statistics with estimated new cases and deaths for 2009 (cited American Cancer Society as reference 1). More InformationABOUT PDQ
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IMPORTANT: This information is intended mainly for use by doctors and other health care professionals. If you have questions about this topic, you can ask your doctor, or call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237). Date Last Modified: 2009-07-01
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