NEW YORKAlthough it is often not possible to offer curative
treatment in pancreatic cancer, significant improvements have taken
place nonetheless, said Ephraim S. Casper, MD, chief medical
oncologist, Memorial Sloan-Kettering Cancer Center at St. Clares
Hospital, Denville, NJ.
Dr. Casper talked with pancreatic cancer patients during a Cancer
Care Inc. teleconference, providing them with information to help
them make informed decisions about their care.
One of the most important developments, he said, has
to do with screening for curative surgery. Even with todays
good quality CT scans, we cannot always fully determine the stage of
disease. Often a patient who has a mass that seems to be confined to
the pancreas on the CT scan turns out, in the operating room, to have
more extensive disease. The result is that one half to two
thirds of patients brought to the operating room for a
pancreatoduodenectomy cannot have it. To prevent this, many centers
are now using laparoscopy, endoscopic ultrasound, and MRIs, including
magnetic resonance cholangiopancreatograms.
In the past, pancreatoduodenectomy, also known as the Whipple
procedure, had a much higher mortality rate, he said. Mortality
used to be as high as 25% to 30%, even in skilled hands, which caused
many to say that no patient should have the operation, Dr.
Today, he said, mortality, in the hands of experienced surgeons who
perform more than 10 or 20 operations per year, runs from 3% down to
1%. So between the skills of the surgeon and the supportive
care provided by gastroenterologists and other health care
practitioners in intensive care units, we can get most patients who
need this operation through it, out of the hospital, and back to a
normal life, Dr. Casper said.
Due to the high rate of recurrence, patients usually get radiation
and chemotherapy after surgery, and many favor continuing
chemotherapy for as long as 6 or even 12 months after completion of
radiation, Dr. Casper said.
Even if all of the cancer cannot be removed, surgery may still
relieve some of the symptoms of pancreatic cancer. A bypass operation
to reduce blockage provides significant relief from nausea, vomiting,
and jaundice. Jaundice can also be alleviated in certain patients
through an endoscopic procedure in which a small tube is inserted to
unplug a blocked bile duct. If that is not possible, an
inter-ventional radiologist may be able to introduce a needle through
the abdominal wall into the liver and insert a tube to drain the
bile. Although the tube drains into an outside bag at first, the bag
can be placed inside later, Dr. Casper said.
Patients with localized pancreatic cancer too extensive for surgery
receive radiation and chemotherapy over a period of 5 to 7 weeks as
their primary treatment.
Adjuvant radiation and chemotherapy that can sometimes make curative
surgery possible is also under study, Dr. Casper said. This
remains experimental, but there are data from several centers
suggesting that patients not only can tolerate it but also can have
tumor shrinkage and even tumor disappearance prior to surgical
removal, he said.
Patients with advanced disease who cannot be helped by surgery or
radiation receive chemotherapy. For a long time, there was
really only one drug that was used in pancreas cancer,
5-fluorouracil, Dr. Casper said. It was never used alone,
but always in combination with other chemotherapy agents.
A series of trials starting around 1990 showed that patients treated
with gemcitabine (Gemzar) were more likely to have symptom relief
than patents treated with fluorouracil (see box ).
A Patient Responds to Gemcitabine
During the Cancer Care teleconference, Dr. Ephraim Casper told a
In 1990, we started working with gemcitabine [Gemzar] in
Gemcitabine is given on a weekly basis. When I saw the patient
The third week, the patient said, Doc, Im really
He was not the only person who experienced that kind of
Today, gemcitabine is probably considered the best standard
drug we have for pancreatic cancer, Dr. Casper said. It
certainly should be clear that it is not, by itself, an adequate
drug. I view it as a building block, and there are a number of
ongoing studies looking at gemcitabine combinationswith
radiation [see article below] or with new drugsfor patients who
have advanced pancreatic cancer.