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. Casper commented.
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(Drug information on gemcitabine) (Gemzar) were more likely to have symptom relief than patents treated with fluorouracil(Drug information on fluorouracil) (see box ).
A Patient Responds to Gemcitabine
During the Cancer Care teleconference, Dr. Ephraim Casper told a story that should give hope to patients and physicians taking part in clinical trials.
In 1990, we started working with gemcitabine [Gemzar] in patients with metastatic pancreatic cancer who really didnt have any other therapeutic options. The first patient that I treated with the new agent was a man with liver metasta-ses who had significant pain. He said, Im willing to try anything if you think it will help.
Gemcitabine is given on a weekly basis. When I saw the patient the next week for his second dose of therapy, he said, Doc, Im better, but I did not really believe it, thinking the improvement was probably due to the placebo effect. I told him, Nothing the matter with that, and gave him the second dose.
The third week, the patient said, Doc, Im really better. In fact, he had experienced regression of his primary pancreatic mass and his liver metastases, and no longer required analgesics.
He was not the only person who experienced that kind of improvement. We also saw many patients who did not benefit from the drug, but many did seem to be stable for longer than we expected and to feel better than we might have expected. That gave rise to the larger randomized trial that led to FDA approval of gemcitabine.
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.