Pancreatic Cancer Chemotherapy Drugs

Chemotherapy can be used to treat pancreatic cancer by slowing or stopping the growth of cancer cells within the body. Most chemotherapy drugs also have some effect on the growth of normal cells, and hence, can cause unwanted side effects. Not everyone will respond to chemotherapy treatment in the same way, and every patient is monitored during the course of therapy. Some chemotherapy drugs are given by injection into a vein, and others may be given as a tablet.

If your cancer has spread beyond the pancreas, chemotherapy can be used to relieve your symptoms and to try and shrink the disease. The chemotherapy will not cure the cancer but may help slow its growth for a period of time.

The drug used most commonly in this instance in the UK is gemcitabine. An important trial undertaken in the 1990’s demonstrated the benefit of gemcitabine chemotherapy in improving both symptom and disease control. Gemcitabine has NICE approval for use in the UK for locally advanced and metastatic pancreatic cancer.

Over recent years many trials have examined new treatments designed to improve on the results achieved with gemcitabine. A UK study called GEMCAP compared the standard therapy of gemcitabine to a combination of gemcitabine given with a chemotherapy tablet called capecitabine (GemCap). The GemCap combination treatment is being used for some patients by some centres in the UK, and is being used as the basis for future trials in the UK. See our page on trials for more information.

Other drug combinations have been studied such as the combination of erlotinib (Tarceva) and gemcitabine. Ongoing trials are taking place to test the impact of various combinations of gemcitabine, erlotinib and capecitabine together with other agents such as bevacizumab or vaccine therapies.

Other trials have investigated use of gemcitabine with platinum drugs (cisplatin and oxaliplatin) and some specialists use this drug combination.

It appears that drugs are more effective in some patients than others and it has been proposed that there should be studies to see if there are any factors to identify which patients are most likely to respond to particular drugs.

When a chemotherapy treatment stops working, alternative drugs may be used to try and further control the disease, this is called second-line therapy. Currently in the UK there is no standard second-line therapy, but trials are investigating various potential treatments. There is some evidence to suggest potential benefit from the use of oxaliplatin and 5-FU in patients who have previously received treatment with gemcitabine.

If your cancer has been totally removed by surgery you may be offered chemotherapy after surgery. This is to try to reduce the chances of the cancer coming back and is called adjuvant chemotherapy. A trial called ESPAC-1 showed that chemotherapy with 5FU after surgery can reduce the risk of the cancer coming back.

The follow up trial to ESPAC-1 called ESPAC-3 has recently completed recruitment. This trial is comparing 5FU with gemcitabine after surgery to see which drug is better at reducing the chances of the cancer coming back. (This trial is still open for patients with ampullary cancers).

Recently another trial has shown benefit from the use of gemcitabine after surgery compared to no treatment so it will be interesting to see the results of the important ESPAC-3 trial which compares 5FU and gemcitabine.

Most chemotherapy will have some side effects although these can usually be relieved providing you let your oncology team know as soon as these develop. Furthermore patients vary in terms of the side effects and the degree to which these affect them. Generally chemotherapy can make you feel tired and this means you have to do things at a slower pace. The specific side effects of gemcitabine and 5FU are given below as these are the drugs most commonly used in the UK for pancreatic cancer.

• Feeling sick or vomiting
• Swelling of ankles or feet or weight gain due to fluid retention
• Flu like symptoms
• Increased risk of infection
• Skin rash

• Diarrhoea
• Mouth ulcers
• Hair thinning or hair loss
• Suppression of the immune system and an increased risk of infection
• Reddening of the hands and feet

• gemcitabine(Gemzar)
• fluorouracil (5FU)
• capecitabine(Xeloda)
• Erlotinib(Tarceva)
• cisplatin
• oxaliplatin

see for example the US National Cancer Institute trials database and select pancreatic cancer

Information on chemotherapy for cancer of the pancreas from CancerHelp UK

NICE Guidance on use of gemcitabine

gemcitabine (NIH med-line)

gemcitabine from Eli Lilly

Metastatic Pancreatic Cancer: Emerging Strategies in Chemotherapy and Palliative Care Francois G. El Kamar, Michael L. Grossbard, Peter S. Kozuch from The Oncologist February 2003

ESPAC-3(v2) Phase III Adjuvant Trial in Pancreatic Cancer Comparing 5FU and D-L-Folinic Acid vs. Gemcitabine. Leeds, UK: National Cancer Research Network Trials Portfolio, 200

Phase III randomised comparison of gemcitabine (GEM) versus gemcitabine plus capecitabine (GEM-CAP) in patients with advanced pancreatic cancer ECCO abstract 2 Nov 2005, D. Cunningham, I. Chau, D. Stocken, C. Davies, J. Dunn, J. Valle, D. Smith, W. Steward, P. Harper, J. Neoptolemos

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M. J. Moore, D. Goldstein, J. Hamm, A. Figer, J. Hecht, S. Gallinger, H. Au, K. Ding, J. Christy-Bittel, W. Parulekar, ASCO 2005, Erlotinib plus gemcitabine compared to gemcitabine alone in patients with advanced pancreatic cancer. A phase III trial of the National Cancer Institute of Canada Clinical Trials Group [NCIC-CTG], Journal of Clinical Oncology, 2005 ASCO Annual Meeting Proceedings. Vol 23, No. 16S, Part I of II (June 1 Supplement), 2005: 1

Malcolm J. Moore,* David Goldstein, John Hamm, Arie Figer, Joel R. Hecht, Steven Gallinger, Heather J. Au, Pawel Murawa, David Walde, Robert A. Wolff, Daniel Campos, Robert Lim, Keyue Ding, Gary Clark, Theodora Voskoglou-Nomikos, Mieke Ptasynski, and Wendy Parulekar 2007 "Erlotinib Plus Gemcitabine Compared With Gemcitabine Alone in Patients With Advanced Pancreatic Cancer: A Phase III Trial of the National Cancer Institute of Canada Clinical Trials Group" JCO published April 23, 2007, 10.1200/JCO.2006.07.9525