Chemotherapy for pancreatic cancer

One of the most common treatments for pancreatic cancer is chemotherapy (using drugs to destroy cancer cells). For pancreatic cancer chemotherapy is used in several different ways:

  • before or after surgery to remove the cancer (resection)
  • when the cancer is localised but inoperable
  • when the cancer has spread beyond the pancreas to other parts of the body
  • on its own or in combination with radiotherapy.

Chemotherapy can be used in several different ways:

  • it can be given as a single agent or as a regimen containing two or three different chemotherapy agents
  • in combination with radiotherapy
  • in combination with targeted agents.

 

What is chemotherapy and how does it work?

Cytotoxic chemotherapy is the use of anti-cancer drugs to destroy cancer cells. Compared to normal healthy cells, cancer cells divide much more frequently and in an uncontrolled way, forming tumours. As the chemotherapy drugs circulate in the blood they damage and kill the dividing cancer cells.

Because chemotherapy is a systemic treatment, which means it works on the whole body, normal cells are also affected. This happens particularly in areas of the body where cells are constantly being replaced - such as hair, skin, bone marrow and the lining of the digestive system. This is why chemotherapy may cause side effects such as nausea, diarrhoea, hair loss, fatigue (extreme tiredness) and can make people more likely to pick up infections.

Most side effects can be well controlled and they usually disappear when chemotherapy treatment stops.

Different chemotherapy drugs are available and they can be used in a variety of ways depending on:

  • the type of cancer being treated
  • where it is in the body
  • how advanced it is
  • the general health and fitness of the person being treated.

The information in this section applies to all exocrine cancers, which make up 95% of all pancreatic cancers. The most common type of exocrine tumour is called pancreatic ductal adenocarcinoma.

People with rarer endocrine cancers (also known as neuroendocrine tumours NETs or pancreatic (P)NETs) may have different chemotherapy and drug treatment options open to them - you can find out more from the NET Patient Foundation.

 

How is chemotherapy given?

Chemotherapy can be given intravenously (as an infusion injected through a vein), orally (tablets) or a combination of both. It is normally given in 'cycles' - two, three or four weekly are the most common. There may be more than one dose of chemotherapy in each cycle. Intravenous chemotherapy is most often given as an outpatient in the hospital's chemotherapy unit. Sometimes it may be given as an inpatient, in the community or at home.

Your oncologist (cancer specialist) will work out the best chemotherapy drug(s), exact dosage and number of cycles for you. As everyone responds differently to chemotherapy patients are closely monitored  throughout their treatment.

 

Chemotherapy after surgery to remove cancer

If you have had surgery to completely remove your cancer  your oncologist will discuss with you the potential benefit of having chemotherapy afterwards. This form of chemotherapy is called adjuvant chemotherapy and the aim is to try to reduce the chances of the cancer coming back.

Following national guidelines the drugs most often used in this situation are gemcitabine or 5-fluorouracil (5-FU). Capecitabine is an oral chemotherapy drug that may be used instead of 5-FU. Clinical trials are trying to improve upon the outcome achieved using either gemcitabine or 5-FU after surgery. For example, the current trial called ESPAC-4 is comparing standard gemcitabine chemotherapy after surgery with a combination of gemcitabine and capecitabine (GemCap). Read more about ESPAC-4 and other clinical trials for pancreatic cancer.

When will chemotherapy be given?

You will need to be well recovered from your operation before starting chemotherapy treatment.

  • Any post-operative complications such as chest infections or bleeding need to have been resolved.
  • Your wound should be healed, with no signs of infection.
  • You should be able to eat and drink well and your bowels should be functioning normally
  • You need to be back to a reasonable level of normal activity and fitness.

The best time to start chemotherapy is within 2-3 months of surgery.

 

Chemotherapy for inoperable cancer

If you have locally advanced or advanced cancer (cancer that involves the structures around the pancreas or has spread to other parts of the body) surgery to remove the cancer will not be possible. However, chemotherapy can be used to relieve your symptoms and to try to shrink or slow down the growth of the cancer. Chemotherapy cannot cure the cancer but may help lengthen life and improve your quality of life.

The initial chemotherapy drug(s) received by a patient is called first-line therapy. The chemotherapy drug most often used in these circumstances is gemcitabine as clinical trials have shown that it is effective in controlling pancreatic cancer and improving symptoms. Gemcitabine may be given on its own or in combination with other chemotherapy drugs. In general, patients who are of good fitness may be considered for combination chemotherapy, whereas patients who are not very well may be considered for single agent chemotherapy with gemcitabine alone.

Other drugs and drug combinations are constantly being tested in clinical trials to see whether they give better results than gemcitabine. The results of some of these trials that have been completed are listed below.

  • Researchers found that the GemCap combination treatment (gemcitabine given with capecitabine) showed increased response rate and survival time over gemcitabine alone in advanced and metastatic disease when three trials were considered together. They recommended it should be considered as a first-line treatment option for advanced and metastatic disease.
  • A recent study found that a combination chemotherapy called FOLFIRINOX (leucovorin, 5-fluorouracil, irinotecan and oxaliplatin) increased survival time by an additional four months for people with advanced disease compared to gemcitabine treatment. The treatment did give rise to significantly greater side effects. It might be an option for people with advanced disease who are well enough and fit enough to cope with this intensive combination treatment.
  • A recent study found that nab-paclitaxel (Abraxane®) combined with gemcitabine showed increased response rate and survival time over gemcitabine alone in metastatic disease. Nab-paclitaxel aims to reduce the level of the enzyme that breaks down gemcitabine in tumour cells and so increase the gemcitabine level. This treatment is licensed for use in pancreaticcancer in the UK. It has been reviewed by the Cancer Drugs Fund (England only) and has been put on their list of priority treatments that can be funded whilst awaiting review by NICE to decide whether it will be approved for routine use by the NHS in England and Wales (Northern Ireland normally follows NICE advice). It is also scheduled to be to be reviewed by the Scottish Medicines Consortium (SMC) to decide if it will be approved for routine use by the NHS in Scotland. For information on how this treatment can be accessed through the Cancer Drugs Fund in England or how you might be able to access it in Northern Ireland, Scotland and Wales read our Abraxane FAQ. but it has not yet been appraised by NICE to decide whether it will be approved for routine use by the NHS. Read more about this drug on the Macmillan Cancer Support website.

So it is a good idea to talk to your specialist about other chemotherapy treatment options that may be available. You may also be eligible to take part in a clinical trial testing other chemotherapy drugs or chemotherapy combined with other treatments. You can ask your doctors if any suitable trials are taking place or read more about ongoing trials on our website.   

Second-line therapy

When a chemotherapy treatment stops working, different drugs may be used to try to control the disease for a bit longer. This is known as second-line therapy. Currently in the UK there is no standard second-line therapy for pancreatic cancer. However a recent clinical trial indicated that patients who have previously received gemcitabine may respond to a combination of oxaliplatin and 5-FU in the second line setting. This regimen is called FOLFOX and has been commonly used in advanced colorectal cancer.  There are fewer clinical trials of second-line chemotherapy, and early (phase 1) clinical trials and other clinical trials investigating novel agents may be considered if available. Read more about ongoing clinical trials investigating various potential treatments.

 

Other uses of chemotherapy

Occasionally chemotherapy is given before surgery, which is known as neo-adjuvant treatment. It is an emerging way of using chemotherapy to treat pancreatic cancer. The aim is to shrink the cancer to improve the chance of successful surgery, so it may be appropriate for someone who is a borderline candidate for surgery. The evidence for the success of this approach is still unclear, and it isn't widely used in the UK, but may be offered as an option within a clinical trial. 

Chemotherapy can also be used in combination with radiotherapy. The chemotherapy drug is given in the normal way, together with a daily dose of radiotherapy. This is known as chemo-radiation. The aim is for the chemotherapy drugs (and sometimes other drugs) to make the cancer cells more susceptible to radiotherapy.

One phase II trial (known as SCALOP) conducted in the UK looked at chemo-radiation for locally advanced pancreatic cancer.After four months of chemotherapy, chemo-radiation was given to patients whose disease had remained stable or was responding to treatment. The study showed that chemo-radiation given in this way is very well tolerated and the trial outcomes were encouraging in terms of survival in this patient group.

For more information read our information on radiotherapy.

 

Side effects of chemotherapy

Chemotherapy drugs do cause side effects, though everyone is affected in different ways. As a general rule, most people who have chemotherapy will get some side effects, but it is unusual for every person to get all the documented side effects. Side effects can also be altered when different chemotherapy drugs are combined.

You should let your oncology team know as soon as you start to experience any side effects as they can give you help and support to manage these. Most of the time side effects are manageable and medication may be given to counteract them. For example, you may be prescribed anti-sickness medication to combat nausea.  

Perhaps the most significant side effect is the impact on your blood count. This can result in anaemia; low platelets, leading to bleeding; or low white cell count (neutropenia) which makes your body more vulnerable to infections. You will have your blood count checked regularly while you are having chemotherapy. Occasionally someone may have a rare or undocumented side effect from their chemotherapy drug. If this happens, the medical team will do their best to treat it.

 

Further information on chemotherapy and pancreatic cancer in this section:

Main drugs used to treat pancreatic cancer

Follow up during treatment

Looking after yourself during chemotherapy

Chemotherapy and clinical trials

Targeted therapies

 

Questions

  • Will I have chemotherapy after my surgery?
  • Which chemotherapy drug(s) will work best for me?
  • What can I expect the chemotherapy to achieve?
  • What are the side effects of chemotherapy?
  • Will chemotherapy help control my cancer?
  • Will chemotherapy improve my quality of life?
  • Will chemotherapy extend my life?
  • Will chemotherapy relieve any of my symptoms?
  • Which hospital will I have this chemotherapy at?
  • Can I receive chemotherapy closer to where I live?
  • Are there any clinical trials involving chemotherapy I could take part in?
  • Can I go on holiday while having chemotherapy treatment?

 

Published October 2012

Review date September 2014