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Pancreatic Cancer

Radiotherapy and chemoradiotherapy for pancreatic cancer

Radiotherapy treats cancer by using high-energy radiation such as X-rays to destroy as many cancer cells as possible, while harming normal cells as little as possible. Radiotherapy maybe effective in treating pancreatic cancer but its precise role is still being determined. Clinical trials are taking place to define the most appropriate place of radiotherapy in pancreatic cancer treatment.
Radiotherapy may be given:
  • before surgery to try to shrink or slow the growth of the cancer and give doctors a greater chance of removing it all with surgery. This is called neo-adjuvant radiotherapy.
  • after surgery to try to reduce the chance of the cancer coming back. This is called adjuvant radiotherapy.
  • to shrink or slow the growth of the cancer for patients with localised, inoperable cancer (cancer that hasn't spread but can't be removed by surgery).
  • to help to relieve symptoms such as pain. This is called palliative radiotherapy.

A specialised form of stereotactic ablative radiotherapy (SABR) known as CyberKnife may be appropriate for some people with pancreatic cancer (see 'CyberKnife stereotactic ablative radiotherapy and its side effects')
 

A consultant explains why the use of radiotherapy in pancreatic cancer is controversial.

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A consultant explains why the use of radiotherapy in pancreatic cancer is controversial.

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The use of radiotherapy in pancreatic cancer is controversial. Some of this arose as a result of, a surprising result in the ESPAC one study, performed in the late nineteen nineties, where patients who have radiotherapy following resection of pancreatic cancer actually did not so well as those that did not have the radiotherapy. 
 
On the other side of the Atlantic in America, however, there is a groundswell of opinion that using a multi-modal approach of chemotherapy, radiotherapy plus or minus surgery is the mainstay of their treatment programmes. And within the UK there are a number of studies looking at the role of radiotherapy in the patient who has not presented early enough to consider surgery, so in a palliative setting. At present, there is insufficient evidence to be dogmatic as to whether radiotherapy is the correct type of treatment to be used in pancreatic cancer but it’s certainly an area where a lot of work is being done on at present.
 
Elaine had surgery followed by radiotherapy. Her doctor had ‘persuaded’ her to have the treatment to reduce the likelihood of recurrence. Doctors diagnosed her cancer in 1995, before it became more common to combine chemotherapy with radiotherapy. Recently doctors have found that the combined use of chemo- and radiotherapy has yielded better results because the chemotherapy sensitises the tumour cells to the radiotherapy. This combined treatment is known as chemoradiotherapy (or chemoradiation).
 

After her surgery Elaine had radiotherapy. She felt a bit nauseated and tired but had no other...

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After her surgery Elaine had radiotherapy. She felt a bit nauseated and tired but had no other...

Age at interview: 73
Sex: Female
Age at diagnosis: 59
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Do you mind just saying a little bit more about your experience of radiotherapy?
 
I don’t mind at all. You know, it, it’s not really, as long as they’ve done the mapping properly and everything else. I had it done from there, there, I’ve got three, three little …
 
Stencils?
 
Stencils. And I had to go and, you know, usually the appointments were not too long. This is all N-, NHS, needless to say. I mean from the start to the finish it was all NHS, and they, and then they’re very good with, with serious things, I think. And you just lie on the table and these great big things come and it goes that way first or that way first through the splenetic area, then straight down and this way. And it didn’t actually bother me very much. But the radiotherapist was passing by one day and he said, quite late on in the treatment, and he said, “Oh, you know, you seem to be standing up to the treatment quite well. You’re not exactly fading away, Elaine.” And I said, “No, I don’t do fade away.” [laugh]. And so even though I was nauseated, it didn’t seem to affect me very much. Because apparently it, going through the liver in particular is, it can be quite unpleasant for some people. But I just sort of thought, “Well, it’s part of the fight” and…
 
And you had that every day?
 
Do you know, again one forgets. …I did get more tired. And I’d find, it was in the summer and I was sitting on the, on the veranda and I’d find myself fast asleep.
 
The other people we interviewed (who had had radiotherapy) all had chemotherapy at the same time. One had this combined treatment to try to shrink his tumour because his doctors hoped it would make surgery possible. Others had it after surgery, and a few as first line treatment for an inoperable tumour. The chemotherapy drugs that were used varied among them. Some had intravenous drugs such as gemcitabine; others had capecitabine chemotherapy tablets. A clinical trial called SCALOP aimed to find out which of these two drugs worked best with radiotherapy in people with inoperable, locally advanced pancreatic cancer. It showed that capecitabine was safer and possibly more effective in combination with radiotherapy, but because few patients were allocated chemoradiotherapy in this study experts interpret these results with caution. (See ‘Chemotherapy’ for more about these drugs.)
 

Steve had neo-adjuvant chemoradiotherapy. His doctors wanted to shrink his tumour, hoping to make...

Steve had neo-adjuvant chemoradiotherapy. His doctors wanted to shrink his tumour, hoping to make...

Age at interview: 47
Sex: Male
Age at diagnosis: 47
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So in a very short space of time, just a matter of a week or so I was able to speak with the oncologist who recommended a treatment of, it’s actually called cisplatin, which is a chemotherapy drug which is administered through a drip and that was done, and it happens over the course of a whole day, you go into a day ward and you have the cisplatin through an infusion. And also an oral chemotherapy drug, one that I would have, I think it was three times a day with a meal, you’d swallow this big tablet. And at the same time each weekday I would go for radiotherapy. So that regime was outlined and that was over I think it was five or six weeks, this regime would take place.

So around yes six weeks after returning to the UK, I started this regime of chemo and radiotherapy and all the time in the back of my mind is, “I wonder if this Whipple’s operation is going to be a possibility.” The things on my mind to do with that were, I knew I had read that the, the prognosis for pancreatic cancer is very grim. The statistics say that you only have a two or three percent possibility of living beyond five years. That the headline statistics tell us that. Everybody’s different, so fortunately some people will live much longer than that. Others, their condition may have been caught quite late, and they may only have a matter of months, maybe even weeks to live. And I didn’t know which category I fell in of course.

 

After her surgery Alison had adjuvant chemotherapy. Then she had adjuvant chemoradiotherapy. She...

After her surgery Alison had adjuvant chemotherapy. Then she had adjuvant chemoradiotherapy. She...

Age at interview: 44
Sex: Female
Age at diagnosis: 41
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I’d gone six months, so we’re now into March. And I had a month off, and we went away on holiday. And came back from that and I was referred to a consultant clinical oncologist. And he prescribed for me roughly six weeks’ worth of chemoradiotherapy. Now that involved having a, a drug called 5FU in a pump which was attached to what’s called a Groshong line, which is a c-, a central line that, that goes into your chest and it delivers the chemotherapy on a 24/7 basis. So you’ve got the pump with you continually. And that was changed once a week in clinic. So, which actually I decided to do myself, because I couldn’t be bothered [laugh] to go back up to the, to the, the clinic to do, and I was given all the kit to do that in a sterile environment. But, yes, and, and included in that was daily sessions of radiotherapy, which are, which are actually done at the NHS unit locally, but as a private patient. 
 
What was the radiotherapy like?
 
It wasn’t painful at all. Beforehand I had to go in for some scans, so that they can perfectly align where they were going to focus the beam. And I had to have some mini tattoos put on me. And the radiotherapy went in three sides, so the middle and then the two sides. And I’ve got three nice little dots to show them where they were going to line the machine up. So it’s, it’s not quite a, a dragon or a butterfly or anything like that. And it, you certainly don’t notice it now. But the process itself, it was only for ten minutes but I had, I had to lie very, very still. And it’s amazing, when you’re trying to lie still you think about not moving and you can’t wait to move. And it’s, it’s really difficult. And, you know, it, it, it doesn’t hurt at all. And you just hear sort of the zapping and the clunking of the machine and, as it’s rotating around you. And that I found worse than the chemotherapy regime I’d been on. The side effects of that were mainly exhaustion.
 
 

Anthony’s wife, Martine, had inoperable pancreatic cancer. After the diagnosis she started...

Anthony’s wife, Martine, had inoperable pancreatic cancer. After the diagnosis she started...

Age at interview: 65
Sex: Male
Age at diagnosis: 56
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I think after that things moved fairly fast in that we were handed over to, from the surgeon to a radiologist, oncologist. And they said straightaway, “We’re going to move you to two things, you’re going to start a course of chemotherapy”, I think there’s a, there’s a drug that’s always used for, and called gemcitabine, “and also you’ll go onto radiotherapy”. 
 
And then we learnt all about the process of having planning, I think it’s called, where she had to go and have these little marks, little tattoos put on her. First when the word tattoo was used, we had visions of great big marks on her body, which she was a bit worried about, but they were only just dots actually.
 
And then she went for the planning and she had these tattoo marks so that when she was lying on the, the big machine with the radiotherapy, whatever it is, the gun, they knew exactly where to focus it so it was straight on the tumour, on the pancreas. 
 
And she never felt anything, during the sessions of radiotherapy. As the radiotherapy went on she got tireder and tireder, but how much was from the radiotherapy and how much was from the chemotherapy, we don’t know because it was joint.
 
People usually have radiotherapy as an out-patient. A clinical oncologist plans the radiotherapy carefully, often with the help of the radiologist. The patient has a “planning” CT scan in the radiotherapy department sometime before treatment starts.
 
The health professionals involved use laser beams and ink markings or skin tattoos to help set up the treatment fields accurately and to pinpoint the exact place where radiation is to be directed. These are just pinprick tattoos, difficult to see without knowing they are there. The radiographers then know where the tattoos should be in relation to the treatment couch so can set up the patient in exactly the same position each day. The planning physicists then work out the ideal beam directions to give the optimum (best) dose of radiotherapy to the tumour while avoiding important organs near the tumour.
 
After planning, the patient starts treatment which usually takes 5-10 minutes. Commonly people have therapy daily from Monday–Friday, with a rest at weekends. A curative course of treatment (radical) may last for 5-6 weeks while palliative treatment will be shorter. Treatment is painless, but Michael said he found the massive machine “rather intimidating”, and Peter (Interview 13) found it difficult to lie still on the table because it was uncomfortable - he had become very thin; he said he felt disorientated after treatment.
 
 

Richard had inoperable cancer. He had chemoradiotherapy. He described what it was like to have...

Richard had inoperable cancer. He had chemoradiotherapy. He described what it was like to have...

Age at interview: 59
Sex: Male
Age at diagnosis: 58
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And so with radiotherapy, the way in which that worked was again every Monday morning I would go in and receive a small dose of gemcitabine, in the hospital intravenously. 
 
Then each day I had, from Monday to Friday, I had to attend the hospital for my radiotherapy. In preparation I had a special scan done which located the tumour precisely, and worked out the as it were the various angles in which it was going to be attacked by the x-rays. And my body was marked in various critical positions which became like the daily target so that when I lay on the x-ray machine I was able to be lined up precisely to the millimetre, exactly to, to receive my radiotherapy.
 
And I had five weeks and three days, so I had 28 individual treatments. And each treatment only lasts about five minutes, but you in, in order to get the treatment you had to get undressed, and then get dressed. And I have to say it was very well organised. I was rarely kept waiting for more than ten/fifteen minutes, and sometimes I would sort of arrive on time for my appointment and almost go straight in. So I certainly couldn’t complain about my, my treatment at all there.
 
People experienced various side effects. It was not always clear which were due to the chemotherapy and which to the radiotherapy (see ‘Side effects of radiotherapy and chemoradiotherapy’). 

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Last reviewed September 2018.
Last updated September 2018.

 

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