Pancreatic Cancer

Chemotherapy for pancreatic cancer

Chemotherapy is the use of cytotoxic drugs to destroy cancer cells, because cancer cells are dividing quickly they are particularly susceptible to chemotherapy (as are bone marrow and gastrointestinal cells)

When is chemotherapy used for pancreatic cancer?
Chemotherapy can be used in various ways in the treatment of pancreatic cancer:

  • It may be given after surgery to try to eradicate any cancer cells that may have spread elsewhere in the body (‘micro-metastases’). This is called adjuvant chemotherapy and studies have shown that it can significantly improve survival.
  • If doctors cannot remove the cancer by surgery, or if it has been only partially removed or the cancer has spread to other parts of the body, chemotherapy can be used to try to shrink the tumour, relieve symptoms and prolong life. Whether or not chemotherapy is recommended depends on several factors, the main one being general fitness to cope with chemotherapy and its possible side effects.
  • It may also be given before surgery, with the aim of improving the successful removal of cancer. This is called pre-operative, or 'neoadjuvant' chemotherapy: it is not yet standard care for pancreatic cancer (clinical trials are looking into its effectiveness see Cancer Research UK for more details).
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What is the standard chemotherapy treatment?
Standard chemotherapy treatment for pancreatic cancer is intravenous gemcitabine given in combination with other chemotherapy drugs for those able to cope. Some oncologists combine it with capecitabine (a tablet form of fluorouracil). The ESPAC-4 clinical trial is looking at whether or not it is better to give people capecitabine as well as gemcitabine after surgery (see ‘Clinical trials’). Some researchers have recommended this combination as first line treatment for people whose pancreatic cancer is inoperable. More recently, a chemotherapy combination called FOLFIRINOX (leucovorin, 5-flourouracil, irinotecan and oxaliplatin), was compared to gemcitabine in patients with advanced pancreatic cancer and was shown to be more effective. However, the side effects are significant, so this regimen is only likely to be an option for patients who are feeling well despite their cancer and are prepared to accept a higher risk of treatment related complications. Gemcitabine is usually given alone for those who are less fit.
Most people we interviewed had the standard treatment of intravenous gemcitabine with or without tablets of capecitabine. Gemcitabine was given once a week for three weeks followed by a week’s rest from treatment (this is called a 'cycle' of treatment). Those who were taking capecitabine took the tablets every day for the first three weeks of each cycle. Having no treatment in the fourth week allows the body and blood cells time to recover before the next treatment. An allergic reaction after Maureen’s first treatment delayed her second treatment. Treatment typically lasts for six cycles with regular check-ups but some people had less. For instance, Adrian’s condition deteriorated, so chemotherapy was abandoned after only one cycle.

However, some people had other drugs. For example, Alison had gemcitabine with cisplatin, and David (Interview 09) had fluorouracil. Peter (Interview 36), who had a neuroendocrine tumour, which is rare, had three chemotherapy drugs' streptozocin, fluorouracil and adriamycin. His doctor had to import the streptozocin from the United States because it is not licensed in the UK. It can be used only in a few people whose specialists think that it may help them. This special arrangement is called named-patient prescribing. Peter received daily chemotherapy as a hospital in-patient for a week each month for three months - the rest of the time he was at home.

Nab-paclitaxel (Abraxane) is also sometimes given for advanced pancreatic cancer in combination with gemcitabine. The National Institute of Health and Care Excellence (NICE) September 2017 has recommended its use in certain circumstances:

  • other combination chemotherapies are unsuitable and they would otherwise have gemcitabine monotherapy and
  • the company provides nab‑paclitaxel with the discount agreed in the patient access scheme.

The Scottish Medicines Consortium (SMC) had already recommend its use on the NHS in Scotland. 

Recent research studies have also shown that pancreatic cancer can be split into four unique types (known as stable, locally rearranged, scattered and unstable* and it was shown that some of the people with the ‘unstable’ type of pancreatic cancer benefited from being given platinum-based chemotherapy drugs (such as cisplatin) typically used for testicular or ovarian cancer but not normally given for pancreatic cancer.** Further research into this is planned.

How is chemotherapy given?
Most chemotherapy drugs are given intravenously (injected into a vein in the arm or back of the hand) usually via a cannula (a tiny flexible tube that is inserted into a vein which can be used to take blood or give medicines) which stays in until the treatment is over. Some chemotherapies  are given as tablets. Gemcitabine is given intravenously. Some people dreaded having intravenous chemotherapy because the nurses sometimes found it difficult to put the needle or cannula into a vein. One man said that his veins ‘went into hiding’ when he went for his chemotherapy and it took nurses three or four attempts before they found a vein. Carol also said that she ‘hated those needles’.

If it is hard to find a vein a ‘central line’ or ‘portacath’ can be fitted to give chemotherapy and other treatments and take blood samples. These are tubes that go into one of the major blood vessels, and which can remain in place for however many months the person is receiving treatment. The end of a ‘central line’ may hang out onto the chest wall and is visible. The external part of the line is secured under a plastic dressing and a small clip is attached to the skin by a couple of stitches. Alison had her chemotherapy via a type of central line called a Groshong line (see ‘Radiotherapy and chemoradiotherapy’). A portacath is a small chamber that sits under the skin at the end of the ‘central line’ so it does not stick out or is as visible as a central line. When a person needs treatment, the nurse puts a needle into the chamber, through the skin, and gives an injection or attaches a drip. Rory, a woman we interviewed, recommended having a portacath.

Starting chemotherapy
The people we interviewed usually had a choice about whether or not they should start chemotherapy. Some people said that their doctors had made all the treatment decisions and that that was fine, but others wanted to be more involved in decision making.

Those who had been offered chemotherapy to shrink the tumour to make surgery possible (neoadjuvant chemotherapy) were keen to have it because it seemed to be the only option. People who had already had surgery usually had chemotherapy without questioning the decision because their doctors usually recommended it, but a few people, like Ann, were very reluctant to start treatment (see below). Tony said he had been frightened because he didn’t know what chemotherapy involved. The people who had inoperable cancer, or who had had a recurrence, often had chemotherapy to alleviate symptoms, or as part of a clinical trial. Some felt that they lacked enough information to make an informed decision (see ‘Finding information’). A few decided to discontinue treatment or decided not to have any treatment at all because their doctor had told them that the side effects might outweigh any benefits.

A scan is often undertaken before chemotherapy treatment starts to act as a baseline measure so doctors can evaluate the effects of treatment by comparing it with later scans. Before each intravenous chemotherapy infusion people had blood tests to check that their blood (red and white cells and platelets) was healthy enough to withstand the drugs, and some had also had their blood pressure and body weight checked.

Most people had their chemotherapy in an NHS outpatient clinic, but a few people had private treatment and had their own room, even as an outpatient.

People having chemotherapy usually spend several hours in the clinic, including seeing a nurse or doctor, having tests and waiting for the drugs to be prepared before having the treatment itself. Most people described the atmosphere in the clinic as ‘pleasant’ and said the nurses were excellent and tried to make them feel relaxed. Some mentioned comfortable arm chairs, books to read, DVDs to watch, and access to refreshments. Chatting to other people who were also having treatment was a pleasure for some and could be a source of support.

However, others had felt uncomfortable sharing their treatment sessions with large numbers of other people, and didn’t want to chat to other people. Phil was shocked when he found himself in a room with 40 other people, and said that it was too impersonal having lots of different nurses looking after him within the same treatment session. Simon and his wife found the clinic rather depressing.

People who didn’t like the idea of having toxic drugs put into their body tried to look on the positive side – that it was intended to help them. Carol referred to her treatment as her ‘best friend’. After their treatment some people continued to associate certain smells with chemotherapy, such as a particular perfume worn by a nurse.

People often experienced side effects of treatment (see ‘Side effects of chemotherapy’). More information about chemotherapy and about ‘central lines’ and portacaths can be found at Macmillan Cancer Support.  

*International Cancer Genome Consortium (ICGC) – a global project which aims to read, analyse and understand the genetic make-up of different cancers.
** Waddell, N., et al. (2015). Whole genomes redefine the mutational landscape of pancreatic cancer Nature, 518 (7540), 495-501 DOI: 10.1038/nature14169

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Last reviewed September 2018.
Last updated September 2018.



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