The following chemotherapy drugs may be included as part of the treatment regimen

depending on the stage of pancreatic cancer:

• Gemcitabine (Gemzar): Gemcitabine is given intravenously once a week for 7

weeks (or until toxicity limits treatment), and then no treatment is given for 1

week. Then, cycles are resumed of gemcitabine once each week for 3 weeks in a

row followed by 1 week off. This drug has direct effects on the cancer cells and is

usually given alone for the treatment of metastatic pancreatic cancer. Side

effects include fatigue, nausea, increased risk of infection because of its effects

on the immune system, and anemia.

• Fluorouracil (5-FU): Fluorouracil is usually given intravenously as a continuous

infusion using a medication pump. This drug has direct effects on the cancer

cells and is usually used in combination with radiation therapy because it makes

cancer cells more sensitive to the effects of radiation. The side effects include

fatigue, diarrhea, mouth sores, and hand-and-foot syndrome (redness, peeling,

and pain on the palms of the hands and the soles of the feet).

• Capecitabine (Xeloda): Capecitabine is given orally and is converted by the body

to a compound similar to 5-FU. Capecitabine has similar effects on the cancer

cells as 5-FU and is also generally used in combination with radiation therapy.

Side effects are similar to intravenous continuous infusion of 5-FU.

Currently, many other drugs are being investigated for the treatment of pancreatic

cancer, generally in combination with gemcitabine. These drugs include bevacizumab,

vatalanib, cetuximab, and erlotinib. Whether any of these drugs will improve the results
obtained with gemcitabine alone is not yet known. Enrollment in clinical trials is

encouraged.

Medications are available to alleviate the side effects of the treatments. If side effects

occur, an oncologist should be notified so that they can be addressed promptly. An

oncologist also monitors blood and urine for signs of toxicity.

Pancrelipase (pancreatic enzyme replacement) may be given if the function of the

pancreas is impaired, usually after the surgical removal of a portion of the pancreas.

This oral medication is taken with meals to aid in the digestion of food and in the

prevention of steatorrhea.

Pain may be associated with pancreatic cancer, and a variety of pain medications exist

to help control any discomfort. Good communication with the oncologist and nurses

allows for optimal management of pain.

Chemotherapy for Pancreatic Cancer:

Chemotherapy involves the use of drugs that are either injected (given as a shot in a vein)
or infused (slowly given to the patient via an IV) into blood vessels or ingested by mouth.
These drugs then travel through the blood stream and reach cancer cells in the pancreas,
lymph nodes and those that have spread to distant sites. Though these drugs may kill some
cancer cells that are sensitive to its effect, chemotherapy is not able to entirely eliminate
the cancer. In advanced pancreatic cancer, chemotherapy has been shown to relieve
symptoms and improve survival when compared to the best supportive care or symptom
management only. Therefore, chemotherapy has become the standard and most often used
treatment for advanced pancreatic cancer. Prior to the middle 1990s, the most important
chemotherapy agent used in pancreatic cancer was intravenous 5-fluorouracil (5FU). This
drug has been used to treat many cancers for more than 40 years. In pancreatic cancer,
5FU was usually given either in a bolus injection or as a continuous infusion (> 24 hrs)
using an implanted catheter. However as its activity as a single agent was relatively low,
5FU was commonly used in combination with other chemotherapy agents. The two most
widely used combinations were 5FU and mitomycin C with either doxorubicin or
streptozotocin.

In May of 1996 the Food and Drug Administration (FDA) approved the intravenous drug
gemcitabine for use in patients with locally advanced or metastatic pancreatic cancer. This
approval was based on two clinical studies which used a measure called clinical benefit
response (CBR) to assess the effectiveness of the drug rather than the traditional use of
tumor shrinkage rate. CBR was determined by assessing the change in the need for pain
medications (analgesic consumption), pain intensity, weight and overall performance status
of patients receiving the drug. In the first study, 63 patients given gemcitabine had a CBR
of 23.8% as compared to 4.8% in 63 patients receiving 5FU. In the second study, 63
patients who had previously received 5FU based chemotherapy were treated with
gemcitabine and had a CBR of 27%. The major side effects of gemcitabine: lowering of the
blood counts, nausea, vomiting, rash and flu-like symptoms, were generally mild in intensity
and manageable. There are now a large number of patients who have been treated with
gemcitabine and the safety and tolerability of the drug remains excellent. Higher doses of
gemcitabine have been evaluated in pancreatic cancer but do not seem to improve upon
results. It does appear that there may be limited benefit to increasing the time (2-3 hrs)
over which the gemcitabine is delivered. This modest benefit needs to be weighed against
the extra time required and need for specialized infusion pumps. It has become apparent
that gemcitabine by itself helps only a minority of patients and therefore clinical
investigators continue to look for better options.

A large number of studies have been conducted to see if adding a second or third
chemotherapy agent to gemcitabine can improve upon the results. Some of the initial
studies added 5FU to gemcitabine in various doses and schedules. In general in these
combination studies, though there have been more patients whose tumor shrinks in
response to the combined treatment, the overall survival in these patients has not been
found to be significantly better. There has been more enthusiasm for combining gemcitabine
with other chemotherapy agents. One such drug is called cisplatin, and this has been
compared in combination with gemcitabine to gemcitabine alone. In these studies, patients
treated with the combination were noted to live on average 2 to 3 months longer, although
statistically this difference was not considered significant. The combination of gemcitabine
and cisplatin leads to a chance for increased side effects and this combination takes a longer
time to deliver and requires hydration with intravenous (IV) fluids before and after. Another
chemotherapy agent related to cisplatin and used in many other cancers of the
gastrointestinal tract is oxaliplatin. Oxaliplatin has fewer side effects then cisplatin and no
requirement for hydration. Gemcitabine combined with oxaliplatin has been studied and
again seems to improve the likelihood of the tumor responding to the treatment but so far
there has not been convincing evidence that the combination improves the overall survival
of all patients. Gemcitabine has been combined with other chemotherapy agents in addition
to those described above but until recently none have shown any significant improvements
in overall survival. In a recent preliminary report, investigators in Europe combined
gemcitabine with an oral form of 5FU called capecitabine. When compared with gemcitabine
by itself, patients treated with the combination lived longer and this result was said to be
statistically different than gemcitabine alone.

Chemotherapy Cycles

Chemo is typically given in cycles, with rest periods between the cycles. A cycle can last 1 or
more days. A cycle is typically given every 1, 2, 3, or 4 weeks. A typical course may consist of
multiple cycles.1

Receiving some chemotherapy drugs may take a relatively short period of time, while others may
take hours. It all depends on the treatment regimen that your doctor prescribes.2
If your chemo is given through an IV, your doctor may suggest an implanted vascular access
device (VAD), such as an implanted catheter or port.1 VADs are surgically placed in a large vein
near the heart and can stay in place for long periods of time. A VAD eliminates the need to have
smaller catheters repeatedly placed in arm veins.

Chemotherapy Schedules

How often you receive chemo depends on the type of cancer you have and the drug or
combination of drugs you receive.2 Different drugs work at varying times in the cancer cell
growth process. Taking all of these factors into consideration, your doctor will help you
determine the most effective treatment schedule for you. Chemotherapy may also be used in
combination with surgery.1

Your doctor has carefully determined your chemotherapy dose and schedule.

Chemotherapy after surgery is referred to as adjuvant chemotherapy1 The goal of adjuvant

chemotherapy is to kill any cancer cells left in the body after surgery. Chemotherapy given
before surgery is referred to as neoadjuvant chemotherapy The goal of neoadjuvant
chemotherapy is to shrink the cancer before it is surgically removed.1 Chemotherapy side effects
can interfere with treatment schedules. Learn how to best manage chemotherapy side effects.

Importance of Dose and Schedule

Your doctor will develop a treatment plan scientifically designed for you, based on your type of
cancer, its stage of advancement, and your overall health. It will consist of specific
chemotherapy agents, at specific doses and intervals. These are called your scheduled cycles.
Generally, treatments are given daily, weekly, or monthly.1 Your doctor will help you determine
the most effective treatment schedule for you.

The goal is to make your chemotherapy as effective, timely, and problem-free as possible.1,6 But
while your chemotherapy treatment works to fight your cancer, it also can cause side effects such
as a lowered white blood cell count. A low white blood cell count means your immune system
isn't as strong as it could be, which can increase your risk of infection. It also can require your
doctor to change your dose or schedule of your chemotherapy.

A chemotherapy-induced low white blood cell count, caused by healthy cells lost during
chemotherapy, is an expected side effect of many chemotherapy drugs.1 A low white blood cell
count typically occurs after the administration of certain types of strong chemotherapy and may
continue for several days. To help reduce the risk of developing side effects like low white blood
cell count that may interfere with your treatment schedule, learn more about managing
chemotherapy side effects.

Under certain circumstances, your doctor may decide your body is too weak to receive
chemotherapy. A low white blood cell count can temporarily disrupt your cancer treatment or
result in having your chemotherapy dose decreased.6
Many doctors agree that it's important to stick to a schedule of treatment.1 Find out about
chemotherapy cycles and schedules.

Why chemotherapy is given Back to top

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. It can be used in
a number of different ways in the treatment of pancreatic cancer.

If a pancreatic cancer has been completely removed with surgery, chemotherapy may be given
afterwards to try to reduce the chance of the cancer coming back. This is known as adjuvant
chemotherapy. If the cancer can only be partially removed you may still be given chemotherapy,
to shrink the remaining tumour.

If the cancer can’t be removed at all but has not spread beyond the pancreas, chemotherapy can’t
cure the cancer, but may shrink it down and control it for a time.

If the cancer has spread, chemotherapy may be used to try and shrink the cancer and relieve
symptoms.

Chemotherapy may be given together with radiotherapy to increase its effectiveness. This is
known as chemoradiation.

How chemotherapy is given Back to top

Chemotherapy drugs are usually given by injection into a vein (intravenously) either in your arm
or through a plastic tube (a central line), into your chest.

The length of time that chemotherapy is given for will depend on the drugs that are used, and
how well the treatment is working. This will be monitored by your doctor at regular
appointments, and you will have regular blood tests and occasional scans. Any decision to use
chemotherapy will be reached after a discussion between you and your doctor.

After you have had your chemotherapy there is usually a rest period of a few weeks, which
allows your body to recover from the side effects of the treatment. Chemotherapy is usually
given to you as an outpatient, but occasionally it may mean spending a few days in hospital.

A number of research trials are being carried out to try to improve the results of treatment for
pancreatic cancer. You may be asked to take part in a trial.

The drugs used Back to top

The chemotherapy drugs used to treat pancreatic cancer include:

• gemcitabine (Gemzar®)
 • 5-flourouracil (5FU)
• cisplatin
• mitomycin
• oxaliplatin (Eloxatin®)
• capecitabine (Xeloda®).

It’s unusual for more than one chemotherapy drug to be given at the same time in the treatment
of pancreatic cancer.

Combinations of drugs are sometimes used as part of research trials. Sometimes gemcitabine is
given in combination with a drug called erlotinib (Tarceva®). Erlotinib is a biological therapy
that works by interfering with the way that cancer cells grow and divide.

Side effects Back to top

Chemotherapy can sometimes cause unpleasant side effects, but it can also make you feel better
by relieving the symptoms of the cancer. Most people have some side effects, but these can often
be well controlled with medicines. Some of the possible side effects are described here, along
with some of the ways in which they can be reduced.

Reduced resistance to infection

While the chemotherapy is acting on the cancer cells in your body, it also temporarily reduces
the number of white blood cells. When these cells are reduced you are more likely to get an
infection. During chemotherapy, your blood will be tested regularly and, if necessary, you will
be given antibiotics to treat any infection.

Sore mouth

Some chemotherapy drugs can make your mouth sore and cause small ulcers. Regular
mouthwashes are important and your nurses will show you how to use these properly. If you
don't feel like eating during treatment, you could try replacing some meals with nutritious drinks
or a soft diet. Our section on eating well has some useful tips on coping with eating problems.

Diarrhoea

Some drugs used to treat cancer of the pancreas can irritate the lining of the digestive system and
cause diarrhoea for a few days. Your doctor can give you medicine to slow down your bowel,
and reduce the diarrhoea. You may also be able to help to control it by eating a low-fibre diet.
This means avoiding wholemeal bread and pasta, raw fruit, cereals and vegetables for a few days
after each treatment.

Feeling sick
Some of the drugs may make you feel sick (nauseated) and you may sometimes be sick. There
are now very effective anti-sickness drugs (anti-emetics) to prevent or reduce nausea and
vomiting. Your doctor can prescribe these for you. Let your doctor or nurse know if your anti-
sickness drugs are not helping you, as different types can be used.

Some anti-emetics can cause constipation. Let your doctor or nurse know if this is a problem.

Hair loss

Ask your doctor whether the drugs you are taking are likely to make your hair fall out. Not all
drugs cause hair loss and certain drugs are more likely to make your hair thin. If your hair does
fall out, it will start to grow back once your treatment is over.

Skin

Chemotherapy can affect the skin and nails, causing dryness and flaking. Some drugs make your
skin more sensitive to the sun, so it is important to cover up and use a high-factor sun cream
(SPF 15 or greater).

Although these side effects may be hard to bear at the time, they will gradually disappear over a
few weeks once your treatment has finished.

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Understanding Radiation Therapy

This is the first article in a three-part series, and it provides an overview of radiation therapy.
Other articles in this series address what to expect when receiving radiation therapy and side
effects of the treatment.

What is radiation?

Radiation is energy that travels through space in the form of subatomic particles or
electromagnetic waves. The various types of radiation have different frequencies (speeds of
repetition) at which they oscillate (swing back and forth in a steady rhythm). Radiation with a
low frequency (and, thus, low energy) is described as non-ionizing and can come from sources
such as AM/FM radios, televisions, microwave ovens, and heat lamps. Meanwhile, ionizing
radiation—such as ultraviolet (UV) light from the sun and x-rays—oscillates at a high enough
frequency to break chemical bonds in atoms. As a result, such high-energy x-rays or other
particles can be used to kill cancer cells in a treatment called radiation therapy.
Radiation as therapy

A doctor called a radiation oncologist oversees radiation therapy, which usually consists of a
specific number of treatments given over a specific time. The goal of this treatment is to kill
cancer cells without harming the surrounding healthy tissue. It may be used as the main
treatment or as an adjuvant therapy (treatment given after the main treatment to target any
potential remaining cancer cells). Meanwhile, radiation therapy can also be used to shrink tumors
and reduce pressure, pain, and other symptoms of cancer (called palliative radiation therapy)
when it is not possible to completely eliminate the disease.

More than half of all people with cancer receive some type of radiation therapy. For some
cancers, radiation therapy alone is an effective treatment, while other types of cancer respond
best to combination treatment approaches that may include radiation plus surgery, chemotherapy,
or immunotherapy.

Types of radiation therapy

External-beam radiation therapy. This is the most common type of radiation treatment in
which the radiation is given from a machine outside the body. It can be used to treat large areas
of the body, if necessary. The machine typically used to create the radiation beam is called a
linear accelerator, or linac. Computers with special software are used to adjust the size and shape
of the beam and to point it in the right direction to target the tumor while sparing the normal
tissue surrounding the cancer cells. External-beam radiation therapy does not make you
radioactive.

Types of external-beam radiation therapy include the following:

• Three-dimensional conformal radiation therapy (3D-CRT): This treatment uses special

computers to create detailed three-dimensional pictures of the cancer. This allows the
treatment team to aim the radiation more precisely, which means that they can use higher
doses of radiation while reducing damage to healthy tissue. Studies have shown that 3D-
CRT can lower the risk of complications.

• Intensity modulated radiation therapy (IMRT): This treatment can better direct the
radiation dose to the tumor than 3D-CRT by precisely modulating (varying) the intensity
of the beam under strict computer guidance. (The positioning of the beam occurs during a
specialized planning process.) IMRT has been shown to allow higher doses of radiation
while protecting normal tissues.

• Proton beam therapy: This treatment uses protons, rather than x-rays, to treat some
cancers. Protons are parts of atoms. They have enough energy to destroy cancer cells
when they are directed to a particular site of cancer in the body while allowing better
control of the radiation dose to nearby healthy tissue, reducing the damage to that tissue.
Because this therapy is relatively new and requires highly specialized equipment, it is
currently only available in certain medical centers across the country. Read more about
proton therapy.
 • Stereotactic radiation therapy: This treatment delivers a large, precise radiation dose to a
small tumor area. Because of the precision involved in this type of treatment, the patient
must remain extremely still. Head frames or individual body molds may be used limit
movement. Although stereotactic radiation therapy is often performed as a single
treatment, some patients may need fractionated radiation therapy, which involves
multiple treatments.

Internal radiation therapy. Also known as brachytherapy, which means short-distance therapy,
internal radiation therapy involves placing radioactive material into the cancer itself or into tissue
surrounding it. These implants may be permanent or temporary and may require a hospital stay.
Permanent implants are tiny steel seeds (capsules) about the size of a grain of rice that contain
radioactive material and are placed inside the body at the tumor site. The seeds deliver most of
the radiation around the area of the implant; however, some radiation can be emitted (sent) from
the patient’s body. This means that the patient needs to take certain precautions to protect others
from radiation exposure while the seeds are still active. (For more information, see the "Safety
for the patient and family" section.) Over time, the implant loses its radioactivity, but the inactive
seeds remain in the body. For temporary implants, the radiation is delivered through needles,
catheters (tubes that carry fluid in or out of the body), or specialized applicators and kept in the
body for a specific time, from a few minutes to a few days. When the temporary radiation is kept
for more than a few minutes, the patient is stationed in a private room while the implants are in
place to limit others’ exposure to the radiation.

Other treatment options

Intraoperative radiation therapy (IORT). Radiation therapy can be delivered directly to the
tumor during surgery, either as external-beam radiation therapy or as internal radiation therapy.
This technique allows the surgeon to move normal tissue out of the way before radiation therapy
occurs, and it may be helpful when healthy, vital (life-sustaining) organs are dangerously close to
the tumor.

Systemic radiation therapy. Systemic (whole body) radiation therapy uses radioactive
materials, such as iodine 131 or strontium 89, that can be taken by mouth or injected into the
body to target cancer cells. These radioactive materials can leave the body through saliva, sweat,
and urine, making these fluids radioactive. Additional safety measures must be used to protect
people who come in close contact with the patient. For more information, see the "Safety for the
patient and family" section.

Radioimmunotherapy. A type of systemic therapy, this treatment uses monoclonal antibodies

(man-made versions of naturally occurring proteins that find and attack things in the body that
the immune system identifies as invaders) that can bind (stick) to some types of cancer cells
while leaving normal cells alone. By attaching radioactive molecules to these antibodies in a
laboratory, they can deliver doses of radiation directly to the tumor. Examples of these
radioactive molecules include ibritumomab (Zevalin) and tositumomab (Bexxar).

Radiosensitizers and radioprotectors. Researchers are studying radiosensitizing and

radioprotectant substances that help radiation better destroy tumors or better protect normal
tissues near the area being treated. Examples of radiosensitizers include fluorouracil (5-FU) and
cisplatin (Platinol). Meanwhile, amifostine (Ethyol) is a radioprotector.

Safety for the patient and family

When receiving external-beam radiation therapy, the patient does not become radioactive; the
radiation remains in the treatment room. However, with internal radiation therapy, a number of
safety measures are necessary.

While the implant is in place, women who are pregnant and children younger than 18 should not
visit. Other visitors should sit at least 6 feet from the patient’s bed and limit their stay to 30
minutes or fewer each day. Permanent implants remain radioactive after the patient is discharged
from the hospital, and he or she should refrain from close (less than 6 feet) or lengthy (more than
5 minutes) contact with women who are pregnant and children for two months.

With systemic radiation therapy, safety precautions must be followed for the first few days after
treatment. The risk of radiation exposure to family and friends can be minimized using the
following precautions.

• Maintaining personal hygiene following toilet use

• Using separate utensils and towels

• Drinking plenty of fluids to flush the remaining radioactive material from the body

• Avoiding sexual contact

• Minimizing contact with infants, children, and women who are pregnant