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Treatment

A combination of one or more of the above examinations will determine whether you indeed have pancreatic cancer. Being told the diagnosis pancreatic cancer can be a difficult and shocking moment. Most people feel that their life is turned up side down. Your physician will take you through all the procedures. It is nice to have someone with you. You also get information to take home. If you find it helpful, you can contact the patient organization to talk to someone who has a similar experience.

When it is established that you have pancreatic cancer, the type of pancreatic cancer is examined. The doctor also determines at what stage the disease is and whether it has spread. When there is a complete status (a diagnosis), a treatment plan can be made. The treatment plan determines what is done to fight the disease. If possible, we strive for a curative treatment. If a cure is no longer possible, the goal is to live as long as possible with good quality of life.

Multidisciplinary approach
The treatment is discussed by a team of doctors. Each doctor has his own specialty. The meeting of experts is called a multidisciplinary oncology meeting. Multidisciplinary means that experts with different professional backgrounds are involved, namely a gastroenterologist, a radiation oncologist, a radiologist, a pathologist, a medical oncologist, a clinical geneticist, a surgical oncologist and an oncology nurse. In the UMC Utrecht the multidisciplinary oncology meeting takes place every Monday. The treatment plan will be discussed with you as soon as possible. At the bottom of this screen you will find a link to information on all specialties. The second link takes you to the website of the Dutch Pancreatic Cancer Group (DPCG), the professional group of specialists who treat pancreatic cancer.

Treatment methods for pancreatic cancer

Curative treatment

If a treatment aims to achieve remission of disease it is called a curative treatment. Whether curative treatment is possible, depends on the circumstances. For example, where the tumour is located, whether the tumour has invaded adjacent organs and whether it has spread. In about a quarter of patients the physicians opt for a treatment plan that aims to cure. Such a curative treatment always includes surgery, sometimes in combination with other treatments.

Palliative treatment

Unfortunately, cure is not always possible. This does not mean that the treatment stops. There is further treated with a new goal: to live as long as possible with a good quality of life. We call that palliative treatment.

Refrain from treatment

We expect patients to benefit from treatment. However, side effects are to be expected. Also it takes time and energy to get to the hospital. It is always the question whether the advantages outweigh the disadvantages. A difficult balance, since you cannot predict the success of the treatment. Nor how many side effects you will experience. Your physician will discuss this with you.

If you are unsure of the sense of (further) treatment, talk to your specialist or general practitioner. Everyone has the right to refrain from (further) treatment. Your physician will give you the necessary medical care and counselling.

Curative treatment

Curative surgery

In patients with jaundice with many symptoms, such as itching and poor appetite, the specialist may decide to address the jaundice first by placing a stent prior to surgery. This is a tube inserted into the bile duct. The bile can flow freely and the jaundice and itching disappear. Usually, the placement of a stent is performed during the work-up phase, at the same time with an ERCP examination.

A curative operation of pancreatic cancer is also called a Whipple operation. It is a major operation, which was first described by Professor Whipple in the United States in 1935. During surgery, the head of the pancreas is removed, along with the gall bladder, duodenum, a part of the bile duct and a portion of the stomach. The pancreas, the bile duct and the remaining part of the stomach are then connected to the small intestine.

Nowadays, the stomach is often spared in the Whipple operation. The stomach sphincter is then connected to the small intestine. The advantage of the stomach-conserving surgery is that the food digestion after the operation is better and there is less suffering from diarrhoea.

At both procedures the lymph nodes surrounding the pancreas are also removed by the surgeon. So, in addition to the tumour, also apparently healthy surrounding tissue is removed. This is because, during surgery, there is no definitive answer whether the tissue outside the tumour area is free of cancer cells.

Adjuvant chemotherapy

In principle, chemotherapy given after surgery. This is called adjuvant chemotherapy. This is given to increase the chance of cure

Chemotherapy concerns drugs that kill cells or prevent cells from dividing. This kind of drugs are called cytotoxic drugs. There are various types of cytostatic agents, each with its own function. The drugs may be administered, for example by infusion, by injection, as a tablet or in different ways. Through the blood they spread through the body and can reach cancer cells in almost all places.
Chemotherapy is given at the Medical Oncology Department. This department is situated in block B of the hospital, on the 2nd floor. The Oncology department has its own website.

Palliative treatment

The following palliative treatments may be used:

Placing a tube (stent or endoprosthesis)
In patients with jaundice the specialist may decide to address the jaundice first by placing a stent. This is a tube inserted into the bile duct. The bile can flow freely and the jaundice and itching disappear. Usually, the placement of a stent is performed during the work-up phase, at the same time with an ERCP examination.

Surgery or stent placement because of blockage of the intestine
Occasionally, it happens that the tumor has invaded the duodenum. The food in the stomach cannot pass, causing an obstruction. This causes bloating and abdominal pain, usually combined with nausea, vomiting and inability to eat or drink. The obstruction can be remedied with surgery. The surgeon makes a connection between the stomach and the healthy part of the small intestine. Nowadays it is also possible to place a stent into the duodenum. In some cases, a “double bypass” is made (a hepaticojejunostomy + gastrojejunostomy) to bypass the obstructed duodenum.

Palliative chemotherapy
Unfortunately, the chance of pancreatic cancer cells being sensitive to chemotherapy is very small. Meanwhile, chemotherapy may also attack healthy cells in addition to cancer cells. As a result, unpleasant side effects, such as hair loss, nausea, vomiting, indigestion, increased risk of infections, fatigue and infertility may occur. Here for it is decided not to give palliative chemotherapy in patients with pancreatic cancer in the UMCU.
Chemotherapy is given at the Medical Oncology Department. This department is situated in block B of the hospital, on the 2nd floor. The Oncology department has its own website.

Palliative radiation therapy (radiotherapy)
Irradiation is a local treatment with X-rays or electron radiation. Another word for radiation is radiotherapy. A radiation beam is targeted on the tumor. As a result cancer cells are killed. In addition healthy cells are damaged, however, these healthy cells have a better recovery radiation than cancer cells.

The radiation oncologist or radiotherapeutic laboratory ensures that the radiation beam is aimed exactly at the tumor and that the surrounding healthy tissue is spared as much as possible. Radiation therapy can reduce the symptoms. Palliative radiation therapy for pancreatic cancer is not often used, but can sometimes be used when a tumor causes pain or bleeding. The radiation is then focused on stopping pain or blood loss. Irradiation can also be used to treat complaints due to metastases, such as pain from bone metastases. Radiation therapy for pancreatic cancer generally consists of one or more short-term radiation treatments. No hospitalization is required.

Because healthy cells may also be damaged by the radiation, it can have unpleasant side effects such as changed bowel habits, fatigue and skin irritation. The radiotherapy department will give you specific advice to minimize burden of side effects.

After the treatment

What are the prospects for pancreatic cancer?
Pancreatic cancer is usually detected late. That is because symptoms occur late. Often, there already are metastases. The chance of cure is thus limited. In some patients, treatment can be started to cure pancreatic cancer. This does not always work. Optionally, at the bottom of this page you will find more information about prospects in pancreatic cancer.

Patients for whom curative surgery is not possible, undergo a palliative treatment. This treatment is focused on good quality of life for as long as possible. This means slowing down the disease and treating symptoms. The palliative phase may take several years.

Follow-up
People who have been treated for pancreatic cancer remain under regular surveillance for a longer period. The controls are focused on detecting:
• Local disease recurrence
• Metastases

Examinations include blood tests, ultrasound of the abdominal organs or CT scan of the abdomen or chest cavity and are guided by any complaints.

Bijlage:

What are the prospects for pancreatic cancer?
Pancreatic cancer is usually detected late. That is because symptoms occur late. Often, there already are metastases. The chance of cure is thus limited. In some patients, treatment can be started to cure pancreatic cancer. This does not always work. Of the patients who receive such treatment after 5 years about 20% is alive. This figure reflects an average across the group of patients who received a curative treatment. You can not plainly translate these figures to your own situation. You can discuss your prospects with your physician.

Effects of disease and treatment

After a Whipple operation
After a Whipple surgery you will stay in the hospital for 10 to 14 days. Initially, you have a number of ‘tubes’ for administration of food, water and medicines, and to drain fluid and urine. These tubes can be removed in the course of time. You will start with a liquids only diet, but will shortly progress through a “easy to digest” to a normal diet. If you experience problems with feeding after surgery, you will get advice from a dietician. The following nutritional problems may occur temporarily or permanently:
• Fatty stools (due to impairment of fat digestion)
• Weight loss
• Dumping Syndrome; symptoms after eating, in people who have a portion of the stomach removed
• Diabetes

Fatigue
Fatigue can be caused by cancer and / or the treatment of cancer. Many people suffer from fatigue. In some people tiredness occurs some time after treatment, or it can persist over a longer period of time. When pancreatic cancer is advanced, fatigue can also be caused by progressive disease. The site “Minder moe bij kanker” of the Helen Dowling Institute (HDI) provides information about the control of fatigue after cancer.

Pain
Pancreatic cancer can cause pain. Early on in the disease pain is scarce. However, as the disease progresses pain may occur. Moreover, metastases can also cause pain.

Sexuality
Cancer turns life thoroughly upside down. This often effects sexuality. While the fun and relaxation that many people enjoy during sex can be very welcome in the period after treatment. The KWF brochure “Cancer and Sexuality” provides a helping hand to talk about sexuality.

Help and support

The message: “you have cancer” is often overwhelming. Everything is suddenly different: future, family life, work, thoughts … It is only natural that the balance in your life is disturbed. And it takes time, even if you have been treated successfully. Many people encounter major support from their family and friends as well as their attending physician and nurses. Yet it is quite normal to call on additional support outside your own circle.

If you are in the hospital for follow-up, you may be asked to fill out a “lastmeter”. This is a questionnaire. The completed list gives the clinician insight into how you are doing. So that, if necessary, additional help can be organized. There is additional help available within the hospital (eg social work or pastoral care department).
Moreover, help is available outside the hospital as well (eg specialized therapists). On the links page you will find web addresses of reliable supporters.

General practitioner
Of course you can expect a lot of help and support from your family doctor. This applies to assistance and support in the medical, emotional and practical level.

Homecare
Homecare services comprise medical care or household care (or a combination). Medical care is covered by the “AWBZ, the Algemene Wet Bijzondere Ziektekosten” (Exceptional Medical Expenses Act). Home care is covered by the WMO, the Wet maatschappelijke ondersteuning (Social Support Act). You are not automatically entitled to home care. There should be an indication provided by the CIZ, the Centrum Indicatiestelling Zorg (Care Assessment Centre).
For medical care you pay a contribution related to the amount of your income. For household care, your municipality can ask for a contribution. The relevant rules can vary by municipality.

Other laws and regulations
There are many laws and regulations to aid the sick and disabled. For example, the continued payment of salary during illness, transportation, home care, rehabilitation at work, home modification. The Wetwijzer on the site of the NFK provides information and overview. NFK is the dome of cancer organizations.

Contact with peers
Some patients prefer contact with fellow patients. Sharing of experiences and feelings can help getting through a difficult period. In addition, sharing practical information can give valuable support. On the Patient organizations page you will find useful contact information.

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