Support for Cancer family members

Treatment of Pancreatic Cancer by Stage

2009-10-14T12:08:00.000-07:00

It is hard to stage pancreatic cancer accurately by imaging tests. Doctors must do their best to decide before surgery whether there is a good chance the cancer can be completely removed. Surgeons usually consider a pancreatic cancer resectable (completely removable by surgery) if it is staged as T1, T2, or T3. That means it doesn't extend far beyond the pancreas, especially into nearby large blood vessels (T4). There is no accurate way to assess the lymph node spread of the tumor before surgery.

Treating resectable pancreatic cancer

If imaging tests show a reasonable chance of completely removing the cancer, surgery should be done if possible, as it offers the only chance to cure this disease. Based on where the cancer started, either a pancreaticoduodenectomy (Whipple procedure) or a distal pancreatectomy is usually used.

In most but not all cases, either chemotherapy alone or chemotherapy plus radiation therapy (chemoradiation) is used as well. This treatment may be given before or after surgery. Some centers favor giving it before surgery because the recovery after surgery is often long, which can delay or even prevent its use. But it is not yet clear whether this approach is better than giving it after surgery. Many surgeons are concerned about preoperative therapy. They feel that patients may become weakened and are therefore less able to withstand the surgery.

A recent study has shown that giving gemcitabine chemotherapy after surgery can delay the average time before cancer returns by about 6 months. It also seems to help patients live longer. 5-FU was commonly used in the past after surgery, but now gemcitabine is used more often. There is currently an ongoing study comparing 5FU and gemcitabine as adjuvant therapy to see if one is better than the other. It is not yet clear whether adding radiation to chemotherapy would result in more of a benefit.

Treating locally advanced pancreatic cancer

Locally advanced cancers of the pancreas are those that have grown too far to be completely removed by surgery, but have not yet reached distant parts of the body. Several studies have shown that attempts to partially remove these cancers do not help patients to live longer. Therefore, surgery has a limited role in these cancers. It is used mainly to relieve bile duct blockage or to bypass a blocked intestine caused by the cancer pressing on other organs.

The standard treatment options for locally advanced cancers are chemotherapy with gemcitabine either alone or along with radiation therapy. A recent study showed that combining radiation with gemcitabine helped patients with locally advanced cancers live longer than giving gemcitibine by itself. At some cancer centers, patients with locally advanced disease receive chemotherapy and radiation together and are then re-evaluated to see if the cancer has shrunk enough to be completely removed by surgery. Sometimes, patients are able to have surgery at this point.

Treating metastatic (widespread) pancreatic cancer

Because these cancers have spread through the lymphatic system or bloodstream, they cannot be removed by surgery. These cancers have also spread too far to be treated by radiation therapy alone. Even when imaging tests show that the spread is only to one area of the body, it has to be assumed that small groups of cancer cells (too small to be seen on imaging tests) are already present in other organs of the body.

Chemotherapy with gemcitabine is the standard treatment for advanced pancreatic cancer. It can cause the cancer to shrink and help patients live longer. People who get chemotherapy also seem to have fewer symptoms related to their cancer. Adding other drugs to gemcitabine may improve the chance the tumors will shrink and may help people live longer. So far, only erlotinib and capecitabine have been shown to help some patients live longer when given along with gemcitabine. Overall, the benefit of giving erlotinib along with gemcitibine was very small (patients lived about 2 weeks longer). Erlotinib doesn't seem to help all patients, so experts are trying to find a way to figure out who should get the drug and who try something else. Capecitabine also only seemed to help some of the people who received it with gemcitabine. Most doctors give chemo with gemcitabine for pancreatic cancer, and consider adding another drug on a case-by-case basis.

Because the treatments now available are largely unsatisfactory, people may want to think about taking part in a clinical trial involving chemotherapy combinations (with or without radiation therapy) and new targeted therapies.

Doctors don't agree on what is the best therapy to give someone when gemcitabine stops working. If a patient wants more treatment and is strong enough, different chemo drugs may be used. Some patients are given one of the targeted agents. Enrolling in a clinical trial may be the best choice at this point.

Treating recurrent pancreatic cancer

Cancer that returns after surgery (recurrent cancer)is essentially treated the same way as metastatic cancer, and is likely to include chemotherapy if the patient can tolerate it.

Treating cancer of the ampulla of Vater

The ampulla of Vater is the area where the pancreatic duct and the common bile duct empty their secretions into the duodenum (the first part of the small intestine). Cancer of this site can arise from the pancreatic duct, the duodenum, or the common bile duct. Surgery with pancreaticoduodenectomy (Whipple procedure) is often successful as cancer treatment with a 5-year survival rate of 30% to 50%. More advanced ampullary cancers are treated like pancreatic cancer. In many patients, ampullary cancer cannot be distinguished from pancreatic cancer until surgery has been done. Post-operative chemoradiotherapy is often recommended in patients who have had successful resection of their ampullary carcinoma.

Stereotactic Radiation Therapy and CyberKnife: Fact or Fiction By Dr. Joseph Herman

2009-10-06T13:55:00.000-07:00

There have been a number of questions on the Johns Hopkins pancreatic website regarding stereotactic radiosurgery for pancreatic cancer. Therefore, we thought it is important to review the literature on stereotactic radiosurgery and help patients better understand the risks and benefits of this treatment and clarify some of the misconceptions. Stereotactic radiosurgery (SRS) can also be called stereotactic body radiotherapy (SBRT) or CyberKnife. It is important to stress that all of these modalities use radiation and that there is no actual surgery done.

The theory is that the radiation doses are high enough to cause ablation of the pancreatic tumor. While the data suggests that SBRT and/or CyberKnife can ablate certain tumors (brain metastasis and lung tumors) there is no prospective data showing that SBRT and/or CyberKnife can effectively ablate pancreatic tumors or shrink them to the point where they can be resectable. As you can see by the two prospective trials posted on this blog, SBRT and CyberKnife appear to prevent pancreatic tumors from progressing (grow) but there is no evidence that it causes pancreatic tumors to shrink or improve survival. Further, the data suggests that high doses of radiation given by SBRT or CyberKnife can cause some unacceptable acute (within 2-3 months of treatment) and chronic side effects from treatment when compared to conventional radiation treatment delivered over 2-6 weeks of treatment. Specifically, approximately 30-40% of all patients treated with SBRT/CyberKnife develop gastrointestinal side effects including a small number of patients who developed ulcers which required surgical repair. The authors suggest that this may be because the duodenum and small bowel is adjacent to the pancreatic tumors and it is hard to treat the pancreatic tumor and avoid irradiating these areas.

It is important that almost all patients in these studies developed metastatic disease, clearly demonstrating a need for better drugs to control pancreatic tumor spread. Finally, the survival in both of these studies unfortunately were very similar to conventional radiation and chemotherapy. While SBRT and CyberKnife are more convenient for patients (1-5 days of treatment) compared with 25 treatments (conventional), the increased risk of side effects with shorter course radiation with no improved survival make us question whether these treatments in their CURRENT FORM are clearly benefiting patients with pancreatic cancer.

It is important to note that the doses of radiation used in these studies are high. In the Stanford CyberKnife study (Koong et al.) the dose was 25 Gy given in one fraction and in the SBRT (Denmark) trial the total dose was 45 Gy. It is possible that lower doses (15-25) delivered over 3-5 fractions may be better tolerated than the doses given in these two studies, however this data has not been published in a prospective controlled fashion. In summary, SBRT/CyberKnife does appear to result in good local control of pancreatic tumors, however it is unlikely that it will shrink a majority of pancreatic tumors enough for surgical resection and patients are likely to have increased chronic (long term) side effects when compared to conventional treatment.

Additional prospective (patients treated on a clinical trial and followed for side effects) studies are needed to test the true benefit and safety of SBRT and Cyberknife treatment for patients with unresectable pancreatic cancer. While SBRT and CyberKnife therapy does hold promise we have to be careful not to tell patients that it is likely to cure them of their cancer….the data simply isn’t there.

The theory is that the radiation doses are high enough to cause ablation of the pancreatic tumor. While the data suggests that SBRT and/or CyberKnife can ablate certain tumors (brain metastasis and lung tumors) there is no prospective data showing that SBRT and/or CyberKnife can effectively ablate pancreatic tumors or shrink them to the point where they can be resectable. As you can see by the two prospective trials posted on this blog, SBRT and CyberKnife appear to prevent pancreatic tumors from progressing (grow) but there is no evidence that it causes pancreatic tumors to shrink or improve survival. Further, the data suggests that high doses of radiation given by SBRT or CyberKnife can cause some unacceptable acute (within 2-3 months of treatment) and chronic side effects from treatment when compared to conventional radiation treatment delivered over 2-6 weeks of treatment. Specifically, approximately 30-40% of all patients treated with SBRT/CyberKnife develop gastrointestinal side effects including a small number of patients who developed ulcers which required surgical repair. The authors suggest that this may be because the duodenum and small bowel is adjacent to the pancreatic tumors and it is hard to treat the pancreatic tumor and avoid irradiating these areas.

It is important that almost all patients in these studies developed metastatic disease, clearly demonstrating a need for better drugs to control pancreatic tumor spread. Finally, the survival in both of these studies unfortunately were very similar to conventional radiation and chemotherapy. While SBRT and CyberKnife are more convenient for patients (1-5 days of treatment) compared with 25 treatments (conventional), the increased risk of side effects with shorter course radiation with no improved survival make us question whether these treatments in their CURRENT FORM are clearly benefiting patients with pancreatic cancer.

It is important to note that the doses of radiation used in these studies are high. In the Stanford CyberKnife study (Koong et al.) the dose was 25 Gy given in one fraction and in the SBRT (Denmark) trial the total dose was 45 Gy. It is possible that lower doses (15-25) delivered over 3-5 fractions may be better tolerated than the doses given in these two studies, however this data has not been published in a prospective controlled fashion. In summary, SBRT/CyberKnife does appear to result in good local control of pancreatic tumors, however it is unlikely that it will shrink a majority of pancreatic tumors enough for surgical resection and patients are likely to have increased chronic (long term) side effects when compared to conventional treatment.

Additional prospective (patients treated on a clinical trial and followed for side effects) studies are needed to test the true benefit and safety of SBRT and Cyberknife treatment for patients with unresectable pancreatic cancer. While SBRT and CyberKnife therapy does hold promise we have to be careful not to tell patients that it is likely to cure them of their cancer….the data simply isn’t there

Patterns of Hope: The Survivor Stories

2009-08-19T12:31:00.000-07:00

After hearing that someone you care about has pancreatic cancer, one of the first things you confront is the reality of statistics. But there are long-term survivors. They do exist - and often thrive. And their stories are important beacons of hope for others confronting this serious foe.
In her book, There's No Place Like Hope, "terminal" cancer survivor observes, "I have often thought of cancer as the schoolyard bully … the mere thought of him can send people running. But all it takes to diminish his power is for a couple of people to stand up to him. That's what a cancer success story does - it stares down the bully."
Such is the long operating principle of the Lorenzen Cancer Foundation and the Pancreatica resource. The aim from the outset has been to shine a hopeful and informational light at this disease. It is also the motivation of the Survivors page on this site. And, as the stories here will attest, it is the meaningful goal for these long-term survivors too, as they transform their private challenges into social good.
A choice from the outset was to let people self-define "long-term". This openness led to a wide array of people raising their hands as survivors, and has brought forth a diversity of success stories. The initial outreach went to a large online community of pancreatic cancer patients, caregivers, doctors and researchers, under the auspices of the Association of Cancer Online Resources (ACOR). As the invitation stipulated, "a long-term survivor is anyone who thinks they are."
It might be theorized that long-term survivors are also (chances are) those who "thought they would be." One of the many commonalities among the initial survivor families is a conviction, almost from the beginning, that they were going to beat the odds.
Due to the self-selective nature of those who feel moved to tell personal stories and why, there are often recurring themes. Multi-generational families tell stories to bequeath history and values to their children. Founders of organizations tell them to transmit their original visions in hopes that those will live on. Military veterans do so because they finally have enough distance from their wars that they feel ready to speak about them. Patterns always emerge. Threads intertwine.
For this particular series, we wanted (primarily) to help people share the details of their exceptional medical journeys. We know what clinical factors make pancreatic cancer survival more likely: overall age and good health, early diagnosis, tumor location, eligibility for surgery, world-class hospitals, skilled doctors. Most (but not all) of our initial interviewees had many (but not all) of those things going for them. But so do many people who still aren't so lucky. We wondered whether there were also other, non-medical situations or attributes that these long-term survivors would turn out to have in common.
There were. And they're not news bulletins. But they do leap off the page as you read these stories. Positivity. Indomitability. Spirituality. Appreciation of the little things. A craving for information. Continuing things they love doing. Not taking no for an answer. Strong, devoted and ever-present caregivers. Hope in the face of (what often seems) no hope. And humor, always humor. One survivor has had this magnet on his refrigerator since the very beginning: I plan to live forever. So far, so good.
And even now - when it seems that the hard part may be over, and the coast clear:
All have an impassioned, downright mission-driven determination to share their experience with people who are taking this journey after them. To continue helping others.
And - they share a certain thankfulness for the experience they've been through. As one wife and caregiver put it, "there was a special sweetness and richness about that time, as we were forced to focus only on each other for a change, and to talk and reflect about what really mattered."

In many cultures, stories have been told out loud and handed down for centuries, from one generation to the next, in order to communicate and preserve the significant. In the telling of those stories, there is respect and honor accorded to those who speak. For those who listen, there is an implied stewardship... the responsibility to receive, embrace, respond, learn, and pass on what they've heard.
We hope you'll feel that too, in these tales - whether you have your own connection to pancreatic cancer, or just want to be inspired and humbled - and reminded - about the insignificance of most of our daily problems. And about the triumph of the human spirit.

2009-07-27T22:22:00.000-07:00

It is not just the cancer patient that you need to worry about, interacting with other family members are also very important, unfortunately cancer hearts everyone close to the patient. Finding a support group is very important. There are cancer support group in every city for the family and friends of the patient. I suggest you seek them out.

Cancer family support

2009-07-27T21:48:00.000-07:00

I started this page to provide support for the friends and families of the Cancer patients. two of my brothers were diagnosed with Cancer in 2002, it was very strenuous dealing with the emotions. I had so many questions and didn’t know where to turn to. I decided to make this blog page to provide some support for those perplexed by this phenomena. Often when we hear about someone who was just diagnosed with this illness we may not realize that it is effecting everyone close to them as well. Please write about your encounter with this disease or any advice you may have that could help families facing this emotional challenge.