Stage IV Pancreatic Cancer

Overview

Pancreatic cancer is considered Stage IV if it has spread to distant locations in the body, such as the liver, lungs, or adjacent organs including the stomach, spleen, and/or the bowel. Sometimes it can only be determined that a pancreatic cancer is in Stage IV once surgery is completed.

Patients diagnosed with Stage IV pancreatic cancer can be broadly divided into two groups:

  • Stage IVA pancreatic cancer is locally confined, but involves adjacent organs or blood vessels, thereby hindering surgical removal. Stage IVA pancreatic cancer is also referred to as localized or locally advanced.
  • Stage IVB pancreatic cancer has spread to distant organs, most commonly the liver. Stage IVB pancreatic cancer is also called metastatic.

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The goal of treatment for patients with localized IVA disease is to induce a remission, or a disease-free period that may last months or years. Management of patients with Stage IVB disease is often aimed at controlling symptoms and pain from the cancer.

Stage IV pancreatic cancer is generally not removable by surgery and is therefore rarely curable and often difficult to control. A surgical procedure may be possible to reduce symptoms and improve quality of life in some patients, but the recommended treatment for advanced pancreatic cancer typically consists of chemotherapy. The standard chemotherapy treatment of pancreatic cancer is Gemzar® (gemcitabine)-based chemotherapy.

The following is a general overview of treatment for Stage IV pancreatic cancer. Treatment may consist of surgery, radiation, chemotherapy, biological therapy, or a combination of these treatment techniques. Multi-modality treatment is treatment using two or more techniques, and is increasingly recognized as an important approach for improving a patient’s chance of cure or prolonging survival. In some cases, participation in a clinical trial utilizing new, innovative therapies may provide the most promising treatment. Circumstances unique to each patient’s situation may influence how these general treatment principles are applied and whether the patient decides to receive treatment. The potential benefits of multi-modality care, participation in a clinical trial, or standard treatment must be carefully balanced with the potential risks. The information on this Web site is intended to help educate patients about their treatment options and to facilitate a mutual or shared decision-making process with their treating cancer physician.

Treatment of Localized Stage IVA Pancreatic Cancer

Pancreatic cancer is often not diagnosed until it is in Stage IVA, meaning the cancer has invaded adjacent organs or major blood vessels. When this occurs surgical removal of the cancer (which provides a chance at long-term cure) is seldom an option. Therefore, the goal of treatment of patients with Stage IVA pancreatic cancer is to induce a remission, which is a cancer-free period that may last months or years, and to prevent and control symptoms.

Treatment for Stage IVA pancreatic cancer may include palliative surgery, chemotherapy, or chemoradiation, which is chemotherapy and radiation delivered together.  Occasionally, a surgical bypass procedure may be performed to alleviate complications of the cancer, such as jaundice, intestinal obstruction, or pain, thereby improving quality of life.

Treatment of Non-localized Stage IVB (Metastatic) Pancreatic Cancer

The majority of patients with Stage IV cancer have metastatic disease (Stage IVB), which means that cancer has spread to distant locations in the body that often include the liver and other areas of the abdominal cavity. To kill cancer cells that have spread throughout the body, a systemic treatment is necessary, and this is typically chemotherapy. Historically, patients with metastatic pancreatic cancer have been considered incurable and rarely survived more than one year. However, with newer treatments, some patients are surviving 1-2 years and can experience improved quality of life. In addition, the management of patients with Stage IV pancreatic cancer is focused on reducing pain and maintaining nutrition. Pain relief can be achieved by destroying the nerves that provide sensation in the area around the pancreas. This is usually performed by injection of alcohol or other chemicals either through the skin or during an open abdominal operation.

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Chemotherapy

Chemotherapy is any treatment involving the use of drugs to kill cancer cells.  Cancer chemotherapy may consist of single drugs or combinations of drugs and can be administered through a vein or delivered orally in the form of a pill.  Chemotherapy is considered a systemic therapy because the drugs circulate throughout the body and can kill cancer cells that have spread to locations distant from where the cancer started. Chemotherapy is commonly used to treat both locally advanced (Stage IVA) and metastatic (Stage IVB) pancreatic cancer.

Gemzar® (gemcitabine): Currently, the standard chemotherapy drug for the treatment of advanced pancreatic cancer is Gemzar, which has been shown to improve response to treatment, time to cancer progression, and survival duration when compared with the older chemotherapy drug 5-fluorouracil.[1] In a clinical trial comparing Gemzar to 5-FU, Gemzar produced significant improvement in disease-related symptoms, as well as prolonging survival. The number of patients surviving one year after treatment with Gemzar was 18%, compared with only 2% with 5-FU.

Combinations of chemotherapy drugs, called regimens, may produce more anticancer responses and improve the outcomes of patients with advanced pancreatic cancer than treatment with Gemzar alone. Many different chemotherapy drugs have been combined with Gemzar, but only Tarceva® (erlotinib) has been demonstrated to improve survival in a direct comparison with Gemzar; 23% of patients treated with the combination of Gemzar and Tarceva survived greater than one year compared with 18% treated with Gemzar alone.[2]


Chemoradiation Therapy

Combining chemotherapy with radiation therapy, a technique called chemoradiation, may provide more benefit than chemotherapy alone for some patients with Stage IVA pancreatic cancer,[3] but is not typically a treatment for patients with Stage IVB disease. Researchers from Taiwan have reported that patients with Stage IVA pancreatic cancer who were treated with radiation therapy plus Gemzar chemotherapy fared better than those treated with radiation therapy plus 5-FU chemotherapy. Anticancer responses occurred in 50% of patients treated with Gemzar, compared with only 17% for those treated with 5-FU. The average time to cancer progression was 14.5 months for patients treated with Gemzar, compared with only 7.1 months for those treated with 5-FU. Patients treated with Gemzar reported better pain control than those treated with 5-FU.[4]

Strategies to Improve Treatment of Stage IV Pancreatic Cancer

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References:


[1] Burris HA III, Moore MJ, Andersen J, et al. Improvements in survival and clinical benefit with gemcitabine as first-line therapy for patients with advanced pancreas cancer: A randomized trial. J Clin Oncol 1997;15:2403-2413.

[2] Moore MJ, Goldstein D, Hamm J et al. Erlotinib plus gemcitabine compared with gemcitabine alone in patients with advanced pancreatic cancer: a phase III trail of the National Cancer Institute of Canada Clinical Trials Group. Journal of Clinical Oncology. 2007;25:1960-6.

[3] Gastrointestinal Tumor Study Group. Treatment of locally unresectable carcinoma of the pancreas: Comparison of combined-modality therapy (chemotherapy plus radiotherapy) to chemotherapy alone. J Natl Cancer Inst 1988;80:751-755.

[4] Li C-P, Chao Y, Chi K-H, et al. Concurrent Chemoradiotherapy Treatment of Locally Advanced Pancreatic Cancer: Gemcitabine versus 5-Fluorouracil, A Randomized Controlled Study. International Journal of Radiation Oncology Biology Physics 2003;57:98-104.

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