After the diagnosis of pancreatic cancer, a multidisciplinary committee made up of specialists in radiology, nuclear medicine, pathology, radiation therapy, oncology, digestive surgery, liver surgery, digestive system, anaesthesia, and advanced practice pancreatic nursing staff (nurses with experience in the management of toxicities related to chemo and radiotherapy ) assesses the clinical situation of each patient and agrees on the best therapeutic option. 

The type of treatment is established based on the following factors:

Patient characteristics Age, other diseases that make some treatment difficult and functional status (ability to carry out activities of daily living)

Tumour location Head, body, tail.

Phase or stage in which the disease is found.

Surgical treatment of pancreatic cancer

Surgical treatment will vary depending on the affected area:

Head of the pancreas The surgery of choice is a cephalic duodenopancreatectomy. The head of the pancreas is removed along with the duodenum (first portion of the small intestine) and the distal portion of the bile duct, including the gallbladder. The stomach can be preserved entirely, or, on occasion, it may be necessary to remove its most distal portion, including the pylorus. After removal, the pancreas duct, bile duct, and stomach are rejoined in the intestine.

Body or tail of the pancreas Distal pancreatectomy with splenectomy is performed. The body and bottom of the pancreas and spleen are removed.

Large size or occupies more than one part of the pancreas. A total pancreatectomy, including the spleen, is performed.

Complications of pancreatic cancer surgery

Pancreatic surgery is very safe when performed by experienced surgeons. However, it represents complications related to the procedure that may appear. Those related to the pancreas depend on making an artificial union of its duct to the intestine and removing part of the gland. Pancreatic fluid can leak into the abdomen, leading to digestion and swelling of surrounding tissues and failure of the gland to function. 

Because the pancreas produces enzymes and hormones for digestion, when a part is removed, malabsorption syndrome can occur, which is the inability to absorb nutrients from the gastrointestinal tract. Taking pancreatic enzyme supplements by mouth can improve digestion. 

The pancreas also produces insulin, which is used to control blood sugar levels. After pancreatic resection, it may be necessary to start insulin therapy. In case of complete removal of the pancreatic gland (total pancreatectomy), one must take insulin and pancreatic enzyme supplements for life.

The most frequent complications of pancreatic surgery are delayed emptying of the stomach, which slows the reintroduction of oral feeding, leakage of bile fluid and the appearance of intra-abdominal bleeding.

Treatment with Chemotherapy and Radiotherapy

Chemotherapy  Chemotherapy is the most commonly applied treatment for pancreatic cancer. Chemotherapy is usually given intravenously, although in some cases, it can given it orally. Chemotherapyinhibits the growth of dividing cells, both tumour and healthy cells, which is why symptoms associated with treatment may appear, the so-called adverse effects or side effects.

Chemotherapy can be given as a combination of two drugs (polychemotherapy) or one drug (monotherapy). Among the most widely used drugs are gemcitabine, fluoropyrimidines (5-fluorouracil, capecitabine), irinotecan, pegylated irinotecan, oxaliplatin, and nab-paclitaxel. 

The number of cycles depends on each patient and tumour stage, although treatment generally lasts between 3-6 months. Throughout the treatment, different tests (analytics, imaging tests) are carried out to assess whether it is effective.  

Radiotherapy  Radiation therapy delivers high-energy x-rays to kill cancer cells. It has different uses in pancreatic cancer and can be given alone or combined with chemotherapy to shrink the tumour before surgery.

Treatment depends on the stage of the disease.

Resectable pancreatic cancer Surgery is the only curative treatment for pancreatic cancer. Adjuvant therapy with gemcitabine or modified Folfirinox is indicated in resected patients with increased survival at five years.  

Borderline resectable or locally advanced pancreatic cancer  In borderline resectable or locally advanced patients, which are those in which there is a high risk or impossibility of performing a complete surgical resection of the tumour, neoadjuvant treatment is recommended (treatment, generally based on chemotherapy or a combination of chemotherapy and radiotherapy ).administered before surgery, with the intention that this surgery is performed in better conditions). Many patients with the borderline disease and some with locally advanced disease respond to neoadjuvant treatment and, at its completion, can undergo surgery with a greater chance of obtaining a complete resection of the tumour and thus improve the chances of curing the disease.

Stage IV pancreatic cancer Treatments with FOLFIRINOX or gemcitabine/nab-paclitaxel are standard of care after having demonstrated their benefit compared to gemcitabine monotherapy. They would be indicated in patients with ECOG PS 0-1. In ECOG PS 2 patients, gemcitabine monotherapy may be considered the treatment of choice, as this patient population is underrepresented in studies and more susceptible to toxicity. In the second line of treatment, the options would be FOLFOX or Naliri (Onyvide).

Complications of chemotherapy treatment

Different side effects of treatment depend on the specific type of chemotherapy given. 

Among the symptoms that may appear are tiredness (asthenia), change in the taste of food, nausea, vomiting, alopecia, inflammation of the mucosa of the mouth, fever, constipation/diarrhoea, muscle pain, neurotoxicity (pain, tingling or loss of sensation in the fingers/toes), redness, pain and wounds in the hands/feet, acneiform rash and nail lesions.

Gemcitabine /Nab-paclitaxel chemotherapy can cause alopecia, diarrhoea, and hematologic toxicity. It can also cause skin erythema and, infrequently, sores in the mouth (mucositis). If these side effects occur, discuss them with your regular doctor.

The combination of oxaliplatin with fluorouracil in continuous infusion (FOLFOX) can also cause mucositis and diarrhoea. The treatment usually produces moderate tiredness, especially on the first days after treatment. Oxaliplatin can also produce neurotoxicity (sensation of numbness in the hands and feet), especially after 8-12 cycles of treatment. This side effect can last even if the treatment is stopped.

The other combination of chemotherapy (FOLFINIROX) can cause diarrhoea, abdominal pain and alopecia than FOLFOX, which is associated with neurotoxicity.

New Therapies

Targeted therapy uses drugs that target a specific or unique characteristic of cancer cells that healthy cells do not have. Because these drugs specifically target cancer cells, they are less likely to harm normal cells throughout the body.

About new therapies in pancreatic cancer, it is essential to know that it is a paradigmatic example of a poor tumour at the immunogenic level due to the high presence of stroma and poor lymphocytic infiltration. PD1 and PD-L1 inhibitors have not shown efficacy in pancreatic cancer. Combinations of vaccine-associated PD1 or PD-L1 inhibitors or drug-associated combinations of PD1 or PD-L1 that deplete stroma and the cytokines they produce are strategies currently being evaluated.