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Chemotherapy

This chapter was written in collaboration with Dr. Daniel Rayson MD, FRCPC and Dr. Ravi Ramjeesingh MD, PhD, FRCPC, both of whom are medical oncologists at the QEII Health Sciences Centre, in Halifax Nova Scotia. For the complete lecture given by Dr. Rayson, click here.

What Is a Medical Oncologist? A medical oncologist is a physician who specializes in the diagnosis and medical treatment of cancer and its’ complications.

Patients are typically referred to a medical oncologist after being diagnosed with cancer but occasionally may see one before a cancer is confirmed.

What is the Role of a Medical Oncologist?
1) Explain the cancer diagnosis and the possible impact of the disease on health.
2) Explain the disease stage and the goals of treatment.
3) Explain all relevant treatment options available, including clinical trials testing new treatments.
4) Recommend the best course of treatment in the context of a patient's health history, symptoms and preferences.
5) Deliver optimal safe and supportive care.
6) Supervise and manage treatments designed to increase the chance of a cure when possible or, if a cure is not possible, controlling/improving symptoms and slowing cancer progression. This is called ‘palliative’ or symptomatic and supportive’ therapy.
7) Initiate and supervise treatments aimed at controlling and improving symptoms such as pain, nausea or loss of appetite when they are a problem.

Do I Need A Biopsy? Pancreatic cancer is not one disease that follows one pathway. Different types of pancreatic cancer respond to different treatments. Up to 10% of pancreatic cancers are not traditional pancreatic cancer. Other types of cancer (like melanoma, ovarian cancer, renal cell carcinomas and others) can spread to the pancreas. Lymphomas and pancreatic neuroendocrine tumors can also present as a pancreatic mass. To receive the best care you must find out what type of pancreatic cancer you have which can be determined by a biopsy. As well, to access most clinical trials, a tissue diagnosis is required.

What is Chemotherapy? Chemotherapies are powerful drugs which are typically given, intravenously (I.V.) but can now sometimes be administered in pill form or through injections. Unfortunately, all chemotherapies used to treat pancreatic cancer are by I.V. at this time.

Chemotherapy drugs disrupt the “growth program” of cancerous cells, however, they also disrupt the “growth program” of normal cells. It is important to remember that unlike our healthy cells that grow, die and rejuvenate, cancerous cells just continue to grow (they forget how to die). Cancerous cells are not reprogrammed to grow, once they die. If we can get the cancer cells to die, they will stay dead. The goal of chemotherapy is to disrupt this cancer cell growth.

Treatment Options Available

Depending on a patient’s diagnosis and stage of disease, medical oncologists may recommend;
- treatment before surgery (neo adjuvant therapy)
- treatment after surgery (adjuvant therapy)
- treatment for symptom and pain control

Neo adjuvant therapy before surgery is recommended when a cancer cannot be removed initially; however, surgery may be possible if radiation, chemotherapy or a combination of these treatments can shrink the mass. Additionally, neo adjuvant therapy is being used with the possibility of prognostic improvement, however, for resectable pancreatic cancer this remains controversial.

Adjuvant therapy after surgery may be recommended for 3 reasons. a) The surgeon may not have been able to remove the cancer completely, so treatment may be used to help shrink or control what was left behind. b) Chemotherapy may be used to reduce the risk of the cancer coming back in the future. c) The surgeon was unable to remove the tumour at all.

Palliative or symptomatic and supportive care is recommended to control the disease and prolong survival, to minimize or improve the symptoms, improve or maintain function and quality of life, and to minimize problems from the disease.

First Line Treatments for Metastatic Pancreatic Adenocarcinoma

Gemzar® (Gemcitabine) was approved in 1996. It can be used prior to surgery (neo adjuvant therapy) and after surgery (adjuvant therapy), as research supports the benefits, in terms of patient survival.

In 2011, FOLFIRINOX was approved in Canada as a first-line treatment for metastatic pancreatic cancer. FOLFIRINOX is a combination of 4 drugs including 5-FU/leucovorin, Irinotecan, and Oxaliplatin. Clinical trials have demonstrated positive results and, as a result, FOLFIRINOX has become a standard of care of metastatic pancreatic cancer. This treatment is often recommended only for patients who are healthy enough to tolerate the side effects.

In 2014, ABRAXANE® (Albumin-bound Paclitaxel) was approved in Canada and is used in combination with Gemzar® (Gemcitabine) as a first-line treatment for metastatic pancreatic adenocarcinoma.

Second Line Treatments for Metastatic Pancreatic Adenocarcinoma ONIVYDE® , which is a irinotecan liposome injection, and used in combination with 5-FU (Fluroouracil) and Leucovorin was approved in August 2017 as a treatment for metastatic pancreatic adenocarcinoma. This can be used when the disease progresses following the treatment of Gemcitabine-based therapies.

Clinical Trials

Before a clinical trial is approved, it undergoes rigorous scientific, ethical and clinical review to ensure that safety is maximized and that all patients approached to participate have a chance to benefit.

If you are interested in participating in a clinical trial, ask your medical oncologist if there is one available for you to participate in. To search for clinical trials, you can go to clinicaltrials.gov which is a database of all clinical trials conducted in North America and elsewhere.

If you need help to finding a clinical trial specific to your needs, please contact us at;
Email: info@craigscauseca
Phone Number: 1-877-212-9582

Clinic Trials page for more information


Symptom Control

There are a variety of medicines which are available to treat the symptoms of pancreatic cancer and the side effects treatment. These include:

Pain Medication- Pain is an issue with pancreatic cancer. See Chapter on Pain Management

Celiac Plexus Nerve Block- The pancreas sits on a nerve bundle that can cause pain. This nerve bundle can be frozen (just like your tooth can be frozen at a dentists’ office)

Appetite/Energy Stimulants- The pancreas is involved with nutrition, so pancreatic cancer can cause weight loss and malabsorption. There are medications that can stimulate appetite and assist in the absorption of foods.

Anti-Nauseants- Patients often experience nausea and/or vomiting, making eating difficult. There are medications that can prevent feelings of nausea and may prevent vomiting.

Seeing a medical oncologist does not mean you will be going through chemotherapy. They are there to discuss with you the risks and benefits of treatments, discuss side effects and provide answers to your questions. They are there to act as a resource for you and your family.

Many medical oncologists work with a primary care nurse. If there are issues that you would like to resolve, you may feel more comfortable speaking with the primary care nurse.

In closing, it is important to remember that a medical oncologist is a very important member of your medical team, so it is important to find one who is willing to work with you and your family and who you are comfortable working with. If you are presently working with a medical oncologist that you are not comfortable with, you can ask for a second opinion. This is completed by going back to your family physician, and asking for a second referral.
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