Pancreatic Cancer. Palliative treatment
Palliative treatment: the two symptoms to palliate are pain and the best modality is a celiac plexus block. For the jaundice, surgical bypass for patients who have good performance status and look like they have reasonable survival. It’s almost worthwhile to invest in long term palliation. Stents can be inserted either endoscopically or percutaneously. Celiac plexus block can either be done at the time of surgery by the surgeon or can be done. They last for months. Commonly they cause some orthostatic hypotension which usually is self-limiting. A couple of years ago I would have said, “No chemotherapy offers a survival advantage in pancreatic cancer.” These are some large trials. And then we go to Memorial Sloan-Kettering’s just baseline data of how their patients did when they presented with non-resectable pancreatic cancer. And we are starting to see some influence on survival. This is the Burrus trial of gemcitabine versus weekly bolus 5FU. Consider the weekly gemcitabine did have a statistically significant survival advantage. I’ll let you decide for yourself whether it’s a clinically significant survival advantage. We are not there yet. This is another comparison. This is not a prospectively randomized trial but it’s almost as good. This is two trials that were done to test in Europe in which they randomized patients between octreotide and best supportive care. The other was done in the United States in which they randomized patients between octreotide or best supportive care. Laid exactly on top of each other, and in the United States protracted 5FU with or without octreotide laid exactly on top of each other. There is some survival advantage there. This is a trial done by Glomelius published in the Annals of Oncology. It’s not quite a randomized objective between any chemo, selected by the patient’s oncologist, and best supportive care. And there was a difference there also. To my thinking, in advanced pancreatic cancer, quality of life is the only end point at this point. They don’t have much of a life expectancy and it’s not going to be influenced very much by chemotherapy. So anything that improves the quality of life.
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We have for low stage lesion surgery … somehow I didn’t get in the GITSG adjuvant chemo-radiotherapy. Adjuvant chemo-radiotherapy and resected pancreatic carcinoma. One of them was a prospective study that took over a decade to accrue. Basically best supportive care followed by – these are all patients who had Whipple resections and no evidence of disease – and half of them got chemo-radiotherapy and a rather poor schedule of 5FU. But nevertheless, there is statistically significant benefit for the chemo-radiotherapy. Not a prospective study but was published from Hopkins and used a better schedule of 5FU and full dose that chemo-radiotherapy is effective. There has been a European trial that did not produce a positive result but had a lot of problems. For locally advanced disease, chemo-radiotherapy is the standard, the usual treatment at some centers with aggressive surgeons. It’s a tossup between chemotherapy and supportive care.
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