Practical recommendations for the management of adenocarcinoma of the pancreas

Pancreatic cancer is widely regarded by medical personnel and the lay publi c as one of the most dreaded of all diagnoses. Although in selected series of operable patients the chance of long term survival may reach 20%, most p atients have unfavourable disease at the time of diagnosis, and for the ent ire group of newly diagnosed patients, 5-year survival is rare. This grim o utlook results from a combination of factors, including an anatomical locat ion which makes early detection by screening tests or by symptoms difficult , a high tendency for spread to regional lymphatics and the liver, a poor p rofile of sensitivity to chemotherapeutic agents and the poor medical condi tion of many patients at the time of diagnosis. These factors mean that it is particularly important that at the time of diagnosis these patients are carefully evaluated, and that they and their families are fully aware of th e treatment options available to them and the associated potential risks an d benefits. For localised cancers, surgical resection alone offers the potential for lo ng term survival. The addition of postoperative radiation therapy (RT) pred ictably improves local control but has minimal impact on survival, which is primarily determined by the development of liver metastases. Randomised tr ial data support the use of combined fluorouracil (5-FU) chemotherapy and R T in patients who have undergone pancreatectomy and have negative margins, although the benefits are modest and the relevant randomised trials enrolle d relatively small patient numbers. For patients with marginally resectable tumours, the feasibility has been demonstrated of using chemotherapy plus RT to reduce tumour size before resection. but it is unclear whether this a pproach will benefit a significant number of patients. Tumours which are un resectable because of local advancement (involvement oft major vessels or r egional nodes) tan be treated with RT alone or in combination with chemothe rapy, but survival past 2 year!, is uncommon. Patients with liver metastases have a poor prognosis. As part of a programm e of supportive care, some of these patients may receive cytotoxic therapy, the goal of which is to relieve cancer-related symptoms such as pain from the primary tumour or metastatic sites, or weakness. nausea and anorexia wh ich may be associated with liver metastases. Although the objective respons e rare of chemotherapy agents is low, in an individual patient they may pro duce an adequate response and acceptable toxicity so that the patient exper iences overall improvement in symptoms. The mainstay of chemotherapy for pa ncreatic cancer, as with other gastrointestinal cancers. has been fluoroura cil. However, recent clinical data have shown that gemcitabine produces sim ilar results in terms of response rate and survival, with more acceptable t oxicity, so that the quality of life was judged to be better than with fluo rouracil. Pancreatic cancer provides a fertile ground for testing new, biologically b ased approaches to cancer therapy because of the limited success of current ly available treatments.