Updated 1 November 2005

Unfortunately, the nature of pancreatic cancer is such that the vast majority of patients either present with or eventually develop advanced disease.

Symptomatic treatments are discussed in Section 4.

Cancer of the pancreas is generally quite resistant to anticancer therapies. For many years, 5-FU, either alone or in combination, was the most active agent with response rates of 0% to 20% in various phase II studies. The median survival in most of these trials was 4 to 5 months.

Chemotherapy with gemcitabine (GIPGEM) remains the agent of choice for its palliative effect. In the pivotal trial, "clinical benefit response" was defined by an index based on patients' pain level, analgesic consumption, performance score (activity) and weight.(17) In the study, 24% of patients treated with gemcitabine had clinical benefit as compared with 5% of those given 5-FU. Some patients treated with the gemcitabine also survived marginally longer versus those treated with 5-FU (18% v 5% 1-year survival)). Treatment with gemcitabine is recommended for patients with reasonable performance score (ECOG 0-2). If chemotherapy is being considered, it should be initiated early, as clinical deterioration may occur very rapidly in this disease.

Treatment involves weekly intravenous injections of gemcitabine, and may cause toxicity including neutropenia, thrombocytopenia, fever, rash, and nausea. This is generally well tolerated, but patients should be monitored closely to ensure that toxicity does not outweigh benefit. If there is evidence of clinical deterioration while on therapy, it should be considered ineffective and discontinued.

A number of "biologic" therapies are under active investigation in this disease. Most recently, the addition of the epidermal growth factor receptor antagonist, Erlotinib (Tarceva™), to gemcitabine showed a small survival benefit in patients with advanced pancreatic cancer (18). While this small benefit is not currently considered sufficient to recommend the standard addition of Erlotinib to Gemcitabine at BCCA, such approaches continue to be evaluated. Patients should be offered participation in clinical research studies when available.