Personalized care only an academic medical center can offer
We bring a multidisciplinary approach to each individual treatment plan
Because of the complicated nature of pancreatic cancer, most patients require several different kinds of treatment. We believe that multidisciplinary care is the best medicine. Our physicians offer expertise in complex surgical procedures, innovative radiation techniques, targeted drug therapies and minimally invasive treatment approaches. You can expect to work with surgical, medical and radiation oncologists; interventional and diagnostic radiologists, palliative care physicians as well as nurse practitioners, physicians assistants and dietitians.Schedule an Appointment
Personalized care plan
Radiation therapy is a key component of care for many patients with pancreatic cancer. Radiation oncologists at Froedtert and MCW are at the forefront of innovative efforts to combine radiation with surgery and drug therapy.
The traditional approach
For the last several decades, the standard care plan for operable pancreatic tumors has been surgery followed by radiation therapy and chemotherapy. The main drawback of this care plan is that patients must recover from surgery before they can undergo drug and radiation therapy. However, adequate healing can take some time and in the interval, many cancers show evidence of metastatic spread. This results in approximately 40 percent of patients that undergo traditional treatment never completing the full course of therapy.
Based on current research, the care team at MCW strongly advocates a “surgery last” approach. What this means is that patients with resectable or borderline resectable pancreatic tumors receive a combination of chemotherapy and radiation therapy (chemoradiation) prior to undergoing surgery to remove the tumor.
Preoperative therapy exposes any microscopic cancer cells to the cancer drug earlier and takes advantage of the tumor’s blood supply, which means drugs can reach cancer cells directly through the arteries that feed the tumor. Not only that, but treating cancers ahead of time with chemoradiation can shrink the tumor. This increases the likelihood of a complete tumor resection with no lymph node involvement, which can be especially important for patients with a borderline resectable tumor.
It also allows the care team to identify patients who won’t benefit from surgery. If metastases appear during or shortly after preoperative chemoradiation, the patient likely already had uncontrollable microscopic spread of the disease. With the traditional surgery-first approach, the patient would have undergone a major operation with no benefit.
Ultimately, the “surgery last” approach increases the number of patients who are able to receive the complete treatment.
What to expect with radiation therapy treatment
The typical course of chemoradiation includes five-and-a-half to six weeks of radiation therapy delivered concurrently with low-dose chemotherapy, which acts as a radiation sensitizer. Some patients with borderline resectable tumors receive a course of chemotherapy alone, followed by the chemoradiation treatment.
Radiation is delivered using technologies that are able to tightly shape the dose to the tumor target. In most cases, the care team uses intensity modulated radiation therapy (IMRT), which maximizes radiation delivered to the tumor while sparing nearby organs such as the kidneys, the small bowel and the liver.
Because the radiation fields are so precise, the care team studies each patient’s breathing motion before therapy using four-dimensional CT scanning. If a study shows that a patient’s organs move significantly during breathing, techniques are used to target radiation only during a certain point in the breathing cycle, when the tumor is in the “target zone.”
Surgery typically takes place four to six weeks after chemoradiation as long as follow-up scans show no evidence of metastatic spread. Certain patients receive more chemotherapy following surgery depending on whether or not complete tumor removal was achieved.
Radiation therapy for inoperable pancreatic cancer
Patients with an inoperable pancreatic tumor may receive radiation therapy depending on the extent of the disease and the tumor’s response to chemotherapy. Radiation is not used to treat pancreatic cancers that have spread to other organs, except when used palliatively to alleviate symptoms of metastatic disease.
Chemotherapy uses drugs to kill cancer cells by stopping their growth and multiplication. These drugs go into circulation to kill cancer cells wherever they may be, even if they have spread outside the pancreas. Chemotherapy can be given intravenously (through a vein) or by mouth and is generally given as an outpatient. Whether chemotherapy is recommended depends on the type of pancreatic cancer being treated. Clinical trials which offer additional therapies may also be available for your cancer.
The frequency and the duration of the chemotherapy schedule will be set by a medical oncologist. Often a mediport will be placed in the chest prior to starting chemotherapy. A mediport is a small medical device that is implanted under the skin. A catheter connects the port to a vein. This allows clinicians to draw blood and administer chemotherapy without having to place an IV every time.
Recent research shows that giving patients a combination of chemotherapy and radiation therapy (chemoradiation) before tumor removal surgery provides several benefits. Chemoradiation can shrink the tumor before surgery, enabling a more complete tumor removal. It can also provide better control of microscopic disease. Patients with borderline resectable tumors may receive an initial course of chemotherapy alone, followed by the chemoradiation treatment.
Drug therapy is sometimes given to patients following surgery in an attempt to eliminate or slow the growth of any remaining microscopic cancer cells.
Chemotherapy for metastatic disease
For patients whose pancreatic cancer has spread to other organs, surgery and radiation therapy offer no benefit. Chemotherapy can help extend survival for these patients.
The best chance for curing pancreatic cancer comes with early diagnosis and surgical removal of the tumor. Surgery combined with the appropriate radiation and drug therapies can significantly extend survival.
A surgeon’s experience heavily influences a patient’s chances for improved outcome after surgery. Our highly specialized pancreatic surgeons have a proven track record in performing a variety of advanced pancreatic surgical techniques, including pancreas-sparing tumor resections and surgeries to remove extensive tumors.
Our "surgery last" approach
Whether or not a patient is eligible for surgery depends on many factors, including the size and location of the tumor and the stage of the disease.
For the last several decades, the standard care plan for operable pancreatic tumors has been surgery followed by radiation therapy and chemotherapy. Based on careful research, our care team strongly advocates a “surgery last” approach. What this means is that most patients with resectable or borderline resectable pancreatic tumors receive combined chemotherapy and radiation therapy (chemoradiation) prior to undergoing surgery to remove their tumor. This approach provides a better chance of controlling the cancer and setting the stage for a successful surgery.
Depending on the location and size of the tumor, the stage of the disease and the patient’s overall health, all or part of the pancreas may be removed. Our surgical oncologists offer the full range of surgical procedures for malignant pancreatic disease.
Even though CT scans and other tests may not find pancreas cancer in other organs within the abdomen, the tumor may have spread outside the pancreas.
To find these small tumors outside of the pancreas, we can look inside the abdomen using a small camera (laparoscope). A surgeon performs this in the operating room when the patient is under general anesthesia. If a small tumor is detected, it can be biopsied. If the cancer has spread beyond the pancreas, the surgeon may not remove the pancreas tumor. Other procedures, such as a bypass, to correct jaundice or help with eating may be performed.
Pancreaticoduodenectomy (the Whipple procedure)
This procedure involves removing the head of the pancreas, along with the bile duct and the upper part of the intestine and the gallbladder. During the surgery, the bile system, stomach and pancreas are reconnected to the intestine. A portion of the pancreas is preserved to produce digestive juices and insulin. Often a feeding tube is inserted into the intestine at the time of surgery to provide immediate nutrition to aid in the healing process. In addition, a temporary drain is left at the time of surgery to evacuate fluid from the abdomen and will be removed in the postoperative period.
This surgical procedure is used to remove all or part of the pancreas. In a total pancreatectomy, the entire pancreas is removed, usually along with the spleen, the gallbladder, the common bile duct, portions of the small intestine and the stomach. After a total pancreatectomy, the body loses the ability to secrete insulin, digestive enzymes and other substances. These conditions are treated with pancreatic enzyme replacement therapy and insulin injections.
In a distal pancreatectomy, only the body and tail of the pancreas are removed, leaving the head of the organ. Central pancreatectomy, in which only the middle section of the pancreas is removed, can be an option for some patients.
This surgical procedure is used to remove tumors located in the ampulla of Vater, which is the junction of the pancreatic duct and the common bile duct at the point where they enter the small intestine.
This is a limited surgical resection in which just the tumor and a surrounding rim of normal tissue is removed and most of the pancreas is left intact.
As pancreatic tumors grow, they often encroach upon adjacent blood vessels. Blood vessel involvement is a major challenge in pancreatic surgery and can cause patients to be ineligible for surgical treatment.
It is generally felt that surgical resection of the primary tumor is necessary to cure the patient with pancreatic cancer. For those patients who are deemed un-resectable due to local tumor extension to adjacent blood vessels, the median survival is 10 to 12 months. In contrast, if the primary tumor can be resected (to include adjacent vessels when necessary), median survival is two to three years and almost one-third of such patients survive five years from the time of diagnosis.
Our surgical oncologists are highly experienced in operating on pancreatic cancers that have invaded nearby veins. During a highly technical procedure, they are able to resect the portal vein and/or the superior mesenteric vein and reconstruct them using blood vessels from another part of the body.
An increasing number of studies have reported an inverse relationship between hospital volume and surgical mortality. This has been seen with pancreatic resections, where high volume hospitals have a significantly lower mortality.
Froedtert and MCW is one of the highest volume pancreatic surgery referral centers in Wisconsin. From 2010 to 2013, over 260 pancreatectomies have been performed, the majority of which are pancreaticoduodenectomies (Whipple procedures). In addition, we are one of the most experienced institutions in the U.S. with combined pancreatic resection and complex vascular reconstruction, accounting for 20 percent of all cases performed since 2010.
After surgery, patients are cared for by a dedicated team of surgeons, specially trained nursing staff, dietitians and endocrine specialists. A standardized pathway has been developed to expedite a safe recovery after the operation which has resulted in an approximately nine-day median hospital stay. From 2010-2013, our re-operative rate after pancreatic surgery has been 0.07 percent and we have had no thirty-day hospital mortalities.
From 2010-2013, the median survival for resectable patients who complete neoadjuvant therapy followed by surgery was 47.2 months. During the same time period, the survival for borderline resectable pancreatic cancer patients who completed all therapy was 21.8 months. These are among the best survival statistics for this challenging disease.
Advanced treatment with clinical trials
MCW physicians and staff are dedicated to providing their patients with the most up-to-date cancer treatment options.