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The European Society for Medical Oncology annually updates recommendations for the treatment of pancreatic cancer, including the stage 4 pancreatic cancer treatment, due to the active development of new therapeutic methods for improving the quality of life and longevity of people with this diagnosis. The National Comprehensive Cancer Network and specialized medical societies are also actively involved in the development of international protocols. According to current recommendations, the treatment regimen for pancreatic carcinomas includes surgical interventions, combination chemotherapy, as well as the use of immunotherapy, humanized monoclonal antibodies and PARP inhibitors.
- Surgical treatment and alternative methods
- Chemotherapy for resectable and unresectable tumors
- Chemoembolization for pancreatic cancer
- Hyperthermic intraperitoneal chemotherapy (HIPEC)
- Radiation therapy and proton therapy
- Systemic therapy and innovative methods
- Stage 4 pancreatic cancer treatment options
- Cost of treatment for pancreatic cancer stage 4
- Selection of a specialized hospital in any country with Booking Health
Surgical treatment and alternative methods
The comprehensive diagnostics of pancreatic cancer is of crucial importance for the selection of optimal starting therapy. This includes:
- Abdominal, endoscopic and intravascular ultrasound scan
- Abdominal CT scan and MRI, PET
- Angiography of the great vessels
- Diagnostic laparoscopy, in some cases with a biopsy
At the moment, the only methods that can significantly increase survival and improve prognosis are surgery for pancreatic cancer and chemotherapy. Depending on the results of studies, they can be carried out in a different order.
Surgery for pancreatic cancer is indicated for patients with localized tumors, without signs of the abdominal arteries damage or metastases in the peritoneum, liver or lungs. Thanks to the modern options of vascular surgery, invasion of a malignant neoplasm into the lumen of the superior mesenteric or portal vein is no longer an absolute contraindication for surgery for pancreatic cancer.
After determining the stage of pancreatic cancer according to the international classification of the American Joint Committee on Cancer, the surgeon will select the suitable type of intervention:
- Segmental pancreas resection or distal resection can be performed when carcinoma is located in the tail or body of the organ. The spleen can be removed as well. Depending on the patient’s anatomical features, resection can be endoscopic or open.
- Total resection, multivisceral resection involves the removal of the entire pancreas with spleen, regional lymph nodes, mesentery and affected areas of the intestine and liver. A total resection requires the subsequent replacement of the endocrine and exocrine functions of the removed pancreas by digestive enzymes and insulin injections.
- Whipple procedure is the surgery for pancreatic cancer that involves the partial removal of the stomach, duodenum, gallbladder, bile ducts, and pancreatic head. The subsequent reconstruction of the gastrointestinal tract is also the part of the Whipple procedure. The Whipple procedure is the complex and invasive intervention that is hard both to perform and to tolerate.
When cancer is not diagnosed early and the tumor is inoperable, the following alternative methods can be used instead of a pancreas resection or Whipple procedure:
- Radiofrequency or microwave ablation
- Irreversible electroporation using the NanoKnife
- Tumor destruction by high-intensity focused ultrasound
- Photodynamic therapy
Palliative surgery for pancreatic cancer can become an option of choice in this situation as well. It aims to alleviate pain, jaundice, bowel obstruction and other symptoms of cancer.
Chemotherapy for resectable and unresectable tumors
European clinics specializing in the treatment of pancreatic cancer carry out chemotherapy in the following cases:
- In patients with inoperable tumors
- In presence of contraindications to surgery for pancreatic cancer
- As a consolidation therapy after the radical surgery
- To enhance the effects of radiation therapy
- In case of distant metastases revealing
As a rule, chemotherapy regimens for pancreatic cancer include the simultaneous administration of several drugs. This mutually enhances their effect and allows them to fight against the chemoresistance of malignancies. The highest efficacy in treating the diagnosis was demonstrated by gemcitabine, oxaliplatin, paclitaxel, docetaxel, and capecitabine.
According to the results of clinical trials conducted in 2018, combination therapy using 4 chemotherapeutic agents prolongs the average life of patients by 2 years. In the course of the trial, the patients received oxaliplatin (Eloxatin), leucovorin (folinic acid), irinotecan (Camptosar) and 5-fluorouracil (Adrucil). Once safety and effectiveness have been confirmed, this treatment regimen was called mFOLFIRINOX. To date, it is used in patients with distant metastases in the liver and lungs.
Chemoembolization for pancreatic cancer
Transarterial chemoembolization for pancreatic cancer (TACE) is one of the stage 4 pancreatic cancer treatment options, as it is mainly carried out in patients with liver metastases. In eligible patients, chemoembolization for pancreatic cancer can be performed before the surgery, if the pancreatic carcinoma is not resectable.
Chemoembolization for pancreatic cancer combines advantages of chemotherapy with absence of the systemic side effects of chemotherapeutic agents. In addition, embolization itself contributes to the tumor shrinkage, as blocked arteries do not supply the neoplasm with nutrients and oxygen. Moreover, a tumor suffers from its own metabolic products. All of these lead to its destruction.
Chemoembolization for pancreatic cancer starts from insertion of the catheter into the femoral artery. Local anesthesia in order to make the procedure painless for the patient. After that the catheter is moved towards and through the celiac and superior mesenteric arteries. The digital subtraction angiography helps physicians to control the trajectory of the catheter.
When the catheter reaches the target blood vessel (e.g. the segmental tumor-feeding artery, splenic artery, super-mesenteric artery or gastroduodenal artery), the active part of chemoembolization for pancreatic cancer starts. The healthcare professional infuses the mixture of iodized oil (i.e. Lipiodol) with Gemcitabine and Oxaliplatin. After making sure that an embolus is in the correct part of the vascular system, the physician removes the catheter. After that, the patient stays under medical supervision for a few days.
Chemoembolization for pancreatic cancer is tolerated well, so patients can leave the hospital early. Due to the simple mechanism of action, it can be performed in combination with surgery, radiation therapy, immunotherapy, etc.
Hyperthermic intraperitoneal chemotherapy (HIPEC)
The hyperthermic intraperitoneal chemotherapy (HIPEC) is performed after the cytoreductive surgery – a surgical intervention that is aimed at maximal removal of the malignant tissues (i.e. the primary tumor and its metastases). HIPEC is another type of administering chemotherapeutic agents that allows healthcare professionals to use their higher doses and at the same time reduce the severity of side effects.
Candidates for HIPEC are people with peritoneal spreading of pancreatic carcinomas. HIPEC can not destroy the primary tumor, as the Whipple procedure or other surgeries do, but it can destroy the tinies metastases in the abdominal cavity. This slows down the disease progression rate and reduces the risk of relapse after the curative surgery.
The intervention requires general anesthesia, as the cytoreductive or curative abdominal surgery is carried out first (e.g. the Whipple procedure). After that, the heated chemotherapeutic drug is pumped into the abdominal cavity. It will circulate there about two hours, affecting all the remaining in the abdominal cavity cancer cells. High temperature allows the drug to penetrate tissues better.
In patients with advanced cancer, HIPEC demonstrates better survival when compared with palliative chemotherapy. When performing even the cytoreductive surgery is not reasonable, HIPEC can be carried out laparoscopically, without opening the abdomen. Such closed technique prevents drug spillage and cooling.
Radiation therapy and proton therapy
Radiation therapy has a number of indications, such as:
- Preoperative treatment of people with borderline resectable tumors. After the irradiation tumors shrink, which facilitates their subsequent removal.
- Treatment after curative surgeries, e.g. the Whipple procedure. In this case it is aimed at relapse prevention.
- Main treatment in people with locally advanced or unresectable tumors (in combination with chemotherapy or immunotherapy).
- Palliative treatment in people with advanced cancer. In this case it is aimed at alleviation of symptoms and improving the patient's condition.
Proton therapy is mainly used in people with advanced cancer, where the precise irradiation is required. Proton therapy for stage 4 pancreatic cancer is one of radiation therapy types and one of the precise non-invasive stage 4 pancreatic cancer treatment options.
Proton therapy for stage 4 pancreatic cancer starts from manufacturing the special device, i.e. the individual immobilizer that fixes the body position during a proton therapy session. Then, according to the treatment scheme, two more devices are manufactured. These are the collimator and the bolus. The collimator determines the shape of the proton beam. The bolus determines the depth of the proton beam penetration.
Proton therapy for stage 4 pancreatic cancer is the outpatient procedure. This is the additional advantage, as the treatment course is rather long – it can take up to 5-7 weeks. Proton therapy for stage 4 pancreatic cancer is carried out once a day, 5 days a week. Its total duration is about 15-30 minutes daily.
Proton therapy for stage 4 pancreatic cancer is painless. It does not require bed rest or other restrictions.
Systemic therapy and innovative methods
In 2018, a reputable international organization FDA approved the use of poly (ADP-ribose) polymerase (PARP) inhibitors for the treatment of pancreatic cancer. The action of the drugs is based on the phenomenon of "synthetic mortality" – cell destruction with insufficient expression of two or more related genes, while blocking only one of them does not have the similar effect.
The main mutant gene affected by PARP inhibitors is the BRCA gene. Such a mutation is detected rarely, in only 4-7% of pancreatic carcinomas. Fortunately, PARP inhibitors are also effective in other mutations that are potentially associated with BRCA genes, namely mutations in the ATM, PALB2, and CHEK2 genes. Genetic tumor testing is carried out in large laboratories using special test systems to search for target mutations.
The first molecule from the group of PARP inhibitors was olaparib (Lynparza). Olaparib is used in first-line maintenance therapy in patients with metastatic pancreatic cancer. According to the results of further clinical trials, rucaparib (Rubraca), niraparib (Zejula) and talazoparib (Talzenna) were implemented into the clinical practice.
The 2019 studies also explore the combination of stereotactic radiation therapy with immunotherapy. The studies in mice have demonstrated that such a therapeutic regimen can not only destroy the tumor, but also retrain the patient’s immune system to recognize and destroy atypical cells. Potentially, this will allow to fight pancreatic carcinoma metastases in the liver.
Stage 4 pancreatic cancer treatment options
Stage 4 pancreatic cancer treatment options include techniques that increase life expectancy and quality of life. Such treatments must be well-tolerated by patients, as people with advanced cancer are often debilitated, have impaired function of kidneys or liver, etc.
The first-line treatment for stage 4 pancreatic cancer is chemotherapy that is administered in the form of:
- Systemic chemotherapy (the FOLFIRINOX scheme)
- Hyperthermic intraperitoneal chemotherapy (open or laparoscopic)
- Chemoembolization for pancreatic cancer with liver metastases
- Chemoradiation therapy
Proton therapy for stage 4 pancreatic cancer is the most precise and sparing type of radiation therapy. Less precise irradiation options are external beam radiation therapy and brachytherapy (i.e. implantation of radioactive seeds inside the pancreas).
Targeted therapy is another stage 4 pancreatic cancer treatment option. Most of targeted drugs are monoclonal antibodies that target HER2 receptor or epidermal growth factor receptors (EGFR). These suppress tumor growth and spread, and make it visible for the patient's immune system.
Palliative surgeries that relieve symptoms but usually do not target the primary tumor are performed:
- Bile duct bypass surgery in patients with mechanical jaundice
- Gastric bypass surgery in patients with gastric outlet obstruction
- Stenting in patients with blocked bile duct or small intestine
Symptomatic treatments, such as pain killers, sleep medications, sedatives, etc.
Cost of treatment for pancreatic cancer stage 4
Cost of treatment depends on the procedure itself, country and the hospital, age of the patient, etc. The approximate prices for different stage 4 pancreatic cancer treatment options are as follows:
- Cost of treatment for pancreatic cancer stage 4 with Whipple procedure (pancreaticoduodenectomy) starts at €32,181
- Cost of treatment for pancreatic cancer stage 4 with chemotherapy and radiation therapy starts at €12,660
- Cost of treatment for pancreatic cancer stage 4 with ERCP and biopsy under CT guidance starts at €4,321
- Cost of treatment for pancreatic cancer stage 4 with the segmental pancreas resection starts at €32,105
- Cost of treatment for cancer stage 4 with chemotherapy starts at €2,485
- Cost of treatment for cancer stage 4 with proton therapy starts at €44,275
- Cost of treatment for cancer stage 4 with ERCP and bougienage starts at €6,858
These prices include the initial diagnosis making, treatment according to the recommended scheme and early rehabilitation.
Selection of a specialized hospital in any country with Booking Health
The choice of a medical institution and a doctor significantly affects the final result of treatment. If you plan to seek medical help at a foreign clinic, it is important to study reliable information and plan the administrative aspects of the trip in advance. This especially concerns people who look for stage 4 pancreatic cancer treatment. Booking Health, which is a certified medical tourism operator, has been helping foreign patients and their relatives with the comprehensive organization of treatment abroad for more than 12 years.
The specialists of Booking Health will help you with the following issues:
- Selection of the right hospital according to information from the annual qualification report
- Direct communication with your attending physician (oncologist, surgeon)
- Preliminary preparation of a medical program for diagnosis making or treatment (without repeating previous examinations)
- Provision of a favorable cost of medical services, including cost of treatment for cancer stage 4, without additional coefficients for foreign patients (saving up to 50%)
- Preliminary appointment with a doctor on the desired date
- Monitoring of implementation of all stages of the medical program
- Insurance against the cost of treatment increase in case of complications (а coverage of 200,000 EUR, valid for 4 years)
- Assistance in buying and forwarding medicines
- Communication with doctors after discharge from the hospital
- Control of invoices and return of unspent funds
- Organization of additional examinations, maintenance therapy and rehabilitation
- Top-class service: booking hotels, airline tickets, transfer
If you need more information about pancreatic tumors, or if you are looking for the most effective stage 4 pancreatic cancer treatment options, leave your request on the Booking health website. A medical advisor or patient case manager will contact you the same day, so you will discuss all the important issues.
Choose treatment abroad and you will for sure get the best results!