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Chemotherapy for advanced exocrine pancreatic cancer

Author
David P Ryan, MD
Section Editor
Richard M Goldberg, MD
Deputy Editor
Diane MF Savarese, MD

INTRODUCTION

Approximately 53,070 people develop exocrine pancreatic cancer each year in the United States, and because of its aggressive character and the fact that most patients present with relatively advanced disease, most die from the disease [1]. The majority of these tumors (85 percent) are adenocarcinomas arising from the ductal epithelium. (See "Pathology of exocrine pancreatic neoplasms".)

Surgical resection offers the only chance of cure. However, only 15 to 20 percent of patients have resectable disease at initial diagnosis; the majority have either locally advanced or metastatic cancer.

The use of chemotherapy in the treatment of metastatic pancreatic adenocarcinoma will be reviewed here. Multimodality management for locally advanced disease, specific methods for symptom palliation, and management of patients with metastatic islet cell (endocrine) tumors are discussed separately. (See "Initial chemotherapy and radiation for nonmetastatic locally advanced unresectable and borderline resectable exocrine pancreatic cancer" and "Supportive care of the patient with locally advanced or metastatic exocrine pancreatic cancer" and "Endoscopic ultrasound-guided celiac plexus and ganglia interventions" and "Metastatic well-differentiated gastroenteropancreatic neuroendocrine tumors: Presentation, prognosis, imaging, and biochemical monitoring".)

TREATMENT ENDPOINTS

Traditional two-dimensional or unidimensional tumor measurements to determine objective response to therapy are often inadequate when evaluating the primary site in the pancreas due to the characteristic desmoplastic reaction and inflammatory response that develops there [2]. Despite this, single-agent chemotherapy trials in pancreatic cancer have commonly used objective response as a primary endpoint. This endpoint is likely more accurate for assessment of liver and other metastatic disease sites than it is for assessing the primary tumor.

Many trials have permitted patients with both locally advanced and metastatic disease to enroll, perhaps leading to an underestimation of response rates. More recent trials have included quality of life endpoints since so many patients with pancreatic cancer present with pain and depression [3-6]. In addition, increasing emphasis has been placed upon "clinical benefit" and survival as more accurate determinants of efficacy [7].

                                         

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