Pancreatic cancer is referred to as stage III cancer if the final pathology report shows that the cancer has spread to local lymph nodes and major blood vessels. A patient may be diagnosed with stage III cancer following surgical removal of the pancreas and surrounding lymph nodes or after surgical sampling of the lymph nodes. Pancreatic cancer diagnosed at this stage is often difficult to cure. To help improve a patient's outcome, a combination of anti-cancer drugs, radiation therapy or participation in a clinical trial is often recommended following surgery. If the cancer cannot be removed by surgery, a combination of anticancer drugs and/or radiation therapy may be given instead.

When complete surgical removal of the cancer is possible, stage III pancreatic cancer is best managed by surgery. The most common surgical procedure is a pancreaticoduodenectomy, or Whipple procedure, which involves removal of a portion of the pancreas, small intestine (duodenum), stomach and the entire gallbladder. The exact surgical procedure may differ based on the location and extent of the cancer within the pancreas. To learn more, go to Surgery & Pancreatic Cancer.

While up to 20% of patients survive without evidence of cancer 5 years after surgery, the majority of patients with stage III pancreatic cancer will develop recurrence of their cancer after surgery. The cause of relapse following treatment is micrometastases, which are small amounts of cancer that have spread outside the pancreas. The majority of patients with stage III disease have micrometastases that cannot be detected with currently available tests and cannot be removed with surgery. The presence of micrometastases causes the relapses that follow treatment with surgery alone. -In order to increase the chance of cure with surgical removal of the cancer, an effective treatment is needed to cleanse the body of micrometastases.

The following is a general overview of treatment for stage III pancreatic cancer. Treatment may consist of surgery, radiation, chemotherapy, biological therapy, or a combination of these treatment techniques. Multi-modality treatment, which is treatment using two or more techniques, is increasingly recognized as an important approach for improving a patient's chance of cure or prolonging survival. In some cases, participation in a clinical trial utilizing new, innovative therapies may provide the most promising treatment. Circumstances unique to each patient's situation may influence how these general treatment principles are applied. The potential benefits of multi-modality care, participation in a clinical trial, or standard treatment must be carefully balanced with the potential risks. The information on this website is intended to help educate patients about their treatment options and to facilitate a mutual or shared decision-making process with their treating cancer physician.

Adjuvant Therapy

The delivery of cancer treatment following surgery is referred to as "adjuvant" therapy. The purpose of adjuvant therapy for patients with stage III pancreatic cancer is to reduce cancer recurrences. Adjuvant therapy may include chemotherapy and/or biological therapy.

Chemotherapy involves the use of anti-cancer drugs to destroy cancer cells throughout the body. Chemotherapy is considered a systemic therapy because the drug circulates throughout the body and can kill cancer cells that have spread to locations distant from where the cancer started. Chemotherapy is commonly used to stage III pancreatic cancer.

Long-term results from a large clinical trial conducted by the European Study Group for Pancreatic Cancer showed that adjuvant chemotherapy increased survival in patients with operable pancreatic cancer, while adjuvant chemoradiation had a detrimental effect . 1 This trial involved 289 patients who underwent surgery plus one of the following treatments:

• 5-FU Chemotherapy 
• 5-FU Chemotherapy and radiation (chemoradiation)
• No additional treatment (surgery alone).

Patients with early stage pancreatic cancer who were treated with adjuvant chemotherapy after surgery lived longer than those who treated with surgery alone.  However, adjuvant treatment with chemotherapy plus radiation produced no benefit compared to surgery alone (see table 1).

Table 1 Adjuvant chemotherapy or adjuvant chemoradiation versus surgery alone in early stage pancreatic cancer

Gemzar®: The standard chemotherapy drug for the treatment of advanced pancreatic cancer is Gemzar®, which has been shown to improve response to treatment, time to cancer progression, and survival duration when compared with the older chemotherapy drug 5-fluorouracil. 2   In a clinical trial comparing Gemzar® and 5-FU, Gemzar® produced significant improvement in disease-related symptoms and prolonged survival.

Strategies to Improve Treatment of Stage III Pancreatic Cancer

The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. Future progress in the treatment of stage III pancreatic cancer will result from the continued evaluation of new treatments in clinical trials. Participation in a clinical trial may offer patients access to better treatments and advance the existing knowledge about treatment of this cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. Areas of active investigation for the purpose of improving the treatment of stage III pancreatic cancer include the following:

New Adjuvant Therapy

Chemotherapy: Several new chemotherapy drugs show promising ability to kill cancer cells in the treatment of advanced or recurrent pancreatic cancer. These anticancer drugs including Gemzar® and Taxotere®, and may be available to patients with stage III disease.

Combination chemotherapy (regimens): Each chemotherapy drug works in a slightly different way. Therefore, administering a combination of two or more chemotherapy drugs, also known as a regimen, may kill more cancer cells than treatment with a single drug. Gemzar®-based combination chemotherapy regimens are being evaluated in patients with stage III disease.

Neoadjuvant Therapy

In an effort to increase the chance that a cancer may be surgically removed, some cancer centers may use radiation therapy and chemotherapy before surgery to shrink the cancer. The use of treatment before surgery is referred to as "neoadjuvant therapy." In addition to potentially shrinking cancer so that it can be removed, neoadjuvant therapy allows patients to avoid the difficulty of undergoing treatments after surgery, which is a time when they may be experiencing side effects. Surgery to remove pancreatic cancer is associated with substantial side effects that may delay further treatment or may even render a patient incapable to tolerating adjuvant treatment. Approximately 25% to 33% of patients are unable to receive chemotherapy or radiation treatment following surgery. Furthermore, a treatment plan that includes neoadjuvant therapy guarantees that systemic therapy is delivered immediately, which may increase the chance of eradicating small amounts of cancer that may have already spread to distant locations in the body and cannot be removed by surgery. Neoadjuvant therapy is currently being administered at some cancer centers and being evaluated in clinical trials.

Photodynamic therapy

Photodynamic therapy works through the use of a photosensitizing agent and light. The photosensitizing agent is injected into a patient's vein a couple of hours prior to surgery. During this time, the agent selectively collects in rapidly growing cells such as cancer cells. During surgery, the physician applies a certain wavelength of light through a hand held wand directly to the site of the cancer and surrounding tissues. The energy from the light activates the photosensitizing agent, causing the production of a toxin that accumulates in the cancer cells and ultimately destroys them.

Researchers from England have reported that photodynamic therapy may be a safe and effective treatment option for some patients with inoperable pancreatic cancer. In this trial, 16 patients were first given the photosensitizing agent meso-tetrahydroxyphenyl chlorin through a vein. Three days later, light was delivered to the cancer through the guidance of computerized tomography (CT) scans. Fourteen patients were able to leave the hospital within 10 days. The average survival time was 9.5 months and 44% of the patients were alive at one year following therapy. Treatment was very well tolerated by the majority of patients; however, two patients developed bleeding that was controlled by surgery and three patients developed an obstruction in their large intestine. 3

Managing Side Effects

Managing the side effects of cancer and/or cancer treatment is an important part of receiving optimal care. Side effects cause inconvenience, discomfort, and may occasionally be fatal. Additionally and perhaps more importantly, side effects may prevent doctors from delivering the prescribed dose of therapy at the specific time and schedule of the treatment plan. Because the expected outcome from therapy is based on delivering treatment at the dose and schedule prescribed in the treatment plan, a change from the treatment plan may reduce your chance of achieving an optimal outcome. This is extremely important to understand. In other words, side effects not only cause discomfort and unpleasantness, but may also compromise your chance of cure by preventing the delivery of therapy at its optimal dose and time. For more information, go the Managing Side Effects section.