Pancreatic Cancer that has spread. Continue treatment?

[mwason]

My 76 year old aunt had pancreatic cancer 17 years ago, had the whipple surgery and had been fine until January of this year. A new tumor was found on what remained of her pancreas. We went to Boston and they removed the rest of her pancreas on March 9th. Her pathology report said none of the nodes were positive. She recovered well and manages her diabetes great. Beginning of June (3 months later) a ct scan reveals 2 spots on her liver. She is desperate to try something and the dr. very reluctantly puts her on Gemzar (75% dose because she is 90 lbs.) She did 3 cycles of three weeks on 1 week off. She tolerates the Gemzar very well. She did a scan on Monday and yesturday we saw the dr. for the results. He said the first two have grown and there are two new ones. He told her he could not "ethically" keep her on something that is not working. When he saw the look of fear in her eyes and she practically begged him to not stop treatment, he agreed to try 5FU. But I can't help but wonder if he's already given up on her. So, I have these questions:
1-How does he know it isn't working? How does he know there wouldn't have been more growth without the chemo? (I asked him this and he said it either works or it doesn't)
2-Should she stay on the Gemzar? It seems to extend the life and quality of better than 5FU as far as I read. It also helps the symptoms of the cancer right?
3-I'm wondering about a second opinion, but I hate to add confusion and upset her. We are right in the middle of treatments with this dr.
I guess I just can't see why we should stop since she feels very good now. It is so sad to see her ask about a liver transplant, liver perfusion, anything....and just keep getting the same answer. She won't give up and I don't blame her. It's all that's keeping her going.
Thanks so much for your time. We do appreciate it so much.

[Kevin Pho, MD]

To answer your questions:
1) The unfortunate fact that the tumors grew while under treatment would suggest that it isn't working.

2) As has been mentioned below, withdrawing treatment would indeed be a sign of giving up, and if your aunt won't give up, certainly her physicians shouldn't either.  As has been mentioned below, an unlikely chance is better than no chance at all.  Typically, a 5-FU based therapy is suggested as adjuvent treatment for pancreatic cancer.  I am not familiar enough with Gemzar to comment if it is a better regimen.  

Again, this is a very difficult issue where a shared decision should be made between the physician team and the family.  There may not be any "right" answers.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
Medical Weblog:
kevinmd_b

[surgeon]

The fact that tumors grew under treatment and new ones appeared show the treatment isn't effective. The hard truth is that pancreatic cancer rarely responds to chemotherapy. It's also true that to withdraw treatment is to signal no hope; and if hope gives a person a way to go on, then it's a hard thing to stop. It's a terrible dilemma for everyone: the patient, the family, the physicians. There's no clearly "right" answer ethically. More drastic measues such as perfusion can't be predicted to have absolutely no benefit an a given situation. But when one looks at the data, people in her situation typically have a life expectancy between 3 and 6 months. Is a one in a million chance significantly different from no chance? How does one deal with such a thing? As a surgeon who has dealt with pancreatic cancer in many patients, I've in general tried to be truthful and candid; and when it looked like time to adopt comfort measures, I felt it best to say so. But in some cases, when there was a desire to go for even the most unlikely outcomes, I didn't feel like I could absolutely say no. I still don't know what's right.

[GallbladderBaby]

Hello,
I sooo appreciate your input on this board Surgeon.  You have provided excellent feedback and info to all.  However, I have a slightly different perspective.  First, I think it is awesome that there is a 17 year survivor of a Whipple!  What an excellent outcome and blessing!  Second, I wouldn't throw in the towel yet.  There are some "chemo cocktails" such as Gemzar, Taxotere, and Xeloda (GTX) that may keep the tumors "at bay" for a while.  Why not try something like that?  If it is too much for her system, she can stop.  Third, I'd like to direct you to the Johns Hopkins Patient and Caregiver Discussion Board for Pancreatic Cancer.  URL:    It is a terrific group of people who really support each other with great information and support.  Here is the address: http://162.129.103.56/N/n.web?EP=N&URL=/MCGI/SEND1^WEBUTLTY(199,8)/43905366  God bless you and yours!  
Sincerely,
GallbladderBaby

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