Pancreatic Cancer

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A Patient’s Guide to Pancreatic Cancer

COMPREHENSIVE CANCER CENTER

Staff of the Comprehensive Cancer Center’s Multidisciplinary Pancreatic Cancer Program provided information for this handbook GI Oncology Program, Patient Education Program, Gastrointestinal Surgery Department, Medical Oncology, Radiation Oncology and Surgical Oncology Digestive System Anatomy

Esophagus

Liver Stomach Gallbladder

Duodenum

Colon

Pancreas (behind the stomach)

Anatomy of the Pancreas

Celiac Plexus

Pancreatic Duct

Common Bile Duct

Sphincter of Oddi Head Body Tail Pancreas

I. Overview of pancreatic cancer A. Where is the pancreas located?...... 1 B. What does the pancreas do? ...... 2 C. What is cancer and how does it affect the pancreas?...... 2 D. How common is pancreatic cancer and who is at risk?...... 3 E. Is pancreatic cancer hereditary?...... 3 F. What are the symptoms of pancreatic cancer?...... 4 G. How is pancreatic cancer diagnosed?...... 7 H. What are the types of cancer found in the pancreas?...... 9

II. Treatment A. Treatment of Pancreatic Cancer...... 11 1. What are the treatment options?...... 11 2. How does a patient decide on treatment?...... 12 3. What factors affect prognosis and recovery?...... 12 D. Surgery...... 13 1. When is surgery a treatment?...... 13 2. What other procedures are done?...... 16 E. Radiation therapy ...... 19 1. What is radiation therapy?...... 19 2. When is radiation therapy given?...... 19 3. What happens at my first appointment? ...... 20 F. Chemotherapy...... 21 1. What is chemotherapy?...... 21 2. How does chemotherapy work?...... 21 3. When is chemotherapy given?...... 21 G. Clinical trials ...... 23 1. What are some examples? ...... 24 2. How do I find out about research?...... 24

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©2012 University of Michigan Comprehensive Cancer Center A Patient’s Guide to Pancreatic Cancer III. After Treatment A. When to call a doctor...... 25 B. What can I do to maintain weight and increase appetite?...... 26 C. What can be done for itching and yellowing of the skin? ...... 28 D. What can be done to treat pain?...... 29 E. Why does high blood sugar and diabetes happen? ...... 33 F. What can be done to prevent constipation?...... 33 G. What do pancreatic enzymes do?...... 35 H. What should I do for swollen legs?...... 36 I. How do I cope with my feelings?...... 37

IV. Resources A. Support and Coping Resources ...... 41 B. Note Pages...... 42 C. Appointments & Calendar...... 45 D. Important Phone Numbers ...... 49 E. Maps & Other Information...... provided in back pocket

Illustrations Figure 1: Anatomy of Pancreas ...... 1 Figure 2: The Pancreas and Surrounding Organs...... 4 Figure 3: Patient Undergoing an ERCP...... 8 Figure 4: The Whipple Procedure...... 14 Figure 5: The Distal Pancreatectomy Procedure...... 15 Figure 6: Pancreatic Head Mass ...... 16 Figure 7: Stent Placement ...... 17 Figure 8: Biliary Drainage Tube Placement ...... 18

The medical team at the University of Michigan Pancreatic Cancer Clinic at the Comprehensive Cancer Center created this booklet to help explain pancreatic cancer and the treatment options available to you. Your medical team is available to help answer questions about this material and to help answer any questions you may have. Do not hesitate to contact us as you make your treatment decisions. Resource phone numbers are listed in the back of this booklet.

All of this information is available at the Patient Education Resource Center located on level B1 of the Cancer Center Building.

The information in this booklet will be reviewed and discussed throughout your treatment.

Please bring this booklet with you to all appointments.

You will find blank pages at the back of the book to use for questions, appointments or other notes.

©2012 University of Michigan Comprehensive Cancer Center A Patient’s Guide to Pancreatic Cancer vi A Patient’s Guide to Pancreatic Cancer ©2012 University of Michigan Comprehensive Cancer Center OVERVIEW Pancreatic Duct Pancreas A Patient’s Guide to Pancreatic Cancer Head Body Tail Celiac Plexus 1

Pancreatic Cancer Pancreatic Figure1. Anatomy of the Pancreas Figure1. The head of the pancreas is on the right side of your pancreas is on the right The head of the Sphincter of Oddi Common Bile Duct ©2012 University of Michigan Comprehensive Cancer Center The pancreas is pear-shaped and approximately 6-8 inches long. It has a wider 6-8 inches long. It is pear-shaped and approximately The pancreas end called the body and a tapered head, the middle part called end called the 1. the tail. Refer to Figure the of the small bowel called to the liver and the section body. It lies close abdomen. on the left side of the tail is close to the stomach ‘duodenum’. The that runs through the pancreas and empties The pancreatic duct is a channel bowel. The common bile duct is another channel digestive juices into the small and runs through the head of the pancreas that drains bile from the gallbladder duct to form the Ampulla of Vater. connecting with the pancreatic Where is the pancreas located? is the pancreas Where OVERVIEW A Patient’s GuidetoPancreatic Cancer This spreadingiscalled metastasis. structures inthebody bywayofthelymphaticsystemand bloodstream. structures. Cancercells spreadandinvadeorgansbytraveling toother Abnormal oruncheckedcellscanalsogrow toinvadenearbyorgansand the pancreas,suchasliver,disease isstillcalledpancreaticcancer. site isthepancreas.Evenwhenpancreatic cancerisfoundinareasoutside growth iscalledthecancer’s“primarysite”. Inpancreaticcancer,theprimary cell site oftheabnormal organ works. Theoriginal tumor thatcanaffectan how Cells thatcontinuetogrowanddivideuncheckedbecomeamalignantmassor treat cancer. abnormalities andcontinuestobeafocusintheunderstandingofhow disturbed. Medicalresearchhasledtoanincreaseunderstandingofthese poorly controlledmannerwherethebalanceofcellgrowthanddeathis in thebody.Cancerisadiseasewherecellsdivideandgrowanabnormal, Normal cellsgrow,divide,anddieinacontrolledfashionthatisregulated What iscancerandhowdoesitaffectthepancreas? endocrine pancreas. exocrine pancreasandtheotherpartthatproducehormonesiscalled The partofthepancreasthatproducesdigestivejuicesiscalled The pancreashas2mainfunctionsinthebody: What doesthepancreasdo? tosecretehormones,likeinsulin,thataffect howthebodyusesand • tomakedigestivejuices(calledenzymes)that flowthroughthe • stores nutrients. digestive system,and pancreatic ductsandhelpbreakdownfatssugarsinthe

OVERVIEW Information Cancer Center. A Patient’s Guide to Pancreatic Cancer (PERC) on level B1 of the about genetic counseling at the University of Michigan can be Patient Education Resource Center or at the found at www.mcancer.org 3

• Cigarette smoking • A diet high in fat and low in fiber • Diabetes mellitus • Chronic pancreatitis • Family history (see below) ©2012 University of Michigan Comprehensive Cancer Center understand possible hereditary factors in pancreatic cancer. There does seem to be a hereditary component in 10-15% of patients pancreatitis, with pancreatic cancer. Genetic syndromes such as hereditary multiple mole hereditary nonpolyposis colorectal cancer, familial atypical currently being studied melanoma syndrome, and Peutz-Jeghers syndrome are for their specific gene changes. Research is being done to better Is pancreatic cancer hereditary? There is no reliable way to prevent pancreatic cancer, however, general cancer There is no reliable way to eating a high-fiber, low-fat diet, exercising, and prevention guidelines include avoiding smoking. How common is pancreatic cancer and who is at risk? and who cancer is pancreatic How common be women will men and that 32,180 Society estimates Cancer The American cause of the fourth leading in 2005. It is cancer with pancreatic diagnosed in the commonly affects patients in the United States. It most cancer death younger patients can be affected. range, although older and 60-80 year age called to cancer-causing agents may be related to exposure Pancreatic cancer carcinogens. cancer are: that increase the risk of pancreatic Some factors OVERVIEW A Patient’s GuidetoPancreatic Cancer of thepancreasmaygrowandblockthesestructures. common bileductandduodenum(smallbowel)sotumorslocatedinthehead of thetumorinpancreas.Theheadpancreasislocatedcloseto Symptoms dovaryandarerelatedtotheextentofdiseaselocation What arethesymptomsofpancreaticcancer? cancer, andmelanomamaybeatanincreasedriskforpancreaticcancer. research setting.Patientswhohaveafamilyhistoryofcoloncancer,pancreatic include pancreaticcancershouldconsidergeneticcounselingandtestingina Families withmedicalhistoriesofknownhereditarycancersyndromesthat Duodenum Bile Duct Common Portal Vein Gallbladder Liver Figure 2.Thepancreasandsurroundingorgans

• of the skin, yellowing • the eyes, of the whites of yellowing • bowel movements, (clay colored) light-colored • urine and dark-colored • itching ©2012 University of Michigan Comprehensive Cancer Center Nausea, Vomiting, Weight Loss Nausea, Vomiting, Weight when the duodenum is compressed. This Stomach emptying can be delayed and contributes to symptoms of nausea and causes a feeling of fullness are initially present in 35-45% of patients with vomiting. These symptoms sometimes have a loss of appetite and nausea that pancreatic cancer. Patients disease, up to 5% of patients have tumors that leads to weight loss. In advanced the duodenum (small bowel). In this case, surgery cause complete blockage of blockage and improve digestion. may be done to bypass the Fatigue of being tired and In more advanced disease, patients can have a feeling fatigued. There are many causes of fatigue in patients with cancer, Abdominal Pain pain. This may be 75-90% of patients with pancreatic cancer have abdominal spread, or radiate, to the described as cramping or gas-like pain. Pain may also back and shoulders. Jaundice in the with tumors of patients in 70-85% lead to jaundice blockage can Bile duct of jaundice include: Symptoms the pancreas. head of OVERVIEW A Patient’s GuidetoPancreatic Cancer on managementofpancreaticinsufficiency withenzymes. intestines thatcausesdiarrheaandcramping. fully digested.Astheindigestiblefoodpasses through,itpullswaterintothe after eating.Thishappensbecausefoodpassesthroughthedigestivetractnot Symptoms ofpancreaticinsufficiencyincludediarrheaandcrampingoften happens, foodisn’tdigestednormally.Thisiscalledpancreaticinsufficiency. may nothaveadequateamountsofthesejuicesintheintestines.Ifthis These juiceshelpdigestfoodintheintestines.Patientswithpancreaticcancer The pancreassecretesdigestiveenzymes,orjuicesintothesmallintestines. Pancreatic Insufficiency so withoutinsulin,bloodsugarlevelsareoftenhigh. to useinsulinproperly.Insulinhelpsyourbodyregulatethebloodsugarlevel, when thebodydoesnotproduceenoughofhormone,insulin,orisunable diagnosed beforeorafterthediagnosisofpancreaticcancer.Diabetesoccurs blood sugarlevelsisalsoassociatedwithpancreaticcancer.Diabetesmaybe The onsetofdiabetesmellitus(calledsimply,diabetes)ordifficultycontrolling Diabetes symptoms, butswelling,painandrednesscanbepresentintheareaofaclot. changes inthebloodthatincreasesriskforclots.Someclotshaveno blood clotcanbeafirstsymptomofpancreaticcancer.Thecanceritselfcauses There isanincreasedriskforbloodclotsinpatientswithpancreaticcancer.A Blood Clots

A Patient’s Guide to Pancreatic Cancer Cancer Center. Further information about these tests and Center on level B1 of the procedures can be found @ www.umich.edu/pteducation visit the Patient Education Resource visit the Patient Education Resource 7

©2012 University of Michigan Comprehensive Cancer Center An ultrasound can identify a tumor or An ultrasound can identify bile duct mass in the pancreas or the a blockage system that may be causing and jaundice. (EUS) Endoscopic Ultrasonography lighted tube that is inserted through the mouth The EUS test is done with a Ultrasound images of the pancreas are obtained and placed into the stomach. It is highly sensitive for diagnosing pancreatic through the stomach wall. useful for detecting small (<2 cm) pancreatic tumors cancer. EUS is particularly tumors that may which may not be well visualized by CT. It can also identify details about involve important blood vessels. The procedure can provide with a small or ‘fine’ the arteries and veins next to the pancreas. A biopsy during an EUS to needle aspiration (FNA) of the tumor may also be performed for this procedure. diagnosis pancreatic cancer. Intravenous sedation is used ERCP (endoscopic retrograde cholangiopancreatography) to look at the bile An ERCP is done with a lighted tube called an endoscope a blocked bile duct ducts. It can also be used to place a stent or tube to open used for this procedure. for drainage. Intravenous sedation is most commonly How is pancreatic cancer diagnosed? cancer diagnosed? pancreatic How is to undergo tests cancer will for pancreatic suspicious with symptoms Patients be cancer can pancreatic Diagnosing of these symptoms. the cause determine adequate biopsy for the pathologist is often difficult to get an a challenge. It the for the patient and the microscope. It is frustrating to look at under beginning in making a diagnosis and to move ahead quickly doctor who want procedures used to diagnose are some of the tests and treatment. Below pancreatic cancer. Ultrasound of the abdomen OVERVIEW A Patient’s GuidetoPancreatic Cancer involvement ofsurrounding vesselsandorgans.Thisisaspecial CTscan for yourfirstclinicvisit tobetterassessthetumorforsize, locationand areas. Thedoctormay suggesta‘pancreaticmass’CTtobe done attheUM organs forspread(metastasis)ofthecancer intolymphnodes,liverandother tumor mightbegrowingintooraround. ACTscancanalsolookatsurrounding The CTscancanshowsmalltumorsaswell asimportantbloodvesselsthatthe Computed Tomography(CT) pathologist toevaluateforcancercells. pancreas. Bileductjuiceandtissuesamplesmaybeobtainedsenttoa tumors, cholangiocarcinoma(bileductcancer),inflammationorcancerofthe what iscausingablockage.Somecausesoftheseblockagesincludeampullary The patientisnotawakeduringthetest.Thisprocedurehelpsdetermine Figure 3.Patientundergoingendoscopicprocedure

OVERVIEW

. A Patient’s Guide to Pancreatic Cancer For more www.cancer.gov information on islet cell or National Cancer Institute at available online through the neuroendocrine cancer, visit the visit the neuroendocrine cancer, Patient Education Resource Center call them at (734) 647-8626. Information is (PERC) on level B1 of the Cancer Center or 9

Tumors may arise from the endocrine Tumors may arise from the part of the pancreas in approximately 5% of the cases. This is sometimes referred as Islet (insulin producing) cell or neuroendocrine cancer. Even rarer tumors are sometimes found, such as sarcomas and lymphomas. of This booklet will focus on treatment for ductal adenocarcinoma the pancreas. There are many different kinds of pancreatic tumors; however, pancreas cancer There are many different kinds This type of pancreatic cancer arises is mainly (95%) ductal adenocarcinoma. the pancreas which of duct is the exocrine part the liningthe pancreatic from of juices. that produces the digestive What are the types of cancer found in the pancreas? What are the types of cancer done at the University of Michigan that examines the pancreas very closely. A A very closely. pancreas the examines that Michigan of University at the done to the radiologist; information give additional the CT, to dye is used for special scan. prior to the will be placed catheter) IV (intravenous a temporary therefore and the consulting doctor reviewed by the radiologist The CT will be in 1-2 days. Radiology Interventional using can perform needle biopsies the radiology department In some cases a the mass (tumor) and obtain technique to locate the CT or ultrasound abdomen for a diagnosis. At the UM Interventional tissue sample through the specialists who may be consulted to do one of Radiology department we have these procedures. OVERVIEW A Patient’s GuidetoPancreatic Cancer

and A Patient’s Guide to Pancreatic Cancer 11 a combination of chemotherapy a combination of chemotherapy and radiation or chemotherapy alone • operable cancer, • locally advanced cancer, • metastatic cancer help to determine These classification groups the cancer. the most effective way to treat can be If it’s determined that the cancer surgery is successfully removed, then localized, considered. For patients with treatment but not operable, cancer, two strategies are used: 1. 2. has spread, For patients with cancer that chemotherapy can be offered as treatment.

means Treatment of Pancreatic Cancer of Pancreatic Treatment F F F F F F unresectable) unresectable) with no evidence of surgically removed. only in the pancreas to be a tumor is able for example, the liver. for example, the liver. (also called resectable) spread to other organs. (tumors at this stage are (tumors at this stage are means Operable cancer to other parts of the body means the tumor is found Locally advanced cancer that the cancer has spread Metastatic disease ©2012 University of Michigan Comprehensive Cancer Center into three main groups; can be classified (or staged) Pancreatic cancer the importance Doctors and nurses discussing treatment options stress those treatments as of treating the disease while at the same time making the growth of the cancer, tolerable as possible. The goal of treatment is to stop quality life for as to shrink it, if possible, and to help the patient live a long as possible. What are the treatment options? the treatment What are TREATMENT A Patient’s GuidetoPancreatic Cancer of thedisease. improve yourquality oflifebycontrollingthesymptomsand complications has spread,orisinoperable, yourdoctorswilldiscusstreatments thatcan before itisspreadandcanberemoved initsentiretybysurgery.Ifthecancer Pancreatic cancercanbecontrolledfora lifetime,orcured,onlyifitisfound depend onmanyfactors.Someoftheseare: The prognosis(chanceofrecovery)andtreatmentoptionsforpancreaticcancer and treatmentoptions? What factorsaffectprognosisorchanceofrecovery of MichiganComprehensiveCancerCenter. treatment approaches,andtheclinicaltrialsthatareavailableatUniversity There istimetodiscussoptionsandlearnmoreaboutpancreaticcancer, case. Treatmentgenerallystartswithinafewweeksoftheinitialevaluation. oncologists andradiationtoreviewdiscussyourindividual The MultidisciplinaryPancreaticCancerClinichassurgeons,medical have familyor friendsaccompany the patient for discussions abouttreatment. it difficulttothinkof everythingyou mightwanttoknow. Itisalwayshelpfulto patients arefirstdiagnosed theyareoverwhelmed. Shock andstresscanmake ourcurrenttreatmentoptions.tocontrolwith When hard very is cancer Pancreatic How doesapatientdecideontreatment? Yourgeneral health • Whetherthecancerhasjustbeendiagnosed orhasrecurred(comeback). • Whether ornotthetumorcanberemovedbysurgery,is • Thestageofthecancer(thesizetumorandwhether • “operable” or“resectable”. nodes ortootherplacesinthebody). cancer hasspreadoutsidethepancreastonearbytissuesorlymph

TREATMENT A Patient’s Guide to Pancreatic Cancer Refer to Figure 4. 13 Surgery

©2012 University of Michigan Comprehensive Cancer Center When patients are diagnosed with pancreatic cancer, approximately 20% of the cancer, approximately are diagnosed with pancreatic When patients pancreas The location of the to be operable or resectable. tumors are found operation. difficulties of a surgical adds to the technical with a wide band of surrounding would remove the tumor Ideally, surgery the and arteries are located near However, important veins normal tissue. possible to do surgery. pancreas and it may not be about the size, location and involvement of Diagnostic tests give information and vessels. These tests help the surgeon determine other surrounding tissues or resectable. In addition, a surgeon will evaluate whether a cancer is operable to determine if they can tolerate the surgical the patient’s overall health In some cases, chemotherapy and radiation procedure. Each case is individual. to potentially reduce the size of the tumor and therapy will be recommended improve the outcome of surgery. in the head of the pancreas and is operable, the If the tumor is found to be is a pancreaticoduodenectomy, also called a surgical procedure performed head of the pancreas, Whipple procedure. This surgery involves removing the stomach. Surgery includes the gallbladder, part of the bile duct, and part of the and stomach to bowel so re-connecting the remainder of the bile duct, pancreas that these structures can drain properly. When is surgery a treatment for pancreatic cancer? pancreatic treatment for is surgery a When TREATMENT Pancreas Head of Gallbladder Liver A Patient’s GuidetoPancreatic Cancer Duodenum Liver Reconstruction and Bowel Bile Duct Figure 4.Whipplesurgicalprocedure

14 Reconstruction and Bowel Pancreas REMOVED ©2012 University ofMichiganComprehensive Cancer Center Pancreas Stomach Reconstruction and Bowel Stomach PRESERVED TREATMENT Spleen Removed 50% removed Cut for resection (removed) Head and Neck of Pancreas preserved A Patient’s Guide to Pancreatic Cancer 15 Refer to Figure 5. Refer to

Figure 5. Distal pancreatectomy surgical procedure Pancreas Duodenum ©2012 University of Michigan Comprehensive Cancer Center Tumors that are in the body or tail of the pancreas, which are less common, can common, are less which the pancreas, tail of or in the body are that Tumors is the spleen. This pancreas and part of the the distal by removing be removed distal pancreatectomy. called a TREATMENT A Patient’s GuidetoPancreatic Cancer outlet obstructionandabdominalpain. caused bythecancer.Thesesymptomsincludebileductobstruction,gastric curative resection.Otherproceduresmaybenecessarytorelievethesymptoms At thetimeofdiagnosis,80%patientsarenotcandidatesforpotentially with pancreaticcancer? What otherproceduresaredonetotreatpatients Figure 6.Pancreaticheadmass(tumor)illustrating anobstruction Normal

Pancreas (mass) Tumor Duct Pancreatic TREATMENT Pancreas Stent A Patient’s Guide to Pancreatic Cancer Common Bile Duct 17 Tumor Tumor (mass)

outside the body. Local anesthesia is most commonly Duodenum (first part of intestine) Endoscope Figure 7. Figure 7. Stent placed endoscopically to relieve bile duct obstruction ©2012 University of Michigan Comprehensive Cancer Center Percutaneous Placement: it may not be When a patient is jaundiced due to a bile duct obstruction transhepatic possible to place a stent endoscopically. A ‘PTC’ (percutaneous directly into the liver cholangiogram) procedure may be done to place a tube This tube will bile ducts through the skin on the right side of the abdomen. drain the bile into a bag Bile Duct Obstruction Duct Bile are candidates to the tumor due bile duct obstruction who develop Patients the mouth scope through done with a either stent placement, for biliary The wall or skin (percutaneously). or through the abdomen (endoscopically) in the and is illustrated and described is called an ‘ERCP’ endoscopic procedure Tests and Procedures section on page 8 of this is The stent placement handbook. illustrated in Endoscopic Placement: Endoscopic Placement: TREATMENT A Patient’s GuidetoPancreatic Cancer stent. Thestentisplaced endoscopically. and vomiting,mayundergo eitherasurgicalbypassorplacement ofaduodenal Patients whodevelop gastricoutletobstruction,whichappears asseverenausea Gastric OutletObstruction that placesastent drainage. Oncethathappens,itmaybepossible toperformasecondprocedure Over time,theliverbileductshouldberelieved ofpressurewiththisexternal to instructyouonthecareofdrainagetube. the procedure.Thisallowstimetomakesuretubeisworkingcorrectlyand used forthisprocedure.Mostpatientswillstayovernightinthehospitalafter Biliary Ducts Drainage Bag Liver inside (Percutaneous transhepaticcholangiogram) Figure 8.Biliarydrainagetubeplacement thebody.

or visit the Patient or visit the Patient A Patient’s Guide to Pancreatic Cancer radiation therapy: radiation therapy: B1 of the Cancer Center B1 of the Cancer information about For more http://www.med.umich.edu/radonc/ Education Resource Center on Level Education Resource patientinfo/patient.htm 19

Radiation Therapy Radiation impossible for these cells material (DNA), making it , or , x-ray therapy a beam ) is the use of not to be operable. • after surgery; to decrease the risk of local recurrence • size of the tumor before surgery (preoperative) and to reduce the • for patients who have a tumor that is found as a primary treatment ©2012 University of Michigan Comprehensive Cancer Center Radiation therapy is used in three ways: Radiation therapy is used in in the same area of Local recurrence means that cancer cells have come back when tumor cells were the body where the tumor started and this can happen left behind or were not killed. chemotherapy which When radiation is used it is often in combination with and chemotherapy has enhances the effectiveness of the radiation. Radiation disease. been found to benefit patients with locally advanced When is radiation therapy given to treat pancreatic cancer? When is radiation therapy of energy cells and shrink tumors. Radiation radiation) to kill cancer (called ionizing cells in the area being treated (the “target tissue”) therapy injures or destroys by damaging their genetic Although radiation damages both cancer cells to continue to grow and divide. cells can recover from the effects of radiation and normal cells, most normal goal of radiation therapy is to damage as many and function properly. The limiting harm to nearby healthy tissue. cancer cells as possible, while

(also called Radiation therapy radiotherapy irradiation What is radiation therapy? radiation What is TREATMENT A Patient’s GuidetoPancreatic Cancer Radiation OncologyDepartmentforseveralhoursthatday. The simulationappointmentmaytakefrom1-2hours.Plantobeinthe contrast improvetheimagesthatCTscantakes. an intravenousformofcontrastjustbeforeyourscan.BoththeliquidandIV be givenaliquiddrinkcalled‘contrast’beforeyourscan.Youwillalsoreceive doctor mayneedtomakeadjustmentsinyourdiabetesmedication.Youwill includes fasting6hourspriortoyourscan;therefore,ifyouarediabetic for theCTscanpriortoyourappointment.Thepreparationa to planhowdirecttheradiation.Youwillreceiveinstructionsprepare aimed. Simulationinvolvesa port or the radiationtherapistusesaspecialx-raymachinetodefineyourtreatment During thevisit,youwillbeaskedtolieverystillonanexaminingtablewhile this firstvisit,itisforplanningonly. your treatmentinaprocesscalled Your initialvisitwillincludemeetingwiththeradiationoncologistwhoplans Your RadiationTherapytreatmentwillneedtobeplannedbeforeitcanbegin. What happensatmyfirstRadiationOncology Appointment? field. Thisistheexactplaceonyourbodywhereradiationwillbe

CT scans,andpossiblyotherimagingstudies simulation. Youwillnotreceivetreatmenton 20 ©2012 University ofMichiganComprehensive Cancer Center TREATMENT . For more For more Cancer Center chemotherapy: chemotherapy: information about information A Patient’s Guide to Pancreatic Cancer Center on Level B1 of the Center on Level Patient Education Resource Patient Education or visit the www.mcancer.org

Chemotherapy is the treatment of cancer is the treatment ©2012 University of Michigan Comprehensive Cancer Center Chemotherapy is the treatment of choice for cancer that is found to be locally Chemotherapy is the treatment of choice for cancer that drugs can have an effect advanced or metastatic (spread to other organs). These their ability to multiply. on the cancer by stopping the growth of cancer cells or cancer, keep it from The goals of chemotherapy treatment are to control the or reduce the symptoms spreading by slowing the cancer’s growth and improve of the disease. When is chemotherapy given to treat pancreatic cancer? When is chemotherapy given to treat pancreatic Work? How Does Chemotherapy in a controlled way. When cancer occurs, the Normal cells grow and die dividing and forming more cells without control. abnormal tumor cells keep cells by stopping them from growing or Anticancer drugs destroy cancer also be harmed, especially those that divide multiplying. Healthy cells can is what causes side effects. These cells usually quickly. Harm to healthy cells repair themselves after chemotherapy. together than alone, two or more drugs are Because some drugs work better This is called combination chemotherapy often given at the same time. Chemotherapy used to treat your cancer. These may include Other types of drugs may be or increase the effect of your body’s response to certain drugs that can block the cancer. What is chemotherapy? What is with drugs that can destroy cancer cells. can destroy cancer cells. with drugs that drugs. are called “anticancer” These drugs often RESOURCES A Patient’s GuidetoPancreatic Cancer be recommended. the typeofchemotherapy.Otherchemotherapyagentsandcombinationsmay considers thepatient’smedicalconditionandotherfactorswhendecidingon Remember, chemotherapytreatmentisplannedbytheoncologistwho has beenshowntodecreasesymptomsandimproveoverallqualityoflife. gemcitabine (Gemzar)aloneorincombinationwithotherdrugs.Gemcitabine If thecancerhasspreadoutsidepancreas,astandardtherapyplanistouse Metastatic Disease and gemcitabine(Gemzar®). area. Examplesofthesedrugsare5-fluorouracil(5-FU®),capecitabine(Xeloda®), considered chemotherapyandareadministeredintheinfusion the effectivenessofradiation.Thesearecalledradiosensitizers.They For patientswithlocallyadvanceddisease,drugsaregiventoincrease Locally AdvancedDisease

A Patient’s Guide to Pancreatic Cancer 23 before the closed and the data analyzed treatment is made widely available to patients. has been achieved. The trial must be has been achieved. know whether any potential improvement any potential improvement know whether There may be some additional risks There may be some additional

Clinical Trials Clinical a trial or study is active or in-progress we will not is active or in-progress we a trial or study

associated with research. Your doctor will discuss in associated with research. Your For more clinical trials: Cancer Center information about information about Center on Level B1 of the Patient Education Resource or visit the www.mcancer.org ©2012 University of Michigan Comprehensive Cancer Center Clinical trials are used to test and develop new treatments. The goal of these new treatments. The goal are used to test and develop Clinical trials While and / or decrease side effects. ways to improve therapy trials is to find (a a clinical trial in consider participating that you may suggest Your doctor of pancreatic cancer. or protocol) for the treatment research study If a patient leaves a study for any reason, standard care and treatment If a patient leaves a study for any reason, standard care will be initiated. detail with you both the potential risks and benefits and obtain your written detail with you both the potential be started on a research protocol. permission before you can University of Michigan Medical Center conduct an Oversight committees at the trials. These committees include an “institution extensive review of all clinical of other cancer doctors, doctors in other review board” or IRB composed before they are specialties and lay people. The IRB reviews all protocols the research to ensure available to patients and again at different times during that the protocol remains appropriate and safe for patients. care possible, All patients who are on a protocol receive the best supportive closely. If the treatment and their reactions to the treatment are watched very and take a patient does not seem to be helping, a doctor can stop the treatment the study at any time. out of a study. Also, the patient may choose to leave TREATMENT A Patient’s GuidetoPancreatic Cancer these problems. multidisciplinary team isheretoworkwithyouinreducing or eliminating to you.Weknowtheseareobstaclesyour healthandqualityoflife.Our section. Weincludethemtohelpyouunderstand whatmaybehappening Not allpatientswillexperiencethesymptoms orsideeffectslistedinthis them aboutanysideeffectsyoumayhave. Theywantandneedtoknow. Ask yourmedicalteamanyquestionsyou mayhave.Alsodon’thesitatetotell can nevertaketheplaceofprofessionalhealthcare. you becomeaninformedpartnerinyourcare,butitisonlyaguide.Self-help aches maymakeyouworry.Theinformationinthissectionisdesignedtohelp If youhavecancer,maynoticeeveryache,pain,orsignofillness.Evenlittle are found athttps://www.umms.med.umich.edu/engage/disp_pub_condition.do You cansearchonlineto findavailableclinicaltrials.ThePancreaticCancertrials How doIfindoutaboutpancreaticcancerresearch? chemotherapy andarebeinginvestigatedinclinicaltrials. drugs aregivenincombinationwithstandard growth andprogression.Someofthese against thecancerorinterferewithtumor the bodies’immunesystemtowork boost may that drugs are therapies Biologic What aresomeexamplesofclinicaltrials? Cancer Center. you haveregardingclinicaltrialsattheUniversityofMichiganComprehensive you decidetojoinaprotocolornot.Talkyourdoctoraboutanyquestions Clinical trialsarevoluntary.Yourpancreaticcancerwillbetreatedwhether

AFTER TREATMENT

A Patient’s Guide to Pancreatic Cancer 25

Notify your doctor immediately if you develop a temperature, immediately if you Notify your doctor do not delay. • C) of 101° F or 38.3° chills or fever (a temperature Shaking • or shortness of breath Unusual cough, sore throat, lung congestion • Burning discomfort when you urinate • Redness, pain or sores in your mouth • for more than 24 hours. Nausea, vomiting or inability to eat or drink • than 24 hours. Diarrhea (loose, watery stools) for more • days) Constipation (no bowel movement in 2-3 • Bleeding or unusual bruising • Pain not controlled by your current medications • you Any new or unusual symptom that concerns ©2012 University of Michigan Comprehensive Cancer Center When to call the doctor? When home, and other by you at can be managed symptoms times when There are to call the Never hesitate medical team. notify your you should times when to The following are reasons unsure or have new symptoms. clinic if you are notify your doctor: AFTER TREATMENT A Patient’s GuidetoPancreatic Cancer call (734)936-6000 Appointments canbe madeinadvanceatyourcliniccheckout areaoryoucan The nutritionclinicisopenMondaythrough Fridayfrom 8amto suggestions andguidance,willprepare adietaryplanduringyour treatment. Also, nutritionspecialistsareavailableat thecancercenterwho canoffer order theseforyou. constipation ordigestionproblemsyou may beexperiencing.Yourdoctorcan There aremedicationsavailabletoreduceortreatanypain,nausea, Talk toyourmedicalteamaboutsymptoms monitor yourweightcloselythroughouttreatment. The overallgoalduringtreatmentistokeepyouatastableweight.Wewill What canbedone? cancer. For allofthesereasons,weightlossiscommoninpatientswithpancreatic additional weightloss. digestive juicesneededtodigestfoodproperly;thiscancausediarrheaand and willcontributetoweightloss.Manypatientsdonotmakeenoughofthe Cancer canalsocausechangesinyourbodythataffectmetabolism common reasonsthatyoumaynotfeelhungryandloseweight. when youfeelnauseated,orhaveconstipationdiarrhea.Thesearesome hard toeatnormallybecausefoodstastedifferentyou.Youmayhavetimes may seeyourappetitedecreaseorfeelbloated‘gassy’aftereating.Itbe Weight losscanbeacommonproblemforpatientswithpancreaticcancer.You Why doesthishappen? What canIdotomaintainmyweightandincreaseappetite?

A Patient’s Guide to Pancreatic Cancer 27

at meals There are several flavors to choose Carnation Instant Breakfast®. whole milk, yogurt and fruit to from and you can add ice cream, increase calories. your chemotherapy treatments. may be recommended by (Megace®)) or dronabinol (Marinol®) your doctor. • the day. throughout meals or snacks to six small Eat five • in protein and calories foods that are high Choose • to day taste can change from day new foods regularly as Try • avoid fullness liquids in-between to fluids at meals and drink Limit • as by using supplements such protein and calories Increase • by your doctor during Take anti-nausea medications as prescribed • megestrol acetate Appetite stimulating medications such as ©2012 University of Michigan Comprehensive Cancer Center There are many nutrition resources available to patients and families at the There are many nutrition resources Education Resource Center (PERC) has many recipe Cancer Center. The Patient resources for patients with cancer. They also have books and other information books, pamphlets a nutrition information guide available that lists websites, information. and other resources for cancer patients seeking nutrition loss is common and we The most important thing to remember is that weight will work with you to help prevent and treat this problem. There are some steps you can take to improve your diet and prevent weight weight and prevent diet your improve take to can you some steps are There include: loss. These AFTER TREATMENT A Patient’s GuidetoPancreatic Cancer doctor abouttheseifyouhavetriedother treatments. Lastly, therearemedicationsthatcanbe suggestedforitching.Talktoyour are waystomakeyoumorecomfortableifjaundicecontinues. Jaundice canbetreatedbyrelievingtheblockagewithabileductstent.There What canbedone? associated withjaundice. urine. Pancreaticcancersthatstartintheheadofpancreasaremoreoften causes ayellowingoftheskin,whiteseyesanddarkening get throughandhasnowheretogo,soitbacksupinthebloodstream.This pancreatic mass.Whenamasscausesblockage,bilirubincan’t is asignthatthebileductpartiallyorcompletelyblocked,possiblyby the gallbladderandbileducttobedumpedintosmallintestine.Jaundice bloodstream. Bilirubinismadeintheliverandmovesfromthrough Jaundice (yellowingoftheskin)occurswhenbilirubinbuildsupin Why doesthishappen? What canbedoneforitchingandyellowingofskin(jaundice)? Keeproomtemperaturescoolerandhydrated.Thismayhelpto • Applylotionsorcreamstopreventskindryness, • Avoidusingveryhotwateroranythingthatmightdryyourskin, • Goodskincareusingmildsoapstobathe, • Some suggestionsinclude: decrease itching.

©2012 University of Michigan Comprehensive Cancer Center What can be done to treat my pain? to treat my be done What can this happen? Why does pain. Pain cancer commonly have are diagnosed with pancreatic Patients who but many describe it as a cramping, by each patient, is described differently areas or shoulders. The most common (spreading) to back aching, and radiating abdominal cancer are the upper by patients with pancreatic of pain experienced itself, pain including the cancer There are many causes of and back areas. nerves and vessels. pressure on other organs, which may cause What can be done? there are barriers that prevent proper Pain can be treated, but oftentimes are a lack of understanding in how to treatment. Some of these barriers fear of addiction and a concern that pain may be take the pain medications, are used at the time of initial pain. These are uncontrollable later if medicines with your medical team. Do not let these all issues that should be addressed keeping any pain you may have under control. barriers prevent you from to increased physical activity and well-being in Good pain control can lead Patients who have chronic pain may need to patients with pancreatic cancer. to obtain the best control of pain. An understanding take medications regularly control of your pain. of how to take these medications will help you get better Narcotics are There are many different medications used to treat pain. treat pain include the most common. Other types of medications used to anti-inflammatory antidepressants, anticonvulsants (anti seizure medications), and steroid medications. skin patches and Narcotic medications come in several forms: tablets, liquids, as a sustained release intravenously via a pump. These medicines are available pain medication. The or long acting preparation, and as an immediate release often used together. long acting and immediate release pain medications are AFTER TREATMENT A Patient’s GuidetoPancreatic Cancer acting painmedications. taken atanytime,evenifitisthesametimeassustainedreleaseorlong- needed’ basisbecausepaincanvaryfromdaytoday.Thesemedicationsbe These medicationsworkwithin15-20minutesandareusuallytakenonan‘as some extramedicationforcontrolandtopreventitfrombecomingsevere. as itoccurswhileyouaretakingregularlyscheduledmedication,butmayneed while takingalongactingpainmedication.Thisiscalled“breakthroughpain” The immediatereleasemedicationsshouldbetakenwhenyouarehavingpain Immediate releasemedications“Breakthroughpainmedications” when thatscheduleisnotchanged. or not.Theyaretakenonascheduleandworkbest usually morningandevening,whetheryouhavepain These shouldbetakenonaregular,scheduledtime, Sustained releaseorlongactingpainmedications Fentanyllozenge(Actiq®) • Morphine oralsolution(Roxanol®) • Morphine immediaterelease(MSIR) • Hydromorphone (Dilaudid®) • Hydrocodone (Vicodin®) • Oxycodone • Examples ofbreakthroughpainmedications; Oxycodone(Oxycontin®) • Morphine(Oramorph®,MSContin®) • Fentanyl(Duragesic®patch) • Examples ofthesetypesmedicationsinclude;

A Patient’s Guide to Pancreatic Cancer

whether you are having pain or not at that time. having pain or not at that whether you are difficult to get good severe or it will become until pain becomes control. is helpful when you call you doctor hour period. This information about poor pain control. If breakthrough pain medication is needed 4-6 times a day regularly If breakthrough pain medication OR at night if pain keeps you up consistently THEN consider increasing your sustained Notify your doctor who may release pain medication. • a regular basis on release medication the sustained Continue • doctor. without talking to your not change this schedule Do • Do not wait medication as needed. your ‘breakthrough’ pain Use • taken over a 24 Keep a record of the breakthrough medications ©2012 University of Michigan Comprehensive Cancer Center Celiac Plexus Nerve Block to control pain then a If medications taken by mouth or patch are not adequate nerve block may be considered. bundle of nerves called a Pain sensations from your abdomen pass through the anesthetic into your back plexus. A celiac plexus block is the injection of a local to the organs in your in the area of a nerve bundle (called a plexus) that goes in pain anesthesia abdomen (see Figure 1 on page 1). Doctors who specialize drug stops the pain can inject a drug that will damage the nerve plexus. The pain medications. Rule of thumb: Suggestions for patients on sustained release/long-acting release/long-acting on sustained patients for Suggestions AFTER TREATMENT A Patient’s GuidetoPancreatic Cancer Cancer Center. Education ResourceCenteronLevelB1of the back pocketofthishandbook,oratthe Patient in thePatientSupportServicesHandbook inthe Information abouttheseprogramscanbe found to ascomplementarytherapiesinclude: in combinationwithmedication.Someofthesestrategies,commonlyreferred enough toeliminatemoderateseverepain,theyareoftenhelpfulwhenused employed torelievepain.Althoughontheirown,thesetoolsmightnotbe In additiontomedications,anumberofothertreatmentstrategiescanbe Other WaystoReducePain and canbefurtherdiscussed,ifneeded. procedure isavailabletopatientswhoareseenintheinterventionalpainclinic a ‘block’.Blockingthenerveshouldhelpdecreasefeelingofpain.This sensation fromreachingthenervesforalongerperiodoftime.Thisiscalled Therapeuticexercise. • Applicationofheatorcold,and • Acupressureandacupuncture, • Massage, • Prayer,meditation, • Creativetherapiessuchasmusicandart, • Biofeedback, • Hypnosis, • Relaxation,guidedimagery, •

32 ©2012 University ofMichiganComprehensive Cancer Center “Preventing Constipation” medications onaregular Many painmedications basis, youwillneedto review thesectionon If youaretakingpain cause constipation. on page33. AFTER TREATMENT A Patient’s Guide to Pancreatic Cancer 33

• frequent urination, • thirst, fatigue, • blurred vision and • weight loss. ©2012 University of Michigan Comprehensive Cancer Center Why does this happen? is a decrease in Constipation is common during cancer treatment. Constipation stool, excessive straining, the number of bowel movements combined with hard bloating, increased gas, and/ or abdominal cramping. because they are Pancreatic cancer patients are at risk for constipation and antinausea often treated with pain medications, receive chemotherapy have had a change in medications, have decreased their physical activity and constipation. Other their eating and drinking habits…. all of these can cause of fiber in your diet. causes of constipation include dehydration and a lack What can be done to prevent constipation? What can be done to prevent What can be done? glucose level. blood to reduce your take medication You may need to basis. Tell a daily the skin on insulin injected under or can be tablets Medications of diabetes. the symptoms any of are experiencing or nurse if you doctor your My glucose is high and I have diabetes. and I have is high My glucose this happen? Why does body of insulin needed for your pancreas secretes the amount Normally, the or if you you have pancreatic cancer normal glucose level. When to maintain a insulin you may not secrete enough of your pancreas removed, have had part level of In these cases, the blood may become resistant to insulin. or your body where it is get into the body’s cells in the blood and doesn’t glucose increases of diabetes that include: This will lead to symptoms needed for energy. AFTER TREATMENT A Patient’s GuidetoPancreatic Cancer Here aresomesuggestions: recommend acombinationofstoolsoftenerandlaxativeonregularbasis. For patientstakingpainmedicationsthatarenarcoticsoropiods,we There areanumberofpreventativethingstodo.Theseinclude: What canbedone? Ifno bowelmovementinany72hourperiod(3days),addoneof • Ifno bowelmovementinany48hourperiod(2days),takethree • Ifnobowelmovementinany24hourperiod(1day),taketwo • TakeSenokot-S®,twotosixtabletsdailyindivideddoseskeep • Gotothebathroomwheneveryouhaveanurgego. • Getregularexerciseeverydayifpossible…keep upyouractivityas • Avoidcheeseproducts • Increasefluidsinyourdiet(drinkatleast 2quartsoffluiddaily). • Increasingthefiberinyourdietwithfoods highinfibersuchas • the following: tablespoons ofMOMatnightbeforebedtime. Senokot-S® tabletstwiceaday(totalof6 tabletsperday)plustwo glass ofwater. tablespoons ofMilkMagnesia®(MOM) atbedtimewithafull information aboutgenericversions.Theyareoftencheaper. of Senokot-S®canbesubstituted.Askyourpharmacistfor increased accordingtoresultsandtolerance.Genericversions regular bowelmovementseveryday.Thiscanbedecreasedor much asyouareable. dates. fresh orrawfruitsandvegetables,wholegrains,prunes,nuts If nobowel movement,thenDulcolax® tablets,two orthreetablets. Magnesium Citrate8 oz(1/2bottle)nowthenrepeatin6hours.

AFTER TREATMENT

® digested. and absorbed. It is important to take will need the enzyme food that needs to be food, not just “meals”. Remember to take the A Patient’s Guide to Pancreatic Cancer enzyme tablets with any enzyme tablets with any This means even a glass tablets to be broken down of milk or a can of Ensure 35

©2012 University of Michigan Comprehensive Cancer Center Symptoms of pancreatic insufficiency include Symptoms of pancreatic insufficiency cramping. This diarrhea, gas, burping and through the happens because food passes As it passes digestive tract not fully digested. the intestines that through, it pulls water into causes diarrhea and cramping. form of Pancreatic enzymes are a tablet just like the juices, pancreatic juice. They work food, they help so when they are taken with discomfort and diarrhea. digestion and lessen the abdominal eating. If they eat a Generally people take 1-2 enzyme tablets as they start into the meal. For larger meal, they will take additional tablets 10-15 minutes smaller meals or snacks, 1-2 tablets alone may be enough. Talk with your doctor if enzymes do not control the problem. My doctor recommended pancreatic enzymes for my frequent loose frequent loose for my enzymes pancreatic recommended My doctor cramping. and abdominal stools they do? What do juices the small intestines. These secretes digestive juices into The pancreas intestines. Patients with pancreatic and absorb food in the help break down adequate removed may not have have had part of the pancreas cancer or who digested If this happens, food isn’t juices in the intestines. amounts of these is called pancreatic insufficiency. normally. This AFTER TREATMENT A Patient’s GuidetoPancreatic Cancer blocked vesselscancauseswellingofthe legs. sometimes thelymphvesselandveinsarecompressedbytumorthese in proteinthebloodthatcausesfluidtoleakoutintotissue.Inaddition, Sometimes patientshaveswellingofbothlegsandthiscanbeduetoadecrease determine ifthereisablockedbloodvesselcausedbyclot. one legyoushouldcallyourclinic.Anultrasoundoftheareawillbedoneto into thelungs,whichcanbeaveryseriouscondition.Ifyounoticeswellingin organs. Somepatientsmayhaveafilterplacedtopreventbloodclottraveling the bloodclotsandlessenchancesoftravelingtoother Patients whohavehadbloodclotsaretreatedwithmedicationsthatstabilize What canbedone? blood clotinclude: develop swellingorpain,butsomepatientshavenosymptomsatall.Signsofa than theaverageperson.Bloodclotsmostcommonlyoccurinlegs.Youmay Patients withpancreaticcancerareatagreaterriskfordevelopingbloodclot Why doesthishappen? My legisswollenanditfeelswarmtotouch. Whensitting,keeplegs uncrossedandifpossibleraiseyour legs • Avoidlongperiodsof standing. • Walkingforshortdistances. • Tightening ofyourlegmusclesregularlyduringtheday • Wearing loosefittingsocks,shoesandpants. • Suggestions forthisinclude: Redness • Painortendernessinanarea • Swelling(usuallyofoneleg,sometimesboth) • higher than yourchest

• of death. Fear • of life plans. Interruption • self-esteem. in body image and Changes • lifestyle. in social role and Changes • Money and legal concerns. • All people with cancer are depressed. • a person with cancer is normal. Depression in • not help the depression. Treatment does • cancer faces suffering and a painful death. Everyone with ©2012 University of Michigan Comprehensive Cancer Center Everyone who is diagnosed with cancer will react to these issues in different Everyone who is diagnosed feelings of anxiety, depression, sadness, stress, ways. Many patients experience or eating. It is important to know when and where and have difficulty sleeping These symptoms and fears usually lessen as a to seek help for these feelings. person adjusts to the diagnosis. about cancer and how people cope with it, such There are many misconceptions as the following: period of time, A person who cannot adjust to the diagnosis after a long Mild symptoms and who loses interest in usual activities, may be depressed. counseling. Even of depression can be distressing and may be helped with benefit from counseling; patients without obvious symptoms of depression may or when they keep however, when symptoms are intense and long-lasting, These are often signs of coming back, more intensive treatment is important. what is called “major depression”. How do I cope with my feelings? I cope with How do for you and it is normal cancer, with pancreatic been diagnosed If you have life issues in the Important range of emotions. a wide to experience your family following: with cancer may include the of any person AFTER TREATMENT A Patient’s GuidetoPancreatic Cancer have lessdepression.Goodcommunication withinthefamilyreducesanxiety. openly andsolveproblemseffectively,both thepatientandfamilymembers If thefamilyofapatientdiagnosedwith cancerisabletoexpressfeelings cancer patients. a gooddealmoreanxietyanddepression thanpeoplewhoarenotcaringfor treatment, sodofamilycaregivers.Caregivershavebeenfoundtoexperience Just aspatientsneedtobeevaluatedfordepressionthroughouttheir Depression canaffectcaregiverstoo depression includethefollowing: is importanttorememberthatthiscanbetreated.Thesymptomsofmajor or whohasahistoryofdepressionshouldtalktotheirhealthcareteam.It problem beforethediagnosisofcancer.Anyoneexperiencingthesesymptoms, is diagnosedwithcancermaybeasignthatthepatienthaddepression diagnosed andtreated.Symptomsofdepressionthatarenoticedwhenapatient affects about25%ofpatientsandhascommonsymptomsthatcanbe Major depressionisnotsimplysadnessorabluemood. Constantthoughtsofdeathorsuicide. • Poorconcentration. • Feelingsofworthlessnessorinappropriateguilt. • Tiredness. • Nervousnessorsluggishness. • Changesineatingandsleepinghabits. • Lossofpleasureandinterestinmostactivities. • Havingadepressedmoodformostofthe dayandonmostdays. •

©2012 University of Michigan Comprehensive Cancer Center Seeking help Seeking helping patients believes that Team Pancreatic Medical The Multidisciplinary care. Our part of providing an essential diagnosis is their cancer cope with the team who provides evaluation, is an essential member of social worker the such as support groups, referral to additional resources counseling, and pancreatic The social worker for the clinic and group therapy. PsychOncology at (877) 907-0859. clinic can be reached or your any emotional needs you team is here to help address Remember, our to contact us. family may have. Do not hesitate AFTER TREATMENT A Patient’s GuidetoPancreatic Cancer

A Patient’s Guide to Pancreatic Cancer

Resources

Pain Services Wig Bank Program Maps, important phone numbers and websites Complementary Therapies The Cancer Center website The Cancer Center website Discounted lodging, parking, meals and other expenses Assistance with transportation, Social Work Support groups and peer counseling PsychOncology Clinic

Nutrition The Patient Education Resource Center (PERC) The Patient & Family Teaching Center (Skills Lab) • Resources: Cancer Center • Information Resources: • Assistance with Practical Matters: • Help You Cope: Resources to counseling Financial • Enhance Treatment: Resources to ©2012 University of Michigan Comprehensive Cancer Center on level B1 of the Cancer Center for a complete list of all events and list of all events and the Cancer Center for a complete on level B1 of you during your cancer treatment. resources available to assist the Patient Support Handbook include: Resources you will find in There are many resources available to patients and families at the University at the University and families to patients available many resources There are We have included a comprehensive Cancer Center. of Michigan Comprehensive programs pocket of this book. These these programs in the back handbook of at the University of Michigan. any patient receiving care are available to cancer center website: are also available on our These programs Center the Patient Education Resource , or you can visit www.mcancer.org RESOURCES A Patient’s GuidetoPancreatic Cancer ______

Appointments ______Time Time Time Time Time Time Time Time ______Other Date Date Date Date Date Date Date

Sunday

Monday

Tuesday

Wednesday 46

Friday

Saturday RESOURCES Saturday

Friday

A Patient’s Guide to Pancreatic Cancer Thursday

47 Wednesday

Tuesday

Monday

Sunday

Monday

Tuesday

Wednesday 48

Friday

Saturday RESOURCES

936-5781 936-8902 936-8902 936-7644 936-5816 615-8839 936-5781 615-1600 936-7944 A Patient’s Guide to Pancreatic Cancer 49

...... Important Phone Numbers Phone Important noted) code unless are 734 area (all numbers ...... General surgery residents for Drs. Simeone, Mulholland, Nguyen and Minter Mulholland, Drs. Simeone, General surgery residents for Drs. Simeone, Mulholland, Nguyen and Minter (HPB) for Hepatopancreatobiliary Dr. Sonneday Transplant surgery resident for Drs. Zalupski and Kim resident for Oncology Dr. Mark Zalupski Nurses: Surgery Nurses: ...... Sonnenday ...... Dr. Christopher Dr. Edward Kim ©2012 University of Michigan Comprehensive Cancer Center ...... Dr. Diane Simeone Dr. Kevin Nguyen Dr. Rebecca Minter while making treatment decisions and for follow-up issues) (for questions during the diagnosis, Problems Monday-Friday after 5pm, To Reach a Doctor For Medical Weekends & Holidays: to page: Call the UM Page Operator @ 936-6267 and ask them (for questions about surgery, preparing surgery, postoperative concerns) (for questions about surgery, preparing Pancreatic Clinic Nurse Coordinator Jan Hampton Doctors: Dr. Michael Mulholland RESOURCES Cancer CenterB2ProcedureRoom Main ORFamilyWaitingRoom. Operating Rooms PsychOncology ClinicAppointments Social Work Patient SupportServices Patient EducationResourceCenter Cancer CenterNutritionClinic Resources A Patient’s GuidetoPancreatic Cancer Patient/Family LearningCenter(SkillsLab) Cancer CenterInfusionAppointments Endoscopy Appointments Radiation OncologyDepartment Nuclear MedicineDepartment. Multidisciplinary PancreaticClinic Appointments physician orotherprofessionalmedicalservices.Our aimistopromoteactiveparticipation This documentisnotintendedtotaketheplaceof careandattentionofyour . Questions aboutindividualhealthconcernsorspecific treatmentoptions in yourcareandtreatmentbyprovidinginformation education. ©2012 The RegentsoftheUniversityMichigan . should be

877-907-0859 877-907-0859 877-907-0859 877-907-0859 877-907-0859 personal

936-4388 615-4657 647-8626 936-5090 647-8908 615-5123 936-4320 647-8902