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  Pancreatic cancer is located at the retroperitoneal region and can’t be diagnosed by physical, endoscopic or routine X-ray examinations, therefore is difficult to have early diagnosis. The majority of pancreatic cancers are on the head of pancreas; this location is close to the junction of common bile duct and pancreatic duct and patients are often presented with jaundice due to the compression of common bile duct by tumors. Bigger pancreatic tumor will invade into the nerve roots and cause severe upper back pain.

  Surgical resection is the treatment of choice for pancreatic cancer. However, complete resection is often not possible because tumor tends to invade the surrounding major vessels in the early stage. Pancreatic cancer also carries a high chance to have intra-abdominal metastasis and therefore rapid recurrence after surgery. Only 25% (or even lower percentage) patients are good candidates for surgical resection at diagnosis.

  For those not suitable for surgical resection, Gemcitabine-based chemotherapy is the standard treatment and could prolong patients’ survival time. The benefit of adding radiotherapy to chemotherapy is still controversial because some patients will have great gastrointestinal toxicities during the concurrent chemoradiation (CCRT). These toxicities make patients not able to complete the treatment or even affect further chemotherapy. General speaking, patients’ survival time is prolonged if CCRT could be completed; good tumor shrinkage might occur in some patients and make surgical resection feasible.

  With the advance of radiotherapy technology in recent years, the side effects are remarkably reduced by using new techniques such as image-guided radiotherapy (IGRT), intensity-modulated radiotherapy (IMRT), Rapidarc and stereotatic body radiation therapy (SBRT). Proton therapy is the “target therapy” for radiotherapy. High energy proton penetrates into tumor and kills tumor cells. The radiation dose is concentrated in the tumors and no dose to the normal liver after the desired depth at tumors. Proton therapy is able to deliver higher radiation dose to tumors than X-ray and achieves longer tumor control. Several proton centers in USA and Japan have reported that the side effects of concurrent proton therapy with chemotherapy are small and nearly all patients are able to complete the whole treatment course. However, proton therapy is not a good treatment tool for patients with distant metastasis.

Article author: Dr. Ji-Hong Hong