Pancreatic Cancer

Pancreatic cancer (adenocarcinoma) is one of the most devastating cancers with a generally poor prognosis.  There is however hope, in particular when surgery is possible.

 

What is pancreatic cancer?

Pancreatic cancer is one of the most deadly of all types of cancer and despite the high mortality rate, there is very poor funding for pancreatic cancer research.  Pancreatic cancer is the fourth leading cause of cancer death for both men and women.

 

Adenocarcinoma is the most common cancer of the pancreas, accounting for 95% of cases.

Islet cell carcinoma involves cells that secrete a variety of hormones. Tumors can be functional and produce high amounts of hormones, or non-functional and not produce any hormones. Most islet cell tumors are malignant, but some such as insulin-producing islet cell tumors generally tend to be benign.

Isolated sarcomas, lymphoma and metastases to the pancreas (particularly melanoma, renal cell cancer and colorectal cancer) can occur in the pancreas, but these are exceedingly rare.

 

Pseudopapillary neoplasms occur mostly in young women in their teens and twenties and can be malignant.

 

Who is at risk?

The precise causes of pancreatic cancer have not yet been determined. Some risk factors associated with this include:

Smoking: The risk of pancreatic cancer is higher among smokers.
The risk of pancreatic cancer increases sharply after 50 years of age.
Race: African-Americans are more likely to have pancreatic cancer than other ethnic groups. There is also an increased risk in people of Ashkenazi Jewish descent.
Family history: Pancreatic cancer seems to run in some families. The exact genes responsible have not been fully identified. People with two or more relatives who have had pancreatic cancer have increased risk. Some implicated gene mutations include the BRCA2, p16, STK11 genes.
Chronic pancreatitis: This long-term inflammation of the pancreas is linked with a slightly higher risk of pancreas cancer. Chronic pancreatitis may be difficult to diagnose with pain being the most common symptom.
Obesity: Increase cancer risk has been associated with obesity, in particular a body mass index (BMI) of over 30.
Sudden onset diabetes: Diabetes has been implicated as a risk factor in some studies and an early symptom of pancreatic cancer. However, the exact relationship between diabetes and pancreatic cancer is unknown.


What are the symptoms?

Pancreatic cancer often develops without early symptoms. The majority of symptoms arise because of the location of the pancreas and its relationship to other organs in the body.  Symptoms are often vague and easily confused with other diseases. There is no reliable screening test for the early detection of pancreatic cancer.  We need to invest in the development of an effective screening test.

 

Symptoms of pancreatic cancer may include:

Jaundice: Jaundice occurs when bilirubin, a substance produced in the liver, builds up in the blood. Bilirubin travels down the bile duct which passes through the pancreas before emptying into the duodenum. If the bile duct becomes blocked, bilirubin levels rise in the in blood rises, causing the skin and whites of the eyes to become a yellow colour. Urine may turn orange or the color of iced tea. Stool may turn yellow or grey.

Pain: Pain occurs when a pancreatic tumor presses against or effects nearby nerves. The pain may be a dull ache, a sensation of bloating or fullness or a burning type discomfort.

Lack of appetite: Lack of appetite, nausea, weight loss. These symptoms are non-specific but may occur in more advanced disease or if the tumour partly blocks the outflow of the stomach.

Blood sugar: Sudden-onset diabetes or a sudden change in blood-sugar control in diabetics: Diabetes may be an early symptom of pancreatic cancer as well as a risk factor.

 

Having one or more of the symptoms listed above does not necessarily mean you have pancreatic cancer. It is important to discuss any symptoms with your doctor since they may indicate that you have a health problem.


What is the treatment?

Pancreatic cancer is potentially curable when caught early, but the vast majority of cases are not diagnosed until too late. Pancreatic cancer (adenocarcinoma) is one of the most devastating cancers with generally poor progress.  There is however hope, in particular when surgery is possible.

 

When imaging suggests that the entire tumour can be removed and there is no evidence of obvious spread to other organs, surgical removal can be considered and may achieve cure. No other therapy can cure pancreatic cancer. Five-year survival rates approach 25% if the cancers are surgically removed while they are still small and have not spread to the lymph nodes.

 

Most curative surgery is designed to treat cancers in the head of the pancreas, near the bile duct. Some of these cancers are found early enough because they block the bile duct and cause jaundice.  There is evidence that surgical complications are lower and survival is improved when pancreatic cancer surgery is performed at specialised centres, compared to surgery performed at hospitals where pancreatic cancer surgery is not commonly performed.

 

About 10-25%  of pancreatic cancers are contained within the pancreas at the time of diagnosis allowing surgery to be considered.  In many cases cancer cells too few to detect may already have spread to other parts of the body. This may explain why the cancer recurs in a large portion of patients after surgical removal.

 

The type of surgery performed is guided by the location of the tumour.

 

In cases of cancers within the head of the pancreas, a pancreaticoduodenectomy is most commonly performed.  Also known as the Whipple procedure, this operation removes:

  • Head of the pancreas
  • Lymph nodes near the pancreas
  • Gallbladder
  • Part of the common bile duct
  • Part of the stomach
  • Duodenum (first part of the small intestine)
  • A small portion of the jejunum (second part of the small intestine)

This is very complex operation and outcomes are generally optimal when the surgery is performed by a specialised surgeon who has performed many of these operations at a hospital with extensive experience in pancreatic surgery. Even in the most experienced centers, there is a 1-5% chance of death related to surgery within the first 30 days after surgery.  Complications occur in 30-50% of patients. 

 

However, most complications do not cause major long-term debility and can be managed by relatively simple means.

 

In cases of tumours located within the tail or body of the pancreas a distal pancreatectomy may be indicated.  This removes only the tail of the pancreas and a portion of the body of the pancreas. The spleen is often removed in this operation.

 

The entire pancreas may need to be removed in some cases of very advanced cancers or when multiple cancers are found within the pancreas. This is called a total pancreatectomy and removes the entire pancreas and the spleen.  In such cases patients develop diabetes and require insulin injections.

 

Chemotherapy is offered to all patients with pancreas cancer, even when tumor removal is achieved.  This reduces the risk of the cancer returning. . Chemotherapy is often used on its own to treat pancreas cancer that has spread and may lengthen survival.

 

Radiation therapy combined with low dose of chemotherapy may be used to reduce the chances of the cancer returning locally.  Sometimes radiotherapy is administered in cases of more advanced cases to try and reduce the tumor size, with the hope of allowing subsequent surgical removal.

 

Remember that there is always hope and you have choices.


More information

Understand the symptoms of disease and raising awareness may help save lives.

Pancreatic Cancer Screening
http://pancare.org.au/familial-pancreatic-cancer-screening
 

Anticancer Council
http://www.cancer.org/cancer/pancreaticcancer/index

Australian Pancreatic Cancer Genome Initiative – Garvan Institute
http://www.pancreaticcancer.net.au/

Mayo Clinic
http://www.mayoclinic.com/health/pancreatic-cancer/DS00357/DSECTION=treatments-and-drugs

National Cancer Institute
http://www.cancer.gov

Cancer Patients Alliance
http://www.pancreatica.org