Pancreatic Cancer Facts - Viewpoints from Expert Doctors

Last updated date: 27-Jul-2022

CloudHospital

15 mins read

There is no doubt that cancer is one of the most challenging diseases humanity has faced. From hearing the diagnosis “You have cancer” to discussing the treatment options, it all represents a quite long and strenuous journey. 

However, some types of cancer are more fatal and more difficult to treat than others. And today’s topic is one of the most aggressive types of cancer. It is pancreatic cancer. 

 

What is pancreatic cancer? 

Pancreatic cancer is the type of cancer that arises when the cells of the pancreas, a glandular organ that lies behind the lower part of the stomach, begin to multiply and divide out of control until they form a mass. This uncontrollable division usually occurs when these cells develop DNA mutations. 

A cell DNA code usually tells the cell what to do, and in case of this mutation, it tells the cell to divide uncontrollably and to continue living beyond its lifespan. These accumulated cells then form a mass.

When left without treatment, these cancerous cells invade nearby tissue and spread to other parts of the pancreas or other organs through the blood.

The pancreas is a very important organ. It is 15 cm long and looks like a pear lying on its side. It produces digestive enzymes that help your body digest food and absorb needed nutrients. It also secretes insulin hormone that helps your body process and control blood sugar.  

There are several types of pancreatic tumors. The most common type arises from the cells that line the ducts carrying pancreatic enzymes to the duodenum, and it is called “Pancreatic ductal adenocarcinoma”. It accounts for about 90% of cases. And, less frequently, about 1-2% of cases of pancreatic cancer are “Neuroendocrine tumors” which arise from the hormone-producing cells of the pancreas, and luckily, they are less aggressive than adenocarcinoma. 

The aggressiveness of pancreatic cancer lies in detecting it in the late stages when it has spread to other organs because it shows few symptoms that may occur with other diseases. It is rarely discovered in its early stages when it is most curable. 

 

Epidemiology

Northern America, Western Europe, Europe, and Australia/New Zealand had the highest incidence of pancreatic cancer in both genders. Middle Africa and South-Central Asia have the lowest incidence rates.

Globally, there are some gender disparities. Men are most likely to acquire pancreatic cancer in Armenia, the Czech Republic, Slovakia, Hungary, Japan, and Lithuania. Pakistan and Guinea have the lowest risk for males. Northern America, Western Europe, Northern Europe, and Australia/New Zealand have the greatest incidence rates in women. Women have the lowest rates in Middle Africa and Polynesia.

The incidence rates for both genders rise with age, with the greatest occurring in those over the age of 70. Approximately 90% of all occurrences of pancreatic cancer occur in persons over the age of 55. 

 

Risk factors of pancreatic cancer

It is not clear yet what causes pancreatic cancer, however, doctors have found some correlated risk factors that might increase the risk of pancreatic cancer such as smoking and certain inherited gene mutation. 

Other risk factors include: 

  • Obesity.
  • Diabetes.
  • Chronic inflammation of the pancreas “Chronic pancreatitis”. 
  • Family history of pancreatic cancer.
  • Family history of genetic syndromes such as Lynch syndrome, and familial malignant melanoma syndrome, or genetic mutations such as BRCA2 gene mutation
  • Old age, as most people are usually diagnosed after age 65. It rarely occurs below 40. 

Surprisingly, a large study was conducted and showed that the combination of several risk factors such as smoking, long-standing diabetes and poor diet increases the risk of pancreatic cancer more than the presence of only one risk factor.

 

Pancreatic cancer symptoms

Symptoms that are specific enough to diagnose pancreatic cancer don't show until the disease has reached an advanced stage, and they include: 

  • Abdominal pain radiates to the back. 
  • Loss of appetite. 
  • Unintended weight loss. 
  • Fatigue.
  • Diarrhea.
  • Jaundice, a yellowish coloring of the skin and the white of eyes. 
  • Pale stool.
  • Dark Urine. 
  • Itchy skin. 
  • Blood clots. 
  • Recent diagnosis of diabetes, or difficult control of already existing diabetes.

Patients with pancreatic adenocarcinoma often appear with painless jaundice (70%) due to blockage of the common bile duct by the pancreatic head tumor. Weight loss happens in about 90% of patients. Around 75% of individuals have abdominal pain.

Anorexia, palpable, non-tender, enlarged gallbladder, acholic stools, and dark urine are all symptoms of bile salts in the skin. Patients may present with recurrent deep vein thrombosis (DVT) owing to hypercoagulability, prompting physicians to suspect malignancy and perform a complete cancer workup.

 

As the disease progresses it causes several complications such as:

  • Jaundice. When the mass grows larger over time, it blocks the liver’s bile duct and causes yellowish coloring of skin and eyes, pale stool, and dark urine. 
  • Bowel obstruction. When the growing tumor reaches the first part of the small intestine, also known as the duodenum, it blocks the flow of the digested food from the stomach to the small intestine. 
  • Weight loss. It is known as cancer cachexia. As the tumor grows it presses on the intestine and stomach making it difficult to eat, it consumes the body’s energy, causes severe nausea and vomiting, and affects digestion. 
  • Pain. It is also caused by the continuous growth of the tumor which, as a result, presses on the nerves. Analgesics might help relieve the pain. Doctors also recommend chemotherapy or radiotherapy to slow down the tumor’s growth and to relieve the agonizing pain. 

 

Diagnosis

The diagnosis should be confirmed by some investigations including:

  • Imaging tests such as CT, MRI, and PET. 
  • Endoscopic ultrasound. 
  • Biopsy; taking a tissue sample. 
  • Blood test searching for specific tumor markers such as CA19-9 which is used in pancreatic cancer. 

If pancreatic adenocarcinoma is suspected, multidetector computed tomography, or MDCT, is the best imaging modality for diagnosing and evaluating the extent of disease, including perivascular extension and distant metastases. MDCT predicts resectability 77 percent of the time and unresectability 93 percent of the time.

 

The multidetector CT protocol for pancreatic imaging employs a multiphase imaging method that comprises a late arterial phase and a portal venous phase following intravenous contrast material delivery. The late arterial or pancreatic phase is obtained 35 to 50 seconds after the injection and provides for the most accurate assessment of the pancreatic parenchyma.  

The portal venous phase is obtained 60 to 90 seconds after the administration of intravenous (IV) contrast and provides for the greatest evaluation of venous architecture and identification of a hepatic and distant metastatic illness. 

Water can be used as oral contrast. Oral contrast with barium is typically not utilized because it interferes with the assessment of vascular architecture and encasement. Multiplanar reformatted pictures in the coronal and sagittal planes, maximum intensity projection images, and volume-rendered images are useful in better identifying vascular encasement and narrowing. 

In the preoperative examination of pancreatic cancer and the assessment of vascular invasion, abdominal MRI/MRCP with IV contrast is just as excellent. MRI is more sensitive to identify metastatic hepatic illness, with a sensitivity reaching 100% compared to CT's 80%. A typical multiphase post-contrast imaging procedure is also used in MRI.

There is a small subset of pancreatic cancer that exhibits a similar attenuation on CT scan, making it more visible on MRI. If pancreatic cancer is highly suspected and the CT scan is negative, it is time to request further imaging, such as an MRI of the abdomen with IV contrast.

 

The disadvantage of MRI is that the pictures will be of poor quality if the patient does not follow breathing instructions or has trouble holding their breath. CT scans are significantly faster to obtain and do not need a considerable amount of breath-holding capacity.

Ultrasound has little use in pancreatic imaging. Because of intestinal gas, the pancreas is frequently poorly visible sonographically. Ultrasound can identify secondary biliary ductal dilatation in pancreatic head cancer, but it is less effective in detecting the pancreatic mass itself.

ERCP with endoscopic ultrasonography and tiny needle aspiration biopsies of suspected lesions for pathologic specimens can be performed. However, with a pancreatic mass, biopsy confirmation is not required, and excision can be performed immediately after a thorough workup.

Endoscopic ultrasonography, a procedure done by gastroenterologists, can define the pancreatic mass and be utilized to biopsy the tumor under ultrasound supervision.

Endoscopic retrograde cholangiopancreatography (ERCP) is a test that uses an endoscope to inject a contrast dye into the biliary and pancreatic channels. It is possible to determine the degree of biliary or pancreatic blockage. In certain cases, a biliary stent might help alleviate jaundice symptoms.

 

Pancreatic cancer treatment

Patients with pancreatic cancer benefit from the expertise of a multidisciplinary team that includes oncologists, surgeons, radiologists, gastroenterologists, radiation oncologists, pathologists, pain management specialists, social workers, dieticians, and (when appropriate) palliative care specialists. 

Pancreatic cancer is a complex illness on many levels, including molecular, pathological, and clinical. Many factors influence a patient's reaction to therapy and outcome, including the biology of their cancer, their performance status, and the pattern of disease development.

Treatment of pancreatic cancer depends on the stage and location of the tumor, as well as the overall health of the patient. The ultimate goal of treatment is to eliminate cancer as much as possible. If it is not, the goal is to provide the best possible quality of life, slow down tumor growth, or reduce tumor size. 

The treatment is either surgical or non-surgical. Let’s start with surgeries. Two general surgeries can be performed: 

  • Curative surgery: when it is possible to remove all the tumors according to tests, clinical assessment, and overall health of the patient.
  • Palliative surgery: when the cancer is too widespread and can’t be completely removed. It is usually done to relieve symptoms and prevent possible complications. 

If the pancreatic adenocarcinoma is considered locally advanced then by definition it is unresectable. Neoadjuvant treatment with chemotherapy and/or radiation is typically preferred in this situation. Treatment with chemotherapy takes approximately.

 

Surgery

Curative surgery can be different based on the tumor location, it includes:

  • For tumors in the head of the pancreas: a procedure called Whipple procedure (pancreaticoduodenectomy).
  • For tumors in the pancreatic body and tail: the body, and tail are removed altogether with the spleen. 
  • Removing the entire pancreas in some cases.

As for the nonsurgical options, chemotherapy is indicated for people with advanced stages to control cancer growth, relieve symptoms and prolong survival. 

Radiation therapy, however, is used to destroy cancerous cells for borderline resectable tumors. It can be given before or after surgery. It can be combined with chemotherapy as well. 

Pancreatic cancer treatment abroad can vary from one country to another. For instance, in India, in addition to traditional ways, they offer affordable treatment plans as well as ablation or embolization treatments, which refer to treatments that destroy tumors using extreme heat or cold. They usually use:

  • High-energy radio waves (Radiofrequency ablation).
  • Microwave thermotherapy.
  • Ethanol ablation.
  • Cryoablation means destroying the tumor by freezing. 

 

The neoadjuvant first-approach in resectable pancreatic adenocarcinoma is becoming more common in high-volume institutions across the country and abroad. The rationale for the neoadjuvant first approach is that the patient is in the greatest possible condition to undergo chemotherapy and has the best chance of finishing treatment for 4-6 months.

Furthermore, tissue is considered to be well-oxygenated despite not having undergone a major surgery such as the Whipple. Many patients may not finish or even begin adjuvant chemotherapy following surgical resection, reducing their chances of survival.

In South Korea, they offer immunotherapy. They use drugs like Pembrolizumab (Keytruda) to stimulate the patient's own immune system to attack and eliminate the tumor effectively. Certain types of immunotherapy showed promising potential to treat pancreatic cancer. 

In the U.S, they also offer immunotherapy. They also discovered what’s called “pancreatic cancer stem cells”. These stem cells are responsible for the growth and renewal of tumor cells. Besides, they may cause treatment resistance.

New therapies are targeting pancreatic ductal adenocarcinoma cancer stem cells including genes located in different developmental cancers pathways. Several preclinical trials have been conducted to target these pathways in human pancreatic ductal adenocarcinoma cancer stem cells. By inhibiting these pathways, investigators were able to achieve longer-term control of the tumor in comparison with current standard chemotherapeutic regimens, in which tumor regression was significantly shorter-lived. 

They also offer embolization therapy where they inject a certain substance into the arteries that feed the tumor cells causing them to die, but it is usually used for larger tumors about 5 cm. There are three main types of embolization: arterial embolization, chemoembolization, and radioembolization. 

 

Staging

  • Stage I: Tumor is located in the pancreas and does not extend elsewhere
  • Stage II: Tumor infiltrates bile duct and other near structures, however lymph nodes are negative
  • Stage III: Any positive lymph nodes
  • Pancreatic cancer stage 4
  1. Stage IVA: Metastases into nearby organs such as stomach, liver, diaphragm, adrenals
  2. Stage IVB: Tumor infiltrates distant organs

Superior mesenteric artery encasement, liver metastases, peritoneal implants, distal lymph node metastases, and distant metastases are all signs of inoperability.

 

Pancreatic cancer prognosis

Despite advancements in cancer treatment, the prognosis for pancreatic adenocarcinoma remains dismal. The 5-year survival rate is estimated to be around 20%. After a year after diagnosis, the prognosis is bleak, with 90 percent of patients dying despite surgery. Palliative surgery, on the other hand, maybe beneficial.

 

Pancreatic cancer survival rate

You may call several health agencies for help, but you would end up more confused. And, unfortunately, compared with other cancers, the five-year survival rate of pancreatic cancer - the percentage of patients who live 5 years after diagnosis- is very low, about 5 to 10%. This is because far more people are diagnosed at stage IV when the disease has metastasized. In other words, it is critical to start treatment as soon as possible.

 

Complications

Pancreatic fistulas, delayed stomach emptying, anastomotic leaks, hemorrhage, and infection are all postoperative consequences of pancreatic surgery.

 

Differential Diagnosis

When pancreatic cancer is diagnosed, 52 percent of patients have distant metastasis and 23 percent have local dissemination.

Acute pancreatitis, chronic pancreatitis, cholangitis, cholecystitis, choledochal cyst, peptic ulcer disease, cholangiocarcinoma, and stomach cancer are all differential diagnoses before imaging and biopsy.

 

Interview

To ensure that you get a comprehensive picture and understand everything regarding pancreatic cancer, we invited Professor Choi who is a leading Professor at Hanyang University Hospital Seoul to address any questions you may have.

Dr. Dong Ho Choi

Today we will be asking you about pancreatic cancer.

1- What is Pancreatic cancer?

Pancreatic cancer affects the organ in our body called the pancreas, which is located very deep within our body. It is located below the liver, above the left kidney. Pancreatic cancer is cancer that starts in the pancreas. Usually, pancreatic cancer does not suddenly start. It normally starts due to a variety of reasons of which the most common is the existence of an inflammation, family heredity story (DNA), and sudden occurrence of diabetes. These are the most common reasons for developing pancreatic cancer. 

Because pancreatic cancer is a very serious illness, if an early diagnosis is not done, then a very negative impact on health has ensued. Thus, early detection is very important in this cancer.

2- What are the symptoms we can look for in pancreatic cancer patients?

That is a good question, but there are not many symptoms. So, it is important to have regular check-ups. But the most common symptom to watch out for is back pain. Also, sudden development of diabetes, and the onset of jaundice.

This is because when pancreatic cancer develops, it also blocks the bile ducts limiting bile flow, which results in jaundice. This tumor development may also cause diabetes. Also, without knowing the cause, digestion is hampered accompanied by back pain. At which point then we can consider the presence of pancreatic cancer.

3- What are treatment options for pancreatic cancer?

The only treatment option is surgery. The only curative option is to remove the tumor. However, these days we try to use chemotherapy in order to reduce the size of the tumor before surgery. Usually, most just go for surgery. However, there are two types – laparoscopic and open surgery. To this day, open surgery is more common. 

Within surgery, the procedure entails the removal of the pancreatic head, the duodenum, a section of the stomach, the gallbladder, and a part of the bile duct. These are not simple surgeries, so unless the cancer is detected early on, many nearby organs and tissue may also be affected and they need to be removed. So, frequent checkups and early detection is the only way to lessen the severity of this cancer and increase the likelihood of a positive outcome from surgery.

4- What is the role of chemotherapy in the management? 

chemotherapy is done for pancreatic cancers, but in comparison to other cancers such as colon cancer, the results are not that good. So, for example, if a person undergoes chemotherapy, the life expectancy may at best increase six months to a year. A full recovery expectation is difficult. So, yes, we can do chemotherapy as a supplemental procedure but clearly compared to other cancers the results are not that great.

5- Can pancreatic cancer be prevented?

Excessive drinking and smoking are said to be potential causes, so it may be helpful to watch out, but most importantly if you are prone to heredity to the disease or have diabetes, then it is important to have frequent check-ups. So, key point is to detect early so that you can have a successful surgery.

6- What is the difference between pancreatitis and pancreatic cancer? 

Pancreatitis is an inflammation of the pancreas, and the most common reason this happens is gallstones that fall and block the pancreatic duct. In such cases, and depending on the severity, the condition is basically 100% cured if the stone is removed. However, if pancreatitis is caused by excessive alcohol drinking, then it is difficult to treat, and eventually, the disease can become chronic and may cause pancreatic cancer. Therefore, alcohol-related pancreatitis is the most serious. And limiting alcohol consumption is the best prevention for it."

 

Conclusion

Pancreatic cancer, also known as pancreatic ductal carcinoma, is a kind of cancer that arises from pancreatic duct cells. In the United States, it is the fourth greatest cause of cancer mortality. 

Pancreatic cancer usually does not have any salient symptoms early on, so many people go for treatment when it is in a late-stage, which makes it very challenging to cure. Thus, it is very important that you get checkups periodically, especially if you are a smoker, excessive drinker, or have an unhealthy eating habit, or any other factor that could place you in a higher risk category for pancreatic cancer. The only available curative option is surgical resection, however, only 20% of pancreatic cancers are surgically resectable at the time of diagnosis.

Patients with metastatic, stage IV pancreatic cancer should have therapy talks with their doctors. Chemotherapy is an option. However, the life-extension will be months at best, depending on the toxicity and side effects of the chemotherapy. Because diet can impact wound healing, it's critical to put nutrition at the center of the patient's treatment.

 

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