About 20-40% of patients with pancreatic cancer appear to have the cancer contained entirely within the pancreas at the time of the diagnosis. Surgical removal of the tumor is recommended in this group of patients and this provides the best option for long term survival. Surgery for pancreatic cancer is a highly specialized operation and therefore the patient should be evaluated by a surgeon who is highly experienced in treating this disorder.
About 60-80% of the patients are found to have a locally advanced cancer because it is invading into the surrounding tissues outside the pancreas or where the cancer has metastasized (spread outside of the pancreas).
Symptoms
Pancreatic cancer symptoms depend on the site of the tumor within the pancreas and the degree of tumor involvement.
In
the early stages of pancreatic cancer there are not many noticeable
symptoms. As the cancer grows, symptoms may include the following:
- Jaundice.
- Light-colored stools or dark urine.
- Pain in the upper or middle abdomen and back.
- Weight loss for no known reason.
- Loss of appetite.
- Fatigue.
Risk factors for cancer of the pancreas
Some of the risk factors for cancer of the pancreas include:
- Cigarette Smoking: Cigarette smoking is the single most risk factor for pancreatic cancer. Approximately 30% of pancreatic cancers are thought to be related to excessive cigarette smoking.
- Diet: A diet high in meat and fats increase pancreatic cancer risks while fruits, vegetables and dietary fiber appear to have a protective effect.
- Diabetes Mellitus: While it is not clear whether diabetes mellitus is a risk factor for pancreatic cancer often patients develop diabetes few months to two to three years prior to manifestation of their cancer. Development of diabetes in an elderly patient should raise concern for pancreatic cancer and lead to a work up for pancreatic cancer.
- Chronic pancreatitis: Chronic pancreatitis is long term inflammation of the pancreas. This condition is associated as an increased risk for pancreatic cancer.
- Family History: Cancer of the pancreas seems to run in some families. An inherited tendency to develop this cancer may occur in about 5 to 10% of all cases of pancreatic cancer. Some of the DNA changes that give rise to pancreatic cancer can be recognized by genetic testing.
Staging and treatment of pancreatic cancer
A simplified staging of pancreatic cancer places patients in the following groups for determining appropriate treatment:
- Surgically resectable (removable) pancreatic cancer
- Advance cancer that is surgically not removable with no evidence of spread to other organs
- Metastatic cancer or cancer that has spread to other organs
Resectable (surgically removable) pancreatic cancer
For patients whose tumors are in the pancreas based on information from preoperative staging removal of the tumor by surgical means is the optimal form of therapy. The type of the surgery depends on the location of the tumor. For tumors that are located in the first part or the head of the pancreas a whipple operation is the required treatment. For patients whose tumors are located in the body and tail of the pancreas removal of the bottom half with a distal pancreatectomy together with removal of the spleen is the preferred form of surgical treatment. All patients who undergo resection (removal) of the pancreas will require chemotherapy and/or radiation therapy after the surgery.
Locally advanced cancer
Here the cancer has grown outside the pancreas to involve surrounding structures particularly blood vessels that are closely associated with the pancreas such as the superior mesenteric artery and superior mesenteric vein. Invasion of the cancer into these blood vessels precludes surgical removal of the tumor. A determination of a locally advanced cancer should be made by an experienced surgeon based on careful evaluation of radiological (x-ray) studies such as a high quality CT scan. It is important to note that CT scans that are not done in centers specialized in the treatment of pancreatic cancer may not provide optimal information for staging of patients with pancreatic cancer. Removal of the pancreas for pancreatic cancer is a highly specialized operation and therefore the evaluation of the patient for possible surgery should be by a surgeon who is highly experienced in treating this disorder. In patients who are determined to have unresectable cancer at a center specialized in the treatment of pancreatic cancer, treatment with chemotherapy and/or radiation therapy is recommended since this treatment has been shown clinical studies to provide improved survival. Some patients with locally advanced tumor may have excellent response to chemotherapy and/or radiation therapy and shrinkage of the tumor may allow an experienced pancreatic surgeon to remove the cancer.
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| CT-scan of pancreatic cancer |
Metastatic pancreatic cancer
In patients with metastatic pancreatic cancer the tumor is found to have spread outside of the pancreas. The common sites for spread of the tumor is to the liver and to the lining of the intestines or peritoneal surfaces. In general the prognosis is poor when pancreatic cancer is metastatic and treatment is directed toward relief of symptoms to provide a good quality of life. In some patients chemotherapy may provide an improvement in their symptoms.
Chemotherapy for exocrine pancreatic cancer
Chemo may be used at any stage of pancreatic cancer:- Chemo can be given before surgery (sometimes along with radiation) to try to shrink the tumor. This is known as neoadjuvant treatment.
- Chemo can be used after surgery (sometimes along with radiation) to try to kill any cancer cells that have been left behind (but can’t be seen). This type of treatment, called adjuvant treatment, lowers the chance that the cancer will come back later.
- Chemo is commonly used when the cancer is advanced and can’t be removed completely with surgery.
Many different chemo drugs can be used to treat pancreatic cancer, including:
- Gemcitabine (Gemzar®)
- 5-fluorouracil (5-FU)
- Irinotecan (Camptosar®)
- Oxaliplatin (Eloxatin®)
- Albumin-bound paclitaxel (Abraxane®)
- Capecitabine (Xeloda®)
- Cisplatin
- Paclitaxel (Taxol®)
- Docetaxel (Taxotere®)
Questions to ask your doctor
Treatment of pancreatic cancer is complex and requires a multidisciplinary program involving a pancreatic surgeon, medical oncologist and radiation oncologist. Outcomes from pancreatic cancer is dependant on the experience of the institution and the surgeon treating the condition. An open and frank discussion with your physician may help you make appropriate choices regarding your therapy.
Sources: University of Southern California / National Cancer Institute / American Cancer Society