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Pancreatic Cancer

What is Cancer

Cancer is the uncontrolled growth of cells that no longer respond to the bodies control system. These cells learn to grow and spread outside where they first appeared.

What is pancreatic cancer?

The pancreas is a gland of the digestive system with two roles and is made up of two types of cells: one produces digestive juices and the other releases hormones that help regulate blood sugar levels. The abnormal growth of pancreatic cells can lead to pancreatic cancer. Most pancreatic cancers are formed in the cells that produce digestive enzymes. Pancreatic cancer often is uncovered when it is advanced but there are many treatments that can be improve how well people do.

How common is Pancreas Cancer ?

Each year, over 3000 new cases of pancreatic cancer are diagnosed in Australia. The risk of being diagnosed with pancreatic cancer by age 85 is 1 in 55 for Australian men and 1 in 74 for Australian women. Pancreas cancer is the tenth most common cancer but the fifth most common cause of cancer death and is predicted to be the second most common by 2020. The five-year survival rate for pancreatic cancer is 8.7%

What are the symptoms of pancreatic cancer?

Pancreatic cancer can cause yellowing of the skin and whites of the eyes (jaundice), upper and middle abdominal pain, back pain, unexplained weight loss, appetite loss, fatigue, dark coloured urine and light-coloured stools.

Although the presence of these symptoms does not always mean you have pancreas cancer. These symptoms can also be caused by conditions that are not pancreatic cancer. But if you have these symptoms, tell your doctor or nurse about them.

What causes pancreatic cancer?

You are at an increased risk of developing pancreatic cancer if you are a smoker, overweight, have diabetes, or have pancreatitis (inflammation of the pancreas) or a family history of pancreatic cancer. Although many people can develop pancreatic cancer have no risk factors, no family history and no genetic predisposing

Age: The risk of developing pancreatic cancer increases with age. Most people who develop pancreatic cancer are older than 45. In fact, 90% are older than 55 and 70% are older than 65. However, adults of any age can be diagnosed with pancreatic cancer.
Gender: Pancreatic cancer is more common in men than women
Race/ethnicity: Black people are more likely than Asian, Hispanic, or white people to develop pancreatic cancer. People of Ashkenazi Jewish heritage are also more likely to develop pancreatic cancer .
Smoking: People who smoke are 2 to 3 times more likely to develop pancreatic cancer.
Obesity and diet:Regularly eating foods high in fat is a risk factor for pancreatic cancer. Research has shown that obese and even overweight men and women have a higher risk of being diagnosed with and dying from pancreatic cancer. Chronic, heavy alcohol use can also increase the risk of pancreatic cancer.
Diabetes: Many studies have indicated that diabetes, especially when a person has had it for many years, increases the risk of developing pancreatic cancer. In addition, suddenly developing diabetes later in adulthood can be an early symptom of pancreatic cancer. However, it is important to remember that not all people who have diabetes or who develop diabetes as adults develop pancreatic cancer.
Chronic pancreatitis: Pancreatitis is the inflammation of the pancreas, a painful pancreatic disease. Some research suggests that having chronic pancreatitis may increase the risk of developing pancreatic cancer.
Pancreatic Cysts: People with certain types of pancreatic cysts have an increased risk of pancreatic cancer.

How is pancreatic cancer diagnosed?

Pancreatic cancer can be diagnosed by reviewing your medical history and performing a thorough physical examination. Your doctor may order blood tests and other radiology tests such as CT scan, ultrasound, and possibly MRI, telescope examination of your internal organs such as endoscopic ultrasound, endoscopic retrograde cholangiopancreatography (ERCP). A biopsy to confirm the diagnosis may also be performed but is not always required.

What other tests may be required?

To ascertain the stage of the cancer and to individualise treatment a PET scan, Laparoscopy or MRI of the liver may be required.

Is Pancreas Cancer curable?

Yes, in the 1 in 5 who are diagnosed before the cancer has spread, over 30% are alive at 5 years.

What is cancer staging?

Cancer staging is the process of determining how much cancer is in the body and where it is located. Staging describes the severity of an individual's cancer based on the magnitude of the original (primary) tumour as well as on the extent cancer has spread in the body. Understanding the stage of the cancer helps doctors to develop a prognosis and design a treatment plan for individual patients.

Staging is based on the clinical or radiological extent of disease, the pathological extend of disease after a tumour is removed. Restaging is when the process is repeated after a round of treatment.

How is pancreatic cancer staged?

Clinical and radiological staging of pancreatic cancer is largely based on the appearance of the diagnostic tests undertaken. These may include a CT scan, MRI, Laparoscopy, endoscopic Ultrasound or PET scan. This is used to determine treatment

The most common form type of clinical staging is based on whether the pancreatic cancer is removable by surgery and whether it has grown into surrounding structures or spread to other organs. It is classified into 4 categories, but these are not the same as stage 1,2,3,4.

Clearly Resectable – tumours clearly confined to the pancreas with no growth into adjacent blood vessels and no spread to other organs
Borderline Resectable – These tumours are confined to the pancreas with no other spread but may have grown into adjacent blood vessels based on the scans performed
Locally advanced – These tumours have not been proven t spread to other organs but significantly involve the major blood vessels around the pancreas
Metastatic – Tumours which have been shown to spread to other organs or have been proven to spread to other organs by biopsy. (this is synonymous to stage 4 disease)
Pathological Staging This staging system is based on more information than clinical staging and can only be fully determined once a cancer has been removed. It is based on the size of the tumour, whether the cancer has spread to lymph glands, grown into blood vessels or spread to other organs.

A simplified category of the pathological staging of pancreatic cancer is below

Stage 1 – tumours that have not spread to lymph glands or other organs
Stage 2 – A tumour that has spread beyond the pancreas or into up to 3 lymph glands
Stage 3 – A tumour that has spread to more than 4 lymph glands or into the surrounding arteries
Stage 4 – A tumour which has spread to other organs

What is the best treatment for pancreatic cancer?

Treatment of pancreatic cancer depends upon how advanced it is and your general fitness. The goal of treatment is to remove or kill all the cancer cells in the body.

The standard treatments for pancreatic cancer involve surgery, radiation and chemotherapy. To undergo these treatments, it may be necessary to undergo an interventional procedure by a radiologist or gastroenterologist. These may include an ERCP, EUS or PTC to help the liver and pancreas work during treatment.

How these standard treatments are delivered is based on the clinical and radiological stage of the disease (see above). The order in which these treatments is applied is based on discussions at a specialist multidisciplinary meeting and is tailored (individualised) to each person and how fit they are to undergo treatment. Patients also have the final say as to which treatments they will undertake, and this is always given the highest priority.

A simplified guide to treatment based on clinical staging

Resectable pancreatic cancer – Upfront surgery followed by chemotherapy or chemotherapy followed by surgery. Some patients may also require radiotherapy after surgery.
Borderline resectable pancreatic cancer – In rare cases upfront surgery will be performed, but all patients will be considered for chemotherapy (or chemotherapy and radiation) prior to surgery with many patients having further chemotherapy after surgery.
Locally advanced pancreatic cancer – Chemotherapy with or without radiation is the mainstay of treatment. A small number of people may be able to undergo surgery to remove the tumour after treatment or ablation of the tumour may be possible if it has not spread after prolonged treatment.
Metastatic pancreatic cancer – Chemotherapy and radiotherapy are the treatments of choice when the tumour has spread to other organs. In this setting removing the tumour is not beneficial. Many clinical trials are specifically aimed at patients who has pancreatic cancer which has spread.

If the cancer is in advanced stages at the time it is diagnosed and has spread to other parts of the body, treatment involves both chemotherapy and occasionally radiation to control the activity of the disease. It is especially important to carefully managing symptoms for the best quality of life. It is best managed by a team of experienced doctors and nurses from many different specialities.

What is the prognosis of pancreatic cancer?

Overall, the prognosis of pancreatic cancer is worse than other abdominal cancers, when compared stage for stage. Prognosis depends on many variables, not least whether your tumour can be removed and whether you are fit enough to undergo radical therapy. There is also a wide variation in the survival of pancreatic cancer from person to person who have the same stage of the disease. The prognosis will also depend on how early the cancer is discovered.

What is the survival of pancreatic cancer?

The survival of pancreatic cancer without treatment is very poor. With treatment improvements in survival can be achieved for nearly all patients. The extent of this depends on the initial stage of the tumour and the therapy that can be tolerated.

Are there any new treatments for pancreatic cancer?

Yes, cancer therapy is constantly advancing and evolving with new drugs and treatments becoming available. Many new treatments are only initially available as part of a clinical trial with others only suitable to a small number of patients. Ask your treating specialist is these would be suitable for you.

Are there clinical trials for pancreatic cancer?

Yes, ask your specialist if you are eligible for a clinical trial. However clinical trials are designed to test to see how newer treatments compare with standard therapies and it is not known which treatment is better.

What is the treatment doesn’t work?

Recovery from Pancreatic cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be become terminal. Further aggressive treatment during this stage but may not be advantageous and worsen quality of life.

This situation is stressful, and for many people, advanced cancer is difficult to discuss, especially with family and friends. However, it is important to have open and honest conversations with your health care team and express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families during this time. Making sure a person is physically comfortable and free from pain is extremely important.

People who have advanced cancer and who are expected to live less than 6 months may find the service of a palliative care team to aid patients and their families.

What is life like after pancreatic cancer?

After potentially curative treatment has finished your journey continues with your doctors and specialist nurses. Regular visits to your treating specialists are conducted by your surgeon and oncologist (usually in an alternating basis). Regular blood test and physical examination is carried out, initially at 3 monthly intervals. CT scans are performed less regularly to assess to see if the tumour has recurred. A waiting these test results can cause significant anxiety given the serious nature of a positive result. Talk to you treating specialists as there may be ways to help with these feelings. A survivorship programme can help return to normal life after treatment and cope with the effects of the diagnosis, disease and treatment.