Pancreatic Cancer

General Information

The pancreas is a gland that produces enzymes to help break down foods and insulin to stabalize blood sugar. Pancreatic cancer occurs when the cells of the pancreas begin dividing abnormally.  Rapid division of immature cells grow in a cluster and eventually form a tumor.  This tumor may grow in the head, body or tail of the pancreas.  The location of the pancreatic cancer greatly determines treatment and prognosis. This particular form of cancer is often diagnosed late, making treatment more difficult than other types of cancer. The symptoms of pancreatic cancer depend on the location of the tumor within the pancreas.  The pancreas does not have pain receptors; therefore patients only feel pain when the tumor has grown large enough to effect another part of the body.  For example, back pain may be felt once the tumor has grown large enough to put pressure on the spine. This is usually the first time that the patient realizes that something is wrong.

Signs and Symptoms

A patient with pancreatic cancer may present with jaundice, or yellowing of the eyes and skin. This jaundice is related to the tumor putting pressure on the billiary duct which in turn causes a back up of bile which is excreated by the gall bladder. As the cancer grows and metastasizes throughout the body, some possible symptoms may include:

• Pain in upper or middle abdomen and/or back
• Light-colored stools
• Dark urine
• Loss of appetite
• Weight loss for unknown reasons

Diagnosis and staging

It is difficult to detect and diagnose pancreatic cancer in the early stages because:

• there are no early symtoms
• when symptoms do present themselves they often are mistaken for other gastric illnesses such as an ulcer, pancreatitis or choleycystitis (infection of the gallbladder)
• the pancreas is hidden by other organs in the abdomen making it difficult to visualize with imaging or feel with palpation

In order to determine proper treatment the physician must determine if the cancer is resectable.  Pancreatic tumors are resistant to chemotherapy and radiation, therefore surgery offers the patient best chance of survival.  The tools that may be used for detemining if the patient is a candidate for surgery are:

• Helical computed tomographic scan (HCT)
• Magnetic resonance imaging scan (MRI)
• Endoscopic ultrasound
• Minimally invasive techniques such as laproscopic ultrasound

Positive cytology of the peritoneal fluid showed a high predictability in patients having non-resectable tumors.

There are no specific tumor markers for pancreatic cancer; however, most patients at the time of diagnosis will present with an elevated CA 19-9. Increased levels of CA 19-9 throughout treatment may identify progression in tumor growth but it is not a diagnostic indicator.  Similarly, a normal CA 19-9 should not be used as an indication of absence of pancreatic cancer or recurrence.

Prognosis

The three factors that determine a patients chance of survival are:

• Is the cancer localized?
• Can the tumor be completely resected?
• Has the cancer metastasized to the lymph nodes?

Only 5% of all patients with pancreatic cancer experience a complete cure from the disease.  With advances in research the 5 year survival rate has increased; sadly, the increase is minimal at only 18-24%.   For the past few decades the incidence of  pancreatic cancer has been on the rise, and it is now the fourth leading cause of cancer deaths.  Despite the high mortality rate associated with this disease the etiology is poorly understood.

The highest cure rate is seen if the tumor is localized in the pancreas with no lymph involvement (stage 1).  Unfortunately, this is seen in less than 20% of newly diagnosed patients. Surgical treatment remains the first choice for these patients, but if their cancer has progressed beyond stage 1, surgery will have decreased effectiveness.

Pallative Care

There are some pallative measures that may be used to ease the patient’s discomfort as the cancer progresses.  Due to the nature of this disease, it is recommended that palliative interventions begin soon after diagnosis in patients diagnosed with later stages. Some interventions include:

• Biliary decompression (may be done in surgery or in Interventional Radiology)
• Gastric obstruction (removal of the obstruction usually done in surgery)
• Pain control (scheduled and breakthrough pain meds, pain pumps, epidurals)
• Psychological/spiritual care to help them through the grief process

References:

Pancreatic Cancer Treatment (PDQ®)–Health Professional Version. Retrieved from https://www.cancer.gov/types/pancreatic/hp/pancreatic-treatment-pdq. 

Pancreatic cancer. Retrieved from https://medlineplus.gov/ency/article/000236.htm.