Pancreatic cancer

Facts about Pancreatic cancer  

Q 1 What is pancreatic cancer? 

Pancreatic cancer starts in the cells of the pancreas. The pancreas is a flat, gland behind the stomach in the upper part of the abdomen. 

The pancreas is made up of exocrine cells and endocrine cells. 

  • Exocrine cells: They make and release pancreatic juice. Enzymes in the pancreatic juice help digest fat, carbohydrates, and protein in food.
  • Endocrine cells: They make and release insulin and glucagon into the blood. These hormones help control the level of sugar, or glucose, in the blood.

Q 2 What causes pancreatic cancer? 

Risk factors for pancreatic cancer include:

  • Age – it mainly affects people aged 50 to 80
  • Being very overweight
  • Smoking or chewing tobacco
  • Having a history of certain health conditions – such as diabetes, long-term inflammation of the pancreas (chronic pancreatitis)
  • Inherited genetic syndromes

Inherited gene changes (mutations) can be passed from parent to child. These gene changes may cause as many as 10% of pancreatic cancers. Sometimes these changes result in syndromes that include increased risks of other cancers (or other health problems). Examples of genetic syndromes that can cause pancreatic cancer include:

  • Hereditary breast and ovarian cancer syndrome, caused by mutations in the BRCA1 or BRCA2 genes
  • Familial atypical multiple mole melanoma (FAMMM) syndrome, caused by mutations in the p16/CDKN2A gene and associated with skin and eye melanomas
  • Familial pancreatitis, usually caused by mutations in the PRSS1 gene
  • Lynch syndrome, also known as hereditary non-polyposis colorectal cancer (HNPCC), most often caused by a defect in the MLH1 or MSH2 genes
  • Peutz-Jeghers syndrome, caused by defects in the STK11 gene. This syndrome is also linked with polyps in the digestive tract and several other cancers.

Changes in the genes that cause some of these syndromes can be found by genetic testing. 

Q 3 What are the types of pancreatic cancer?

  • Ductal adenocarcinomas  

The most common cancerous tumors of the pancreas. They make up about 95% of all pancreatic cancers.

  • Adenosquamous carcinomas 
  • Pancreatic neuroendocrine tumors (pNETs) 
  • Acinar cell carcinomas

Q 4 What are the symptoms of pancreatic cancer? 

In the early stages, a tumor in the pancreas does not usually cause any symptoms, which can make it difficult to diagnose.

Common symptoms of pancreatic cancer are:

  • Pain in the back or stomach area – which may come and go at first and is often worse when lying down or after eating
  • Unexpected weight loss & loss of appetite 
  • Yellowing of the skin and whites of the eyes (jaundice), pale-colored stool and itchy skin
  • Swelling in the right upper abdomen 

A word of caution

It’s important to remember that these symptoms can be caused by many different conditions and are not usually the result of cancer.

Q 5 How is pancreatic cancer diagnosed? 

  • Health history and physical examination 
  • Ultrasound: It is the 1st investigation to be done for any abdominal problem. 

When ultrasound suspects pancreatic cancer, you’ll usually be referred for further investigation.

Depending on the results of the scan, further tests may include:

  • Endoscopic ultrasound (EUS) – a type of endoscopy that allows close-up ultrasound pictures to be taken of your pancreas
  • Endoscopic retrograde cholangiopancreatography (ERCP) – a type of endoscopy used to inject a special dye into your bile and pancreatic ducts; the dye will show up on an X-ray and highlight any tumors
  • Blood tumor marker tests CA19-9 & CEA 
  • Blood tests – To assess the state of liver, kidneys and bone marrow
  • Chest X-ray – To check if cancer has spread to the lungs or not 

Q 6 What is pancreatic cancer staging?

It is not always possible for a doctor to tell exactly how big the tumor is or where it has grown until they do surgery. So doctors often divide pancreatic cancers into groups based on resectability. Resectability means that entire cancer can be removed with surgery. 

With the above concept, most of the oncologist divide staging into three categories based on CT scan findings 

  • Resectable pancreatic cancer

This means that the entire tumor can be removed with surgery. The cancer is only in the pancreas and has not spread to surrounding blood vessels and other parts of the body 

  • Borderline resectable pancreatic cancer 

A tumor is borderline resectable when it has grown into a surrounding major blood vessel but it is still possible to remove the tumor completely and rebuild the blood vessel. 

  • Unresectable or advanced pancreatic cancer 

A tumor is unresectable if it can’t be entirely removed with surgery. This may be because cancer has grown too far into nearby blood vessels or other tissues to be completely removed and/or has spread to other organs.

A word of caution 

The above staging is a simplified version for your basic understanding. The reader is advised to follow the TNM staging system developed by the American Joint Committee on Cancer (AJCC) in which 

  • T stands for the size and location of the primary tumor
  • N stands for nodes. It tells whether cancer has spread to the nearby lymph nodes
  • M stands for metastasis. It tells whether cancer has spread to distant parts of the body

Q 7 How is pancreatic cancer treated? 

Pancreatic cancer is often curable if it’s diagnosed at an early stage.

When deciding treatment options for a particular patient, the doctor will consider the following factors and will decide individual treatment plan:

  • The size of the cancer
  • The stage of the cancer
  • The location of the cancer
  • Your overall health and ability to recover from surgery, radiation therapy or chemotherapy
  • Your personal preferences

Following are the general guidelines but treatment may vary from patient to patient:  

  • Resectable pancreatic tumors

They are treated with surgery to remove a part, or all, of the pancreas. Chemotherapy may be given after surgery (called adjuvant chemotherapy). 

  • Borderline resectable pancreatic tumors 

They are treated before surgery with chemotherapy and chemoradiation (called neoadjuvant therapy). Once chemotherapy or chemoradiation is over, a repeat CT scan is done and the decision for surgery is taken. 

  • Unresectable or advanced pancreatic cancer 

Treated with chemotherapy, with or without targeted therapy

Surgery: Is the only curative option for pancreatic cancer 

Depending on the stage, size, and location of the tumor, you may have one of the following types of surgery.

  • The Whipple procedure (also called pancreaticoduodenectomy) is used to remove tumors in the head of the pancreas or in the opening of the pancreatic duct. It removes the head of the pancreas along with the duodenum (the first part of the small intestine), the gallbladder, and part of the common bile duct, the pylorus (bottom part of the stomach that attaches to the duodenum) and lymph nodes near the head of the pancreas.
  • The modified Whipple procedure (also called pylorus-preserving pancreaticoduodenectomy) Modified Whipple procedure doesn’t affect normal stomach function, it avoids nutrition problems that can happen after the Whipple procedure.
  • Distal pancreatectomy is used to remove tumors in the body or tail of the pancreas. 
  • Total pancreatectomy may be used only if necessary to completely remove the tumor.