Clinical Description
Pancreatic cancer is the fourth leading cause of cancer deaths in the United States. There are over 37,000 patients diagnosed each year and unfortunately 34,000 deaths. The most common type is adenocarcinoma involving the head of the pancreas. However cancer can occur anywhere in the pancreas including the body and tail.
Symptoms of Pancreatic Cancer
Pancreatic cancer often develops without any early symptoms. The majority of symptoms arise because of their location in the pancreas and its relationship to other organs. When symptoms do occur, they are often vague. One of the most common presentations is painless jaundice. Patients or family members notice yellowing of the eyes or skin. The urine could turn dark yellow. As it gets worse patients will get white stool and general itchiness. This is caused by a blockage in the bile duct that comes from the liver and is obstructed by the pancreatic tumor in the head of the pancreas. Other symptoms can be caused by a number of other things as well. These include general fatigue, weight loss, vomiting, diarrhea, abdominal pain, and new onset diabetes. This is why pancreatic cancer is sometimes not found until it potentially has already spread.
Risk Factors of Pancreatic Cancer
It is generally accepted that smokers are two to three times more likely to get pancreatic cancer than nonsmokers. The cause of this is unknown except for the possible carcinogens in cigarettes. There is also a genetic link. There are certain families that are at higher risk that can be associated with other types of cancers or pancreatic cancer alone. Knowing this family trait can help with screening.
How Pancreatic Cancer is Diagnosed
Only about 20 percent of pancreatic cancers are diagnosed while the tumor is confined entirely within the pancreas.
Blood Tests - No single blood test can determine the diagnosis of pancreatic cancer. Some tests, known as tumor markers, measure the levels of proteins produced by cancer cells. Known tumor markers for pancreatic cancer include carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA). Although these tests may be useful when pancreatic cancer is suspected and to monitor the status of the cancer, they are not a good screening tool.
Imaging - Advances in imaging technologies have been important in promoting the detection and treatment of pancreatic cancer. Some of the imaging techniques commonly used include the following: computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), Endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), positron emission tomography (PET).
Biopsy - To confirm suspected pancreatic cancer, sometimes a tissue sample may be obtained for microscopic examination. Once cancer of the pancreas is diagnosed, it is important to determine the extent (stage) of the disease to help plan for the best treatment.
Staging - Staging is an attempt to determine the size of the tumor, whether lymph nodes are involved, and if the tumor has invaded or spread to other organs
The tumor has metastasized when cancer cells spread to another organ. This can either be through the blood stream or the lymphatic channels. The most common site of metastasis is to the liver. Even though the tumor is now in the liver, it is still pancreatic cancer, and treated as such.
Treatment Options for Pancreatic Cancer at Tufts Medical Center
Treatment options include surgery, chemotherapy, and radiation therapy. These treatments are usually used in some combination to give the best outcomes.
The best treatment options depend on the extent of the tumor and individual characteristics of the patient. The best survival for pancreatic cancer is when it is found at an early stage (before it spreads) and only if the surgeon can completely remove the tumor. This is usually followed by chemotherapy and sometimes radiation therapy. This can give a 5 year survival of 45%. If the tumor seems to be too extensive locally but has not spread, then chemotherapy and radiation can be given to shrink the tumor so it can be removed later. Although the chance to extend survival is the best before the tumor has spread, many treatments can help control symptoms, of advanced disease, while improving quality of life and can extend survival.
Surgery - When performed on patients with localized disease, surgery currently offers the best opportunity to extend survival. The surgeon usually removes only the part of the pancreas that has cancer. In some cases, the whole pancreas may be removed.
Whipple procedure (pancreatoduodenectomy) is the most common type of surgery for pancreatic cancer. The head of the pancreas is removed along with the gallbladder, part of the stomach, part of the bile duct and part of the small intestine. The reason is that all these structure are in a very small space and the only way to get out the tumor is to remove these structures. Once it is removed the area is reconstructed so patients are able to eat and function normally.
Distal Pancreatectomy removes the tail and sometimes a portion of the body of the pancreas. The spleen is sometimes removed as well. This procedure can be done minimally invasively through small incisions which help in the recovery.
Total Pancreatectomy -- removes the entire pancreas and the spleen, was once used for tumors in the body or head of the pancreas. However, when the entire pancreas is removed, patients are left without any “islet cells”, which produce insulin. This means patients will develop diabetes and be dependent on insulin. There doesn't appear to be any treatment advantage to removing the whole pancreas.
Chemotherapy - Chemotherapy is often used in addition to surgery or radiation therapy in an attempt to slow the growth or prevent recurrence of pancreatic cancer. Gemcitabine is the standard chemotherapy drug for patients with pancreatic cancer. A targeted agent called erlotinib may help some patients with pancreatic cancer when combined with gemcitabine. Aggressive treatment combinations, such as 5-flurouracil + leucovorin + irinotecan + oxaliplatin, may give better survival, but they also have more side effects.
For patients whose tumors cannot be removed by surgery, chemotherapy can be used to decrease the rate of tumor growth, to control symptoms, and prolong survival.
Radiation Therapy - Radiation therapy in combination with chemotherapy is sometimes used to prevent local recurrence of pancreatic cancer after surgery. Radiation therapy can also be used before surgery to help shrink larger tumors.
Nutrition - Many patients with pancreatic cancer have problems with eating, often because of lack of appetite, nausea and vomiting. It is very important for patients to take in enough calories and protein to control weight and maintain strength. Eating many small meals a day of high-protein, a high-calorie food diet is recommended.
Some pancreatic cancer patients may require a feeding (enteral) tube, which provides nutrition to patients who have problems keeping up with their calories. Tube feeding may be temporary to treat acute conditions, or long term in the case of chronic illness. A dietitian will teach patients and caregivers how to use and manage the tube, and provide information about nutritional supplements. On occasion patients will require nutrition through the veins call total parenteral nutrition (TPN). This is given through a special IV and administered for a period of time throughout the day.
Programs + Services
The Pancreatic Cancer Program at Tufts Medical Center in Boston offers specialized diagnoses and treatments for pancreatic disease and tumors.
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Research + Clinical Trials
The purpose of this study is to compare the usual treatment approach (surgery followed by chemotherapy) to using chemotherapy followed by surgery and then more chemotherapy
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