Pancreatic Cancer -- August 22, 2011 -- Dr. David McMillen and Dr. Bill Polk

Posted: Updated:

Bill Polk, MD: thoracic surgeon
BAPTIST HOSPITAL

Monday, August 15, 2011
TOPIC: Pancreatic Cancer
David McMillen, MD: gastroenterologist

news notes via www.webmd.com

Pancreatic Cancer Overview

Each year, about 37,000 people in the U.S. are diagnosed with pancreatic cancer. About one in 76 people in the U.S. will develop the disease. Pancreatic cancer affects about equal numbers of men and women, almost always after the age of 45.

Cancer of the pancreas barely makes the top 10 most common cancers in the U.S. However, pancreatic cancer's tendency to spread silently before diagnosis makes it the fourth deadliest cancer diagnosis.

Types of Pancreatic Cancer

Pancreatic cancer is classified according to which part of the pancreas is affected: the part that makes digestive secretions (exocrine) or the part that makes insulin and other hormones (endocrine).

Exocrine Pancreatic Cancer

Although there are several different types of pancreatic cancer, 95% of cases are due to pancreatic adenocarcinoma.

Other less common exocrine pancreatic cancers include:

Adenosquamous carcinoma
Squamous cell carcinoma
Giant cell carcinoma
Acinar cell carcinoma

The exocrine pancreas makes up 95% of the pancreas, so it's not surprising that most pancreatic cancers arise here.

Endocrine Pancreatic Cancer

Other cells of the pancreas make hormones that are released directly into the bloodstream (endocrine system). Cancer arising from one of these cells is called neuroendocrine pancreatic cancer or islet cell pancreatic cancer.

Endocrine pancreatic cancers are quite rare, and are named according to what kind of hormone-producing cell it starts from:

Insulinomas (from an insulin-producing cell)
Glucagonomas (from a glucagon-producing cell)
Somatostatinomas (from a somatostatin-making cell)
Gastrinomas (from a gastrin-producing cell)
VIPomas (from vasoactive intestinal peptide-making cell)

Endocrine tumors usually are not cancer at all; they are nonmalignant growths. These "benign" tumors are not considered pancreatic cancer. However, they may grow to a large size or secrete unhealthy quantities of hormones, causing medical problems.

Ampullary Cancer (Carcinoma of the Ampulla of Vater)

Cancer can develop where the tube (duct) that drains the pancreas enters the small intestine (an opening called the ampulla). Although it's not technically pancreatic cancer, ampullary cancer causes symptoms similar to pancreatic cancer, and is treated similarly.

Causes of Pancreatic Cancer

Pancreatic cancer occurs when cells in the pancreas grow, divide, and spread uncontrollably, forming a malignant tumor. The exact cause of pancreatic cancer is unknown.

Smoking is the major risk factor for pancreatic cancer. Cigarette smoking roughly doubles the risk for pancreatic cancer. People with diabetes or chronic pancreatitis are also at increased risk.

Age, male gender, and family history are other risk factors for pancreatic cancer.

Prevention of Pancreatic Cancer

There is no known way to prevent pancreatic cancer. Not smoking, keeping a healthy weight, and eating a plant-based diet should reduce your risk for pancreatic cancer.

Diagnosis of Pancreatic Cancer

In addition to a history and physical exam, imaging tests may be performed to help make the diagnosis of pancreatic cancer. These tests include:

Ultrasound
Magnetic resonance imaging
Endoscopic retrograde cholangiopancreatography (ERCP)

A definitive diagnosis of pancreatic cancer only comes from removal of cancer tissue (biopsy). This can be done with a needle through the skin, during endoscopy, or with an operation.

Further Reading:

Treatment for Pancreatic Cancer

Pancreatic cancer is treated in several ways, alone or in combination:

Surgery
Chemotherapy
Radiation therapy
Palliative care

Surgery is generally done to attempt to cure pancreatic cancer, but it may also be done to lessen or prevent symptoms. Chemotherapy and radiation are often given together, with or without surgery, to slow pancreatic cancer's growth. Palliative care aims to reduce discomfort for people whose pancreatic cancer cannot be cured.

What to Expect From Pancreatic Cancer

Pancreatic cancer is a serious condition. Most cases of pancreatic cancer have already spread at the time of diagnosis, making a full cure unlikely. Treatments can allow people to live longer with pancreatic cancer, and help them feel better. Clinical trials are ongoing to discover more effective ways of treating pancreatic cancer.

Pancreatic Cancer Symptoms

Pancreatic cancer often goes undetected until it's advanced and difficult to treat. In the vast majority of cases, symptoms only develop after pancreatic cancer has grown and begun to spread. What are the symptoms of pancreatic cancer, and can any symptoms lead to earlier detection?

Because more than 95% of pancreatic cancer is the adenocarcinoma type, we'll describe those symptoms first, followed by symptoms of rare forms of pancreatic cancer.

Pancreatic Cancer Symptoms: Location Matters

Initially, pancreatic cancer tends to be silent and painless as it grows. By the time it's large enough to cause symptoms, pancreatic cancer has generally grown outside the pancreas. At this point, symptoms depend on the cancer's location within the pancreas:

Pancreatic cancer in the head of the pancreas tends to cause symptoms such as weight loss, jaundice (yellow skin), and fat in the stool, with or without abdominal pain.
Pancreatic cancer in the body or tail of the pancreas usually causes belly pain and weight loss.

In general, symptoms appear earlier from pancreatic cancers in the head of the pancreas, compared to those in the body and tail.

Pancreatic Cancer: Gastrointestinal Symptoms

Because pancreatic cancer grows around important areas of the digestive system, gastrointestinal symptoms often predominate:

Abdominal pain. More than 80% of people with pancreatic cancer eventually experience some abdominal pain as the tumor grows. Pancreatic cancer can cause a dull ache in the upper belly and back pain. The pain may come and go.
Bloating. Some people with pancreatic cancer have a sense of early fullness with meals (satiety) or an uncomfortable swelling in the abdomen.
Nausea
Diarrhea
Fat in the stool (steatorrhea). As pancreatic cancer reduces the pancreas' ability to secrete fat-digesting enzymes, more fat ends up in the stool. These fatty stools can be strange-smelling, and float more than normal.
Pale-colored stools. If the duct draining bile into the intestine is blocked by pancreatic cancer, the stools may lose their brown color and become pale or clay-colored. Urine may become darker.

Pancreatic Cancer: Constitutional (Whole-Body) Symptoms

As it grows and spreads, pancreatic cancer affects the whole body. Constitutional symptoms can include:

Weight loss
Malaise
Loss of appetite
Elevated blood sugars. Some people with pancreatic cancer develop diabetes as the cancer impairs the pancreas' ability to produce insulin. (However, the vast majority of people with a new diagnosis of diabetes do not have pancreatic cancer.)

Pancreatic Cancer: Skin Symptoms

Jaundice: As pancreatic cancer blocks the duct that releases bile into the intestine (common bile duct), the ingredients of bile build up in the blood. This turns the skin and the eyes yellow, a condition called jaundice.

Itching: People with pancreatic cancer sometimes report itching all over. Blockage of the bile ducts is often responsible.

Further Reading:

Pancreatic Cancer's Sneaky Symptoms

In a very small number of people with pancreatic cancer, early symptoms might be present that could lead to earlier diagnosis. Unfortunately, researchers have been unable to identify any predictable pattern. One study that surveyed 305 people with pancreatic cancer illustrated the challenge:

About 4% reported having a sudden disgust for preferred tastes (like coffee, smoking, or wine) that preceded other symptoms by more than six months.
5% of people had loss of appetite, a feeling of early fullness with meals, or profound weakness, more than six months before more obvious symptoms developed.
1% of people had attacks of acute pancreatitis more than six months before their diagnosis with pancreatic cancer.

The rarity of these situations points out the difficulty of using early symptoms to catch pancreatic cancer at a curable stage.

That said, symptoms like weight loss, persistent loss of appetite, or light-colored stools should always prompt concern. Consistent or worsening discomfort, nausea, vomiting, or diarrhea are also worrisome. If you feel something's not right, see your doctor.

Pancreatic Cancer Treatments by Stage

The best treatment for pancreatic cancer depends on how far it has spread, or its stage. The stages of pancreatic cancer are easy to understand. What's harder is determining the stage without resorting to major surgery. In practice, doctors choose pancreatic cancer treatments based on imaging studies and a person's individual factors.

Understanding Pancreatic Cancer

Stages of Pancreatic Cancer

Stage is a term used in cancer treatment to describe the extent of spread. The stages of pancreatic cancer exist partly to guide treatment, but also to classify patients for clinical trials. The stages of pancreatic cancer are:

Stage 0: No spread. Pancreatic cancer is limited to a single layer of cells in the pancreas. The pancreatic cancer is not visible on imaging tests or even to the naked eye.
Stage I: Local growth. Pancreatic cancer is limited to the pancreas, but has grown to be less than 2 centimeters across (stage IA) or greater than 2 centimeters (stage IB).
Stage II: Local spread. Pancreatic cancer has grown outside the pancreas, and/or has spread to nearby lymph nodes.
Stage III: Wider spread. The tumor has expanded into nearby major blood vessels or nerves. As yet, pancreatic cancer can't be seen in other organs.
Stage IV: Confirmed spread. Pancreatic cancer is found in distant organs.

Determining pancreatic cancer's stage is often tricky. Imaging tests like CT scans and MRIs provide some information, but knowing exactly how far pancreatic cancer has spread usually requires surgery.

Since surgery has risks, doctors first determine whether pancreatic cancer appears to be removable by surgery (resectable). Pancreatic cancer is then described as follows:

Resectable: On imaging tests, pancreatic cancer hasn't spread (or at least not far), and a surgeon feels it might all be removable. About 10% of pancreatic cancers are considered resectable when diagnosed.
Locally advanced (unresectable): Pancreatic cancer has grown into major blood vessels on imaging tests, so the tumor can't safely be removed by surgery.
Metastatic: Pancreatic cancer has clearly spread to other organs, so surgery can't remove it.

If pancreatic cancer is resectable, surgery could extend life and offer a small chance of cure.

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Pancreatic Cancer -- August 22, 2011 -- Dr. David McMillen and Dr. Bill Polk