Pancreatic Cancer

Pancreatic cancer, currently the fourth leading cause of death from cancer in the United States, is the growth of malignant cells in the pancreas, a pear-shaped organ located just below and behind the stomach. The pancreas secretes digestive enzymes into the small intestine via the common bile duct, and islet cells of the pancreas secrete hormones (insulin and glucagon) into the blood. Pancreatic cancer impairs the digestive process and may block the bile duct as it grows. A cure is possible with early diagnosis and surgical removal. However, pancreatic cancer is extremely difficult to diagnose and has usually spread by the time symptoms appear, so cures are uncommon. This is because there are no validated, specific screening tests that can easily and reliably find early-stage pancreatic cancer in people who do not show symptoms.

Pancreatic neuroendocrine tumors (PNETs) are often slow growing tumors and have a better prognosis. However, most pancreatic cancers (90%) are exocrine adenocarcinoma and due to difficulties in diagnosis, the aggressive nature of pancreatic cancer, and the limited systemic treatments available, the five-year survival rate for patients who have pancreatic adenocarcinoma is only about 5%.

Who Gets Pancreatic Cancer?

According to the American Cancer Society, in the United States in 2023 more than 64,000 people—slightly more men than women—will be diagnosed with pancreatic cancer. About 50,550 people will die of pancreatic cancer. Rates of pancreatic cancer have been slowly increasing over the past 10 years, although it is unclear why. Most cases occur after age 50; men are affected slightly more often than women. The lifetime risk of developing pancreatic cancer for men is about 1 in 63. The lifetime risk for women is about 1 in 65. Pancreatic cancer accounts for about 3 percent of all cancers and about 7 percent of all cancer deaths in the United States.

Symptoms

• Poor appetite; weight loss.

• Pain in the upper-central or right abdomen. The pain may spread to the back and may be relieved by sitting up and leaning forward.

• Jaundice, which causes yellowing of the skin, is present in approximately 50 percent of patients at the time of diagnosis and may be associated with less-advanced disease.

• Itching skin.

• Nausea and vomiting.

• Diarrhea or constipation, dark-colored urine, or pale stools.

• A feeling of fullness.

• Blood clots

• Fatigue, depression, and mood swings.

• Shakiness, irritability, profuse perspiration, chills, dizziness, or muscle spasms in patients with an islet cell tumor, due to associated hypoglycemia.

Causes/Risk Factors

The risk for pancreatic cancer increases with age. The disease is relatively rare in people who are younger than age 40, and most patients are diagnosed after the age of 45. About 90 percent of patients with the disease are older than 55 years and about 70 percent are older than age 65. Environmental factors, medical/surgical factors, genetic factors, and occupational exposures also can increase the risk for pancreatic cancer. Other risk factors include:

• Race – pancreatic cancer is more common in African Americans than in Caucasians.

• Smoking – smokers develop pancreatic cancer more than twice as often as nonsmokers.

• Diet – pancreatic cancer may be associated with high intakes of meat and fat.

• Medical factors – pancreatic cancer is more common in patients who have a history of cirrhosis, chronic pancreatitis, diabetes, and surgery to the upper digestive tract.

• Environmental factors – long-term exposure to certain chemicals, such as gasoline and related compounds, as well as certain insecticides, may increase the risk of developing cancer of the pancreas.

• Genetic factors – genetic mutations, including the BRCA2 gene mutation, PRSS1 gene mutation, hereditary non-polyposis colorectal cancer (HNPCC; Lynch syndrome), and Peutz-Jeghers syndrome, can increase the risk for pancreatic cancer. Other genetic factors may decrease this risk.

What If You Do Nothing?

Pancreatic cancer is life threatening. Seek medical attention if you have any symptoms that could indicate pancreatic cancer.

Diagnosis

• Ultrasound scans or computed tomography scans detect about 80 percent of cases. Further tests are performed if diagnosis is questionable. One such test is an internal ultrasound called EUS. This test is very sensitive for finding small pancreatic cancers.

• Endoscopic retrograde cholangiopancreatogram is done using a thin, lighted, viewing tube or endoscope that is passed down the throat and into the small intestine. Contrast material is injected into the bile duct, and x-rays are taken. The endoscope may also be used to take a biopsy.

• A biopsy of pancreatic tissue is extracted with a needle, or, in some cases, using exploratory abdominal surgery.

Treatment

Treatment for pancreatic cancer depends largely on the stage of the disease. Treatment options include surgery, chemotherapy, radiation, and targeted therapy. In pancreatic cancer, tumor growth can result in abnormal levels of pressure on nerves, which can cause pain. Pain is a major concern for patients who have pancreatic cancer. Treatments can help reduce pain when the reduction of the tumor through surgery, chemotherapy, or radiation relieves pressure on the nerves. Alcohol injections into a nerve inhibit pain response and surgically severing nerves prevents transmission of pain impulses.

• Surgical removal of the tumor is possible with a relatively small tumor that has not yet spread, which may prolong survival time. Surgery may involve removal of the entire pancreas as well as a portion of the small intestine. More extensive surgery, called the Whipple procedure, involves removal of the pancreas head and nearby structures. It also may be necessary to remove the entire pancreas, as well as the spleen, gallbladder, and bile duct. Sometimes, the tumor cannot be completely removed. Most specialists believe that partial removal is not beneficial. Following surgery for pancreatic cancer, the pancreas often no longer produces digestive juices and hormones. This can lead to digestive problems and/or diabetes, conditions that may be treated with changes in diet, medications, or hormone replacement therapy.

• Surgery to bypass a bile duct blocked by the tumor may be performed to relieve symptoms and this surgery can be done in those patients whose tumor cannot be removed.

• Chemotherapy in combination with radiation therapy may destroy cancerous cells and ease symptoms. Radiation therapy involves using radioactive substances or high-energy rays, to destroy cancer cells. In this treatment, special machines are used to direct radiation at the parts of the body with cancerous tumors, to destroy cancer cells while minimizing damage to healthy tissue. Unlike chemotherapy, radiation is not carried throughout the body. As such, it is known as local therapy, rather than systemic therapy. However, there are still potential side effects associated with radiation therapy.

• Targeted therapy can also be used, mainly in those patients with specific genetic alterations as BRCA gene mutation.

• Analgesics or narcotics are administered to reduce pain.

• Antihistamines or amphetamines may be used to enhance analgesic effects. In cases of severe pain, the relevant nerves may be destroyed by an alcohol injection at the time of surgery.

• Tablets containing pancreatic enzymes may be prescribed if food is poorly absorbed because of a blockage of pancreatic secretions.

Prevention

Minimize exposure to toxic chemicals at home and in the workplace, and avoid cigarettes.

When To Call A Doctor

Call a doctor if you develop any symptoms of pancreatic cancer.

**Reviewed by Jenifer K. Lehrer, M.D., Department of Gastroenterology, Aria-Torresdale Hospital, Aria Health System, Philadelphia, PA. Review provided by VeriMed Healthcare Network.**