Overview
Pancreatic cancer is one of the most difficult cancers to treat because of the position of the pancreas, the relatively fast growth of pancreatic cancer and its tendency to spread to other areas in the body at an early stage.
The results of treatment are better in specialised centres so, whenever possible, people with pancreatic cancer should be referred to a hospital specialising in its treatment.
Pancreatic cancer is rare below the age of 45, and most cases affect people over 65. It is increasing in frequency, which might be associated with the increased frequency of diabetes or increased alcohol consumption.
It is generally more common in men although the statistics quoted below show only marginal gender differences.
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Key Figures
| Total number of new cancer cases in Europe (2006) |
3.2 million |
| Total number of cancer deaths in Europe (2006) |
1.7 million |
| Number of new pancreatic cancer cases (2006) |
59,900 (EEA) |
|
(30.700 men) |
|
(29,200 women) |
|
58,200 (EU25) |
|
(29,700 men) |
|
(28,500 women) |
| Number of pancreatic cancer deaths (2006) |
65,000 (EEA) |
|
(32,500 men) |
|
(33,200 women) |
|
64,000 (EU25) |
|
(31,700 men) |
|
(32,300 women) |
Pancreatic cancer are estimated to be 2% of all cancers and 6% of all cancer deaths.
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Cancer Types
The two types of pancreatic cancer are:
- ductal adenocarcinomas which develop from the cells that make digestive juices
- cancer developing from the cells in the pancreas which make insulin
About 90% of pancreatic cancers are ductal adenocarcinomas. The remainder develop from the insulin-producing cells.
Ductal adenocarcinomas are aggressive tumours that spread to other areas of the body even when the original tumour volume is quite small (less than 1cm).
70% of all pancreatic cancers occur in the head of the pancreas, which is where the bile duct passes through it. Tumours in the head of the pancreas frequently cause jaundice by blocking the bile duct, preventing the bile from draining into the intestine.
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Causes of Pancreatic Cancer
- Most patients are aged between 60 and 80 years old when diagnosed.
- Smokers are three times more likely to develop pancreatic cancer.
- High alcohol consumption increases the risk of pancreatic cancer.
- Pancreatitis is a risk factor of pancreatic cancer and is more common in heavy drinkers.
- Family history: about 10% of people with pancreatic cancer have a family history of the disease.
- Diabetics (particularly long-standing diabetics) are at an increased risk of developing pancreatic cancer.
- Diet: as with many cancers of the gastro-intestinal tract, diet appears to be a significant factor. People who eat a lot of fat and few vegetables may also be at increased risk.
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Prevention of Pancreatic Cancer
Avoiding the risk factors set out above will reduce the statistical risk - in particular giving up smoking and drinking alcohol in moderation.
Having a healthy low fat diet combined with regular exercise combats obesity, which is a risk factor for many cancers including pancreatic cancer.
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Common Symptoms
- Jaundice (usually painless) due to obstruction of the bile duct
- Pain can sometimes occur
Pancreatic cancer can also cause:
- Nausea
- Weight loss
- Weakness
However, often when the jaundice appears there are no other symptoms at all. By this stage the cancer will often have metastasised.
In the rarer form of cancer in which the pancreas manufactures too much insulin, typical symptoms are dizziness and feeling faint. Sometimes the patient may also collapse and/or experience muscle spasms and/or diarrhoea.
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Diagnosing Pancreatic Cancer
A number of tests are used to confirm the presence of a tumour in the pancreas, which may be due to a cancer or a pancreatic cyst:
- Ultrasound scan using an endoscope. By using an ultrasound probe attached to a flexible telescope passed into the intestine through the mouth, an image of the tumour can be obtained. An ultrasound can distinguish between solid and cystic lesions.
- Computerised Tomography (a CT scan) is a type of X-ray that shows the body organs in cross section, allowing localisation of any abnormalities present. A CT scan is also able to distinguish between solid and cystic lesions.
- Positron Emission Tomography (a PET scan) uses small amounts of radioactive material to detect cancer and other diseases in the body.
- ERCP is Endoscopic Retrograde CholangioPancreatography. This uses a specialised endoscope. Once it is in position, radioactive dye is injected into the pancreatic duct. Abnormalities can then be seen on the X-ray.
- Magnetic Resonance Imaging (a MRI scan) is another way of building up images of organs inside the body.
Confirming that the tumour is a cancer requires histological examination of a biopsy.
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Treatment
Available treatments for pancreatic cancer include:
However, pancreatic cancer is difficult to treat.
Surgery
Partial and total pancreatectomy are major procedures with significant mortality and morbidity, and are only used in about 20% of cases. Many patients undergoing surgery have to stay in hospital for several weeks.
Pancreatic cancers are resectable if staged as T1, T2, or T3 tumours, which means that the cancer has not spread beyond the pancreas. Pancreatic cancers frequently spread to the mesenteric blood vessels (T4) which makes surgical removal of the cancer, without interfering with the blood supply to the gut, impossible.
Most pancreatic cancers are located in the head of the pancreas – if these tumours are operable a pancreatoduodenectomy (Whipple procedure) offers the chance of a cure. If the tumour is located away from the head of the pancreas, a distal pancreatectomy is the usual operation. Sometimes the spleen is also removed.
Following surgical removal, patients must take enzyme supplements to digest food and insulin injections. If the spleen has been removed, patients will require vaccinations and possibly antibiotics for life to prevent/combat infections.
Diarrhoea can be a problem after pancreatic surgery and is often caused by difficulty in digesting fats. Proper dietetic advice is essential in planning a suitable diet.
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Chemotherapy and Chemoradiation
Radiotherapy may be combined with chemotherapy (chemoradiation or concurrent therapy) particularly if surgery is not possible. Chemotherapy and radiotherapy can also be used, during and/or after surgery to kill any cells that have spread to other areas of the body or that have not been removed during surgery.
Gemcitabine and 5FU are frequently used after surgery for pancreatic cancers as adjuvant therapy. Gemcitabine has been a standard treatment for patients with advanced pancreatic cancer for over 10 years.
Chemotherapy side effects
Chemotherapy does have side effects, which vary according to the drugs used and the individual patient’s response to them. These may include:
- suppression of the bone marrow (leading to anaemia)
- susceptibility to infection and bruising
- nausea and vomiting
- hair loss
- diarrhoea
- mouth ulcers
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Radiotherapy
External beam radiotherapy is normally given as a series of short regular treatments in a radiotherapy department (each treatment may be referred to as a fraction).
Complications and side effects of radiotherapy
Radiotherapy affects normal cells as well as cancer cells. The effects on normal cells will be reduced as much as possible but nevertheless nearby tissues will be affected and as a result patients experience a range of symptoms including:
- nausea (sometimes with vomiting)
- diarrhoea
- a reddening of the skin in the treatment area
These symptoms diminish after treatment has finished and can be treated symptomatically if they occur. Radiotherapy also causes tiredness, which does gradually improve after the treatment has finished.
Stereotactic radiotherapy
Stereotactic RadioTherapy (SRT) is a high-precision radiotherapy which provides radiation focused on the whole tumour with very little effect on surrounding normal tissues.
Biological agents - Monoclonal antibody treatment
Monoclonal antibodies are used in the treatment of many forms of cancer. Specific proteins on cancer cells which are necessary for the cancer to develop can be targeted by monoclonal antibodies. As yet there is only limited experience with these agents and treatment with them continues to be evaluated - the real question is whether they remain effective in long term use. Side effects are uncommon.
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Prognosis
Many factors affect prognosis. These include the stage of the pancreatic cancer, the patient’s age, their general health and the individual response to treatment (which will vary). For this reason, statistics can only be considered as a general guide as they are produced by grouping together patients in whom these factors are similar but not identical. These figures are historical, often covering a 10 or 20 year period, and so do not reflect improvements in survival through more modern treatment.
Survival rates indicate the percentage of people who survive the disease for a specific period of time after their diagnosis – usually 5 or 10 years.
Published 5-year survival rates for pancreatic cancer are:
- 16.4 % for localised cancers – cancers confined to the pancreas.
- 7% for cancers that have spread outside the pancreas but not to the mesenteric vessels or formed distant metastases.
- 1.8% for cancers that have spread outside the pancreas and have formed distant metastases.
- 4.3% for cancers not staged at the commencement of treatment.
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Key Trends
Pancreatic cancer is increasing in frequency.
Symptoms occur relatively late in the disease, often after it has spread to other areas of the body, making treatment difficult.
New radiotherapy treatments including stereotactic radiotherapy and Carbon14 radiotherapy are being used in some centres.
Improving methods of identifying cancers at an early stage should result in more effective treatments.
The development of genetic and other markers will individualise therapy.
Further research evaluating pre- and postoperative chemoradiation will refine its use.
There is also the evaluation of treatment with biological agents in pancreatic cancer.
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