Introduction
Each year in Europe approximately 65,000 people are diagnosed as suffering from pancreatic cancer. Although cancer of the pancreas may be diagnosed when the tumour is quite small, it remains one of the more difficult cancers to treat, because of its position, its relatively fast growth and a tendency to spread to other areas in the body at an early stage. 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, with most cases affecting people over 65. It is more common in men.
Pancreatic cancer is becoming more common. No-one knows why: it might be associated with the increased frequency of diabetes, or increased alcohol consumption.
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The Pancreas
The pancreas has two distinct roles. It produces chemicals (digestive enzymes) to help digest food, and it produces insulin, which helps the body regulate the amount of sugar in the blood. The bile duct, which empties bile from the gall bladder passes through the pancreas. If the pancreas is swollen the bile duct can be blocked causing jaundice, and this is often the first sign that there is something wrong.
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Pancreatic Cancer
All cancers are uncontrolled growths of cells. In pancreatic cancer this uncontrolled growth happens in the cells in the glands that produce the digestive enzymes.
About 70% of 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 and so preventing the bile from draining into the intestine.
One of the characteristics of cancer is that it can spread to other parts of the body, either by directly invading neighbouring areas - the part of the small bowel called the duodenum, the stomach, the spleen, the liver and bile ducts (blocking them and causing a build up of bile in the liver which then causes jaundice), or into the blood vessels that take blood to and from the gut (the mesenteric artery and portal vein). Pancreatic cancer may spread through the blood or lymphatic system to other areas of the body.
There are 2 types of pancreatic cancer:
- carcinoma of the pancreas, which develops from the cells that make digestive juices
- far more rarely, cancer developing from different cells in the pancreas, which make insulin
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Diagnosing Pancreatic Cancer
There are a number of tests that can be used to diagnose pancreatic cancer:
- Ultrasound scans use sound waves to create images of the inside of the body which can distinguish between normal and abnormal tissues.
- A computerised tomography (CT) scanner is a type of X-ray machine. It uses beams from several different angles, building up a picture of all the body tissues it passes through. The result is a series of pictures showing the shape of the body organs in cross section. A series of these pictures allows experts to say whether there are any abnormalities present.
- Positron emission tomography (PET scan) uses small amounts of radioactive material to detect cancer and other diseases in the body. Different radioactive materials are given as an injection or a drink. Once in the body the material concentrates in certain tissues giving off focal radiation which can be detected by the scanner to produce visual images. Experts can then use these images to help make a diagnosis.
- Magnetic resonance imaging (MRI) scans use a strong magnetic field and radio waves to produce detailed pictures of the inside of the body. They can show muscles, joints, bone marrow, blood vessels, nerves and other structures, and are particularly useful in pancreatic cancer to assess the blood vessels going to and from the gut.
- A laparoscope is a thin tube used to look inside the abdomen. Through it tissue samples (biopsies) can be taken which are needed to make a firm diagnosis. Cells from the tumour can be examined under a microscope and any cancer cells identified.
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Pancreatic Cancer Risk Factors
There are a number of known risk factors - things which make you more likely to develop pancreatic cancer:
- Age is an important factor – it is rare before the age of 45 and most patients are between 60 and 80 when diagnosed.
- Smokers are three times more likely to get the disease.
- High alcohol consumption also increases the risk of pancreatic cancer.
- Inflammation of the pancreas or pancreatitis is a risk factor for pancreatic cancer, and more common in heavy drinkers.
- Family history: about 10% of people with pancreatic cancer have a family history of the disease. There are diseases that run in families such as familial polyposis (which causes polyps in the large bowel) and Lynch syndrome which are also associated with a greater risk of developing pancreatic cancer.
- Diabetics, particularly long-standing diabetics, are at increased risk of developing pancreatic cancer.
- People who eat too much fat and not enough vegetables may also be at increased risk.
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Preventing Pancreatic Cancer
There is no certain way to prevent pancreatic cancer but avoiding the risk factors set out above (insofar as you can) will reduce the risk - in particular giving up smoking and taking 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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Symptoms of Pancreatic Cancer
Jaundice is often the first symptom of pancreatic cancer due to obstruction of the bile duct. The jaundice is usually painless. In this sort of jaundice the skin becomes yellow, the urine is very dark and the stools or faeces are pale and hard to flush away.
Pain can occur and may be worse after eating when the digestive juices are produced. Pancreatic cancer can also cause nausea, weight loss and weakness, but often when the jaundice appears there are no other symptoms at all.
In the rarer form of cancer in which the pancreas makes too much insulin, typical symptoms are dizziness, feeling faint, and sometimes collapse, muscle spasms or diarrhoea.
To confirm that the tumour is a cancer, some cells from the tumour must be examined under a microscope.
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Treating Pancreatic Cancer
Pancreatic cancer is one of the more difficult cancers to treat and treatment may involve surgery, radiotherapy and/or chemotherapy.
Surgery
Surgery may be used to remove the cancer, or even the entire pancreas, which is a major operation. But, if the cancer has spread to the stomach, spleen, or other organs surgery may not be the best option. For this reason it is only used in about 20% of cases.
Chemotherapy is often used in addition to surgery to kill any cells that have spread to other areas of the body. It can be given at the same time as surgery (or radiotherapy) or after these treatments are completed. In a few centres, radiotherapy is used during surgery (intra-operative radiotherapy) to kill cancer cells that may have spread to the back of the abdomen.
External Beam Radiotherapy
External radiotherapy uses high energy X-ray beams generated from machines to kill cancer cells. Some normal cells will also be affected, but the treatment is planned so that the radiation is focused on the affected areas from a variety of different angles so normal tissues receive a smaller dose. In addition normal cells are better at repairing themselves than cancer cells.
External radiotherapy is normally given as a series of short regular treatments in a radiotherapy department (each treatment may be referred to as a fraction). External beam radiation may be used in conjunction with surgery, and/or chemotherapy to treat pancreatic cancer.
All radiotherapy treatments are delivered to an area that conforms to the shape of the cancer, so a higher dose of radiation can be more precisely targeted at the cancer avoiding neighbouring healthy tissue and resulting in fewer side effects.
Radiotherapy may be combined with chemotherapy (chemoradiation or concurrent therapy).
Newer forms of radiotherapy using carbon ions and protons are also used in some hospitals.
Stereotactic radiotherapy
Stereotactic radiotherapy (SRT) is a form of high-precision radiotherapy that is now becoming available in some centres. SRT provides radiotherapy focused on the whole tumour, with very little effect on surrounding normal tissues. This allows the use of very high doses of radiation in 3-8 treatment sessions or fractions over a two week period. During SRT patients are positioned very precisely during treatment to minimise radiation of nearby normal tissues. SRT also includes measures to allow for movement of the cancer during imaging, treatment planning as well as during radiotherapy.
Radiotherapy - Brachytherapy
Brachytherapy is the use of radioactive implants placed in, or very near to the tumour. It has been used in the treatment of pancreatic cancer for over 80 years. Its main use now is for the relief of symptoms.
Biological treatments - Monoclonal antibody treatment
Monoclonal antibodies are used in the treatment of many forms of cancer and cause relatively few side effects. These agents target specific proteins on cancer cells which are necessary for the cancer to develop. As yet there is only limited experience with these agents and treatment with them continues to be evaluated.
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Questions for Your Doctor
Before making up your mind about the best treatment option for you, you will need information about your cancer, the treatments available in your area and what this will involve, what to expect from the treatment, what side effects you might experience and how these may change over time as well as what your doctors believe would be most effective in combating your cancer.
For different patients the answers will be different, so it is important to discuss all these issues with your doctor so that you make the right choice for you.
You will have your own questions but some issues you might want to raise are:
- What does the treatment involve?
- What are the benefits I might get?
- How good are my chances of getting those benefits?
- Could having treatment make me feel worse? If so, in what way?
- Are there alternative treatments?
- What are the risks of the treatment?
- Are the risks minor or serious? How likely are they to happen?
- What care will I need after treatment?
- What happens if something goes wrong?
- What may happen if I don’t have the treatment?
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Conclusion
There is no one solution to the management of pancreatic cancer, which remains one of the more difficult cancers to treat. Research into new forms of treatment and combinations of existing treatments are leading to improvements, but it is earlier diagnosis that will have the greatest impact on the effectiveness of treatment.
For clinical and personal reasons, particular treatments will suit some patients better than others so patients need comprehensive information so that they can make the right decision for them.
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