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What is pancreatic cancer?
Pancreatic cancer originates from the tissues of your pancreas, an organ in your abdomen that lies horizontally at the posteroinferior part of your stomach. Your pancreas secretes digestive enzymes and hormones that help regulate the blood glucose.
Pancreatic cancer typically spreads to nearby organs. It is rarely diagnosed at an early stage. However, some screening tests may help diagnosing the disease at early stage in persons with a pancreatic cyst or a family history of pancreatic cancer. Diabetes mellitus is a sign of pancreatic cancer, especially when it is associated with weight loss, jaundice or pain in the upper abdomen that radiates to the back.
The treatment may include surgery, chemotherapy, radiotherapy or a combination thereof.
Diabetes is among the symptoms of pancreatic cancer.
What are symptoms of pancreatic cancer?
Signs and symptoms of pancreatic cancer do not usually appear until the disease progresses. The signs and symptoms include:
- Pain in the upper abdomen that radiates to the back
- Loss of appetite or unintentional weight loss
- New-onset diabetes
- Blood clots
- Jaundice in your skin and the whites of your eye
When should you consult a doctor?
You should consult a doctor if you have idiopathic (with no clear cause) weight loss, persistent fatigue, abdominal pain, jaundice, or other signs and symptoms that worry you. As these symptoms may develop in many other conditions, your doctor may also check them along with the pancreatic cancer.
What are causes of pancreatic cancer?
The exact underlying cause is not clear in most cases. Doctors have identified certain factors, such as smoking, that increase the risk of the disease.
Understanding your pancreas
Your pancreas measures about 6 inches (15 centimeters) in length and looks like a pear lying on its side. It secretes hormones that include also insulin to help your body process sugar found in foods you eat. Moreover, it produces digestive juices that help digestion of foods by your body.
How does pancreatic cancer develop?
Pancreatic cancer is caused by mutations in DNA of the pancreatic cells. These mutations cause uncontrolled growth of cells and survival after normal cells would die. These cells accumulate and form a tumor. Pancreatic cancer spreads to nearby organs and blood vessels, if left untreated.
Pancreatic cancer originates from the cells that line the pancreatic ducts. This type of cancer is called pancreatic adenocarcinoma or pancreatic exocrine cancer. Rarely, the cancer begins in the hormone-producing cells or the pancreatic neuroendocrine cells. These types of cancer are called islet cell tumors, pancreatic endocrine cancer, and pancreatic neuroendocrine tumors.
Pancreatic cancer is rarely diagnosed at an early stage.
What are risk factors of pancreatic cancer?
Following factors increase the risk of pancreatic cancer:
- Chronic inflammation of the pancreas (pancreatitis)
- Family history of genetic syndromes that increase the risk of cancer, including BRCA2 gene mutation, Lynch syndrome, and familial atypical mole-malignant melanoma (FAMMM) syndrome
- Family history notable for pancreatic cancer
- Older age (most people are diagnosed after the age of 65)
A comprehensive study demonstrated that the combination of smoking, chronic diabetes and poor diet increases the risk of pancreatic cancer than presence of any one of these factors alone.
What are complications of pancreatic cancer?
Progression of pancreatic cancer may cause following complications:
- Weight Loss: Various factors may cause weight loss in patients with pancreatic cancer. The cancer itself may cause weight loss. Moreover, nausea and vomiting that are side effects of anti-cancer treatments or occur due to compression of the stomach by the tumor may lead to lack of appetite, or your body may have a difficulty to digest foods, as your pancreas does not produce and secrete sufficient amount of digestive juices. Your doctor may recommend pancreatic enzyme supplements that will help your digestive system. Moreover, you should try to maintain your body weight by adding extra calories whenever possible and spending a pleasant mealtime as much as you can.
- Jaundice: Pancreatic cancer can cause jaundice by blocking the bile ducts in the liver. The potential signs include yellowness of the skin and eyes, darkurine, and pale-colored stool. Jaundice is usually not associated with abdominal pain. Your doctor may recommend inserting a plastic or metal tube (stent) into the bile duct to maintain patency of the ducts. This is done with a procedure called endoscopic retrograde cholangiopancreatography (ERCP). During ERCP, an endoscope is inserted to your throat and advanced into your stomach and upper portion of your small intestine. Next, a contrast agent is injected into pancreas and bile ducts through a small, hollow tube (catheter) that is inserted and advanced through the endoscope. Finally, images of the ducts are acquired.
- Pain: An enlarging tumor may cause pain that may become severe by compressing the abdominal nerves. Pain killers can make you feel more comfortable. Moreover, radiation therapy can help stop growth of the tumor for temporary relief. In severe cases, your doctor may recommend injecting alcohol into the nerves in order to manage your abdominal pain (celiac plexus block). This procedure hinders conduction of pain signals to your brain.
- Bowel obstruction: If pancreatic cancer grows and compresses the first part of the small intestine (duodenum), the digested foods may not move from stomach to your intestines. Your doctor may recommend placement of a tube (stent) into your small intestine to hold it patent. Or, a surgical procedure may be necessary to reconnect your stomach to a non-obstructed lower part of your small intestine.
What measures can be taken to prevent pancreatic cancer?
Following recommendations may help reduce the risk of pancreatic cancer:
- Stop smoking: If you smoke, try to quit. Talk to your doctor about coping strategies such as support groups, drugs and nicotine replacement therapy that can help you quit smoking. If you do not smoke, do not start.
- Maintain healthy weight: If you have healthy body weight, strive to maintain it. If you are overweight, lose weight slowly and continuously, such as 1 to 2 pounds (0.5 to 1 kilogram) per week. Combine your daily exercise with small servings of a diet rich in vegetables, fruits and whole grains in order to help the weight loss.
- Choose a healthy diet: A diet that is rich in colorful fruits, vegetables and whole grains may help reduce your risk of cancer.
If your family history is notable for pancreatic cancer, genetic counseling can be considered. Your counselor reviews your family health history with you to determine whether genetic tests will be useful to understand risks of pancreatic cancer or other cancers.
What are the diagnostic methods for pancreatic cancer?
If you are suspected to have pancreatic cancer, your doctor may order one or more of the following tests:
- Imaging tests to acquire detailed images of your internal organs: Your doctors use these tests to image your internal organs, including the pancreas. Imaging modalities used to diagnose pancreas cancer include ultrasound, computerized tomography (CT) scans, magnetic resonance imaging (MRI) and, sometimes, positron emission tomography (PET) scans.
- Using a scope to acquire sonographic images of your pancreas: An endoscopic ultrasound (EUS) is an ultrasound device that creates sonographic images of your pancreas with intra-abdominal approach. The device is inserted and advanced through a thin and flexible tube (endoscope) down your esophagus into your stomach in order to create the images.
- Collecting a tissue sample for testing (biopsy): Biopsy implies collecting a small tissue sample in order to examine under microscope. Your doctor may biopsy your pancreas by inserting a needle through your skin into your pancreas (fine-needle aspiration), or special tools are guided into your pancreas to collect a sample during the EUS.
- Blood test: Your doctor may order blood tests to look for specific proteins (tumor markers) produced by pancreatic cancer cells. CA19-9 is a tumor marker test used in pancreatic cancer. However, this test is not always reliable and there is no consensus on the best use of the CA19-9 test results. Some doctors analyze your level before, during and after treatment.
If your doctor confirms the diagnosis of pancreatic cancer, the next step will be to determine the stage (spread) of the cancer. The data obtained from these tests will be used by your doctor to assign a stage that will guide the best treatment for you.
What are stages of pancreatic cancer?
- Stage I. The cancer is completely confined to the pancreas, and it is resectable (or can be removed surgically).
- Stage II. The cancer has spread to nearby tissues and organs beyond the pancreas , and to nearby lymph nodes. At this stage, surgery is an option to eliminate the cancer.
- Stage III. The cancer has already spread to major blood vessels beyond the pancreas or to nearby lymph nodes. At this stage, surgery may be or may not be an option to eliminate the cancer.
- Stage IV. The cancer has spread to distant body parts such as the liver, lung, and the lining of the abdominal cavity (peritoneum). At this stage, surgery is not a choice.
Do not hesitate to ask your doctor about his or her experience in the diagnosis of pancreatic cancer. If you have any concern, get a second opinion.
What are treatment methods for pancreatic cancer?
Treatment options for pancreatic cancer are dictated by the stage and location of the cancer as well as on your overall health and personal preferences. Treatment for pancreatic cancer primarily aims elimination of the cancer, whenever possible, in most cases. However, if this aim fails, efforts are made to improve your quality of life and preventing the cancer from growing or causing more harm.
Treatment options are surgery, radiotherapy, chemotherapy or a combination of them. If these treatment will not likely to help due to an advanced stage cancer, your doctor will recommend a palliative treatment to make you feel as comfortable as possible.
Surgeries used in patients with pancreatic cancer include the following procedures:
- Surgery for pancreatic head tumors: If the cancer is located in the head of the pancreas, a specific surgery, called the Whipple Procedure (pancreaticoduodenectomy), can be considered for you. The Whipple procedure is difficult surgery that is performed to remove the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and a part of the bile duct. In some cases, it may also be necessary to remove a part of the stomach and nearby lymph nodes. Your surgeon connects the remaining parts of your pancreas, stomach and intestines again to ensure maintenance of digestive activities in your body.
- Surgical removal of tumors located in corpus and tail of the pancreas: Distal pancreatectomy involves removal of the left side (corpus and tail) of the pancreas. Your surgeon may also remove your spleen.
- Surgical removal of the entire pancreas: It may be necessary to remove the entire pancreas in some people. This procedure is called total pancreatectomy. You can live a relatively normal life after your pancreas is entirely removed, but your may need insulin and enzyme replacement therapies in the rest of your life.
- Surgical procedures for tumors that involve nearby blood vessels: If an advanced stage pancreatic cancer has already involved nearby blood vessels, Whipple Procedure or other pancreatic surgeries are not mostly considered for the treatment. In several healthcare facilities in the United States of America, highly specialized and experienced surgeons can safely perform these surgeries and certain parts of blood vessels are removed and re-connected in good candidates of the surgery.
Each surgery poses risks of bleeding and infection. Postoperative difficulty in gastric emptying (delayed gastric emptying) can cause nausea and vomiting in some patients. You should be ready for a long-term postoperative recovery for these procedures. You will stay at the hospital for several days and your recovery will continue at home for several weeks.
Comprehensive studies have shown that fewer complications are faced after pancreatic cancer surgery, if it is performed by highly experienced surgeons with history of many cases. Do not hesitate to talk to your surgeon about the experience of him/her and the hospital with pancreatic cancer surgery. If you have any concern, seek second opinion.
Chemotherapy uses drugs to kill cancer cells. These drugs can be administered into a vein or taken by mouth. You may receive one chemotherapeutic agent or a combination thereof.
Chemotherapy can also be combined with radiation therapy (chemoradiation). Chemoradiation is typically used to treat cancer that has spread to nearby organs beyond the pancreas, but does not involve distant parts of the body. This combination can be used at specialized healthcare facilities to reduce the size of tumor before the surgery. It may, sometimes, be used after surgery to help reduce the risk of recurrence.
In people with advanced pancreatic cancer, chemotherapy is often used to control growth of cancer and prolong the survival.
Radiation therapy uses high-energy beams, such as X-rays and protons, to destruct cancer cells. You may receive radiation therapy before or after cancer surgery, but it is usually combined with chemotherapy. However, your doctor may recommend chemoradiotherapy – combination of both treatments – if your cancer is inoperable.
External radiotherapy is the common form of this treatment, wherein a machine maneuvers around you to target the beams to specific coordinates in your body. In specialized healthcare facilities, intraoperative radiation (radiation therapy during surgery) can be available.
X-rays are most commonly used in radiation therapy to treat cancer. Some medical centers offer proton radiotherapy which is considered as an option for advanced pancreatic cancer.
Supportive (palliative) care
Palliative care is a special medical care that focuses on relieving pain and other symptoms of a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an additional support to complement your treatment. Palliative care can be combined with aggressive treatments such as surgery, chemotherapy and radiation therapy.
When palliative care is combined with other appropriate treatment- even immediately after the diagnosis is established-, patient comfort is maximized and survival is prolonged.
Palliative care is provided by a team that includes doctors, nurses and other specially trained healthcare professionals. This team strives to improve the quality of life for people with cancer and their families. Palliative care should not be mistaken with hospice care or end-of-life care.