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Pancreatic cancer originates in the tissues of your pancreas, an organ located behind your stomach that secretes vital substances to aid digestion and to regulate the metabolism of carbohydrates (or sugars) in your body. One type of cell in the pancreas, referred to as exocrine cells, secretes enzymes (specialized proteins that allow chemical processes to occur) into the small intestine for digestion. The other types of cell in the pancreas are endocrine cells, which secrete hormones (insulin and glucagon) into the bloodstream to aid in the regulation of sugar levels.
The exocrine and endocrine cells of the pancreas form very different tumors/cancers. It’s vital to distinguish between these different cancers as they have different risk factors, diagnostic tests, treatments, and prognoses.
However, as more and more people have diagnostic tests performed, such as imaging studies like MRIs and CT scans, the number of pancreatic growths identified continues to increase. Many of the detected growths are not cancerous, such as serous cystic neoplasm (SCN), mucinous cystic neoplasms (MCN), and intraductal papillary mucinous neoplasms (IPMN). However, MCN and IPMNs should be followed as they have the potential to become cancerous.
Endocrine tumors of the pancreas, also known as neuroendocrine tumors (NET) or islet cell tumors, start from endocrine cells. There are many types of pancreatic NET, and these tumors can be benign or cancerous. However, they are quite rare. Examples of NETs include:
The most common type—and most dangerous form—of pancreatic cancer originates from exocrine cells. Sub-types of exocrine pancreatic cancers include:
Unfortunately, pancreatic cancer often has a poor prognosis, or disease outlook, especially if it is exocrine cancer. The cancer is known to spread quickly and is often not diagnosed until late stages when it has progressed and may be difficult to surgically remove. Most pancreatic cancer result from exocrine cells, which do not make hormones and generally do not cause symptoms, which often times allows the tumor to grow before diagnosis. Other types of pancreatic cancer, such as neuroendocrine cancers like islet cell tumors, may be detected earlier and carry a better prognosis.
It is not clear what causes pancreatic cancer. However, certain risk factors associated with developing the disease has been identified. These are outlined below in the Risk Factors section.
It is known that pancreatic cancer, as well as all other cancers, are a disease characterized uncontrolled cellular growth. Normally, specific genes within the DNA (genetic material) of cells have functions to regulate cell division. Genes involved in cell replication (or division), cellular growth, and cellular survival are called oncogenes; while those involved in limiting cell growth and division and induce cell death when necessary are called tumor suppressor genes (such as TP53 and RB1 genes).
When cell DNA is damaged, these genes may be altered and the oncogenes are turned on and the tumor suppressor genes are turned off. As a result, there is uncontrollable cell growth and possible cancer. These changes to cellular DNA are caused by the environment, but changes or mutations to DNA can also be inherited. If these mutations in the DNA correspond to genes that are involved with effective and correct cell replication, a person’s risk for developing kidney cancers and other cancers may be increased.
Although the cause of pancreatic cancer is still largely unknown, there are some genetic conditions and environmental factors, which may contribute to the development of this disease.
Environmental, or modifiable, risk factors include:
Genetic and non-modifiable risk factors:
A diagnosis of pancreatic cancer will likely start with a visit to your primary care physician, who will obtain a thorough medical history and then perform a physical examination, which will likely focus on your abdomen to evaluate for masses or fluid. Further, a pancreatic cancer can obstruct your bile duct and cause jaundice, which manifests as a yellowing of your skin the sclera (whites of your eyes). As the cancer can spread to nearby lymph nodes, these areas will also be palpated for enlargement.
In addition to the history and physical, he or she will then utilize any of the following tools to arrive at a diagnosis:
A CT scan also uses x-rays to generate an image, but it has several advantages compared to the chest x-ray. It will show the precise location, shape, and size of masses. In order to obtain even sharper images, some patients are asked to drink or receive IV contrast. This contrast makes some tissues appear brighter,
which makes the images and the structures more apparent and easier to discern. Allergies to contrast medium may cause hives, flushing, shortness of breath, and low blood pressure. If you have had a reaction to contrast before, you should inform your physician. In addition to masses (such as cancers), it can show enlarged lymph nodes, which may have cancer cells. Many patients will have CT scans of the chest, as well as the abdomen to look for cancer spread, which may involve the liver, adrenal glands, or other internal organs. The CT scan may also involve the brain to look for cancer metastasis. A CT scan may also be used to obtain biopsies of masses or cancers what lie deep within or nearby other vital structures, which is termed CT guided needle biopsy.
A magnetic resonance imaging (MRI) study also provides detailed soft tissue “pictures.” As opposed to CT scans, which utilizes x-rays, MRIs use magnetic radio waves to generate images. MRIs are particularly useful for imaging the brain and spinal cord. Gadolinium, a contrast, is often used to produce even better MRI images. A specific MRI scan called an MRA uses contrast to assess blood vessels, which may be supplying nutrients to the cancerous tissue. In addition, a MRCP (magnetic resonance cholangiopancreatography) exam can help visualize the pancreatic and bile ducts, which may become narrowed or dilated with an invading pancreatic cancer.
Ultrasound imaging may also prove useful in the diagnostic process. By utilizing sound waves, ultrasound generates images of the organs. It is easily done by placing a transducer on the abdomen and evaluating the image on the screen. And, there is no radiation. Further, an endoscopic ultrasound (EUS) allows for even better images by utilizing an ultrasound probe on an endoscope (a small scope that is passed down the esophagus and into the small intestine). During this procedure, you are sedated (made sleepy) and this camera is passed to the beginning of your small intestine and then directed towards the pancreas, which is very close. Thus, the images are extremely clear.
A similar procedure with the endoscope, but which utilizes dye injected into the common bile duct and then uses x-rays to generate images, is called an ERCP (endoscopic retrograde cholangiopancreatography). Tissue and fluid samples can also be obtained during an ERCP.
Another study like the ERCP is the percutaneous transhepatic cholangiography (PTC). During this procedure, a small hollow needle is passed through the skin and into the bile duct of the liver. Then, dye is injected and x-rays taken to assess the bile duct and pancreatic duct. Like the ERCP, tissue and fluid samples can be taken, but because it is slightly more painful and invasive, it is usually reserved for cases that cannot be completed via ERCP.
PET scans, also known as positron emission tomography, are especially useful to look for cancer spread. This study involves injecting a special radioactive sugar (flourodeoxyglucose, or FDP) into the vein. The amount of radioactivity is very low and will not cause you harm. After the injection, a special scanner will pick up areas in your body where the sugar has accumulated. As cancer cells are very active and require a great amount of energy (sugar), the FDP will concentrate in these areas. The PET scan does not produce extremely detailed images, but rather indicates spread of cancer throughout the body.
Bone scans can also be performed to detect spread of cancer to bones. During this procedure, a radioactive dye is injected in the vein, where is it transported to areas of bone with abundant activity, which may occur in cancerous and non-cancerous states.
A simple chest x-ray or radiograph will usually be performed, as it is convenient, cheap, and will reveal if the cancer has progressed to the lungs.
Angiography, which utilizes a specialized intravenous dye to visualize the arteries of the body, may also be used to help demonstrate the blood supply of the tumor and to help the surgeon plan his or her surgery.
If a suspicious mass is identified via the aforementioned tests, a biopsy may need to be performed to ensure proper diagnosis. During a biopsy, a small amount of tissue is removed from the suspicious mass and then assessed under the microscope. A biopsy is commonly performed as a fine needle aspiration, or FNA, which utilizes CT imaging and a long, thin needle to pierce the skin and to obtain a small tissue sample of the mass. A pathologist will then study the biopsy to determine if the mass is benign or malignant and will then identify the exact type of malignancy.
Possible lab tests used to diagnosis pancreatic cancer include liver tests, such as AST, ALT, and bilirubin levels, as the liver can be impacted by invading pancreatic tissue. Tumor markers, such as CA-19 and CEA, may also be elevated in pancreatic cancer patients.
Symptoms of pancreatic cancer are usually absent until the disease is advanced. Unfortunately, prognosis declines as the disease progresses.
Other common signs and symptoms include:
Prognosis refers to the likely course of a disease or ailment. To determine the prognosis of pancreatic cancer, many factors must be considered. For example, the age of the patient and his or her functional status, or level of functioning, also plays a vital role in prognosis. Generally, younger and higher functioning patients will do best. Further, the amount of tumor able to be removed, also known as resected, impacts prognosis. If the entire tumor is removed, prognosis improves, while if only part of the tumor is removed, prognosis will likely deteriorate. If the tumor recurs, or comes back after removal, the prognosis is worse.
Also very important for prognosis is staging and grading of the cancer. Staging of a cancer is the process of classifying how far a cancer has spread, while grading determines the makeup and characteristics of the cancer’s cells. In addition to prognostic value, staging and grading can help predict what therapy would be ideal and the effectiveness of said therapy.
The American Joint Committee on Cancer (AJCC) has standardized staging system that employs:
Thus, it is referred to as the TNM staging system. The more advanced each of these categories, i.e. tumor size, the higher the number that follows the letter. The size of the tumor ranges from 0-4, while the staging of involved
lymph nodes varies from 0-2 and the presence of metastases is determined with 0 or 1. A combination of these three variables and numbers then determines the stage of the cancer.
The grade of a cancer cell describes how similar or dissimilar the cell looks compared to a healthy cell observed under a microscope. Healthy tissue will have many different types of cells grouped together. If the tumor has many different types of cells and appears similar to healthy tissue, it is termed differentiated, or a low-grade tumor. Conversely, if the tumor appears very different from the healthy tissue, it is termed poorly differentiated, or a high-grade tumor. In general, the lower the grade of tumor, the better chance of treatment, survival, and prognosis.
Generally, the earlier the cancer is detected, the better the prognosis. Unfortunately, pancreatic cancer is often times too advanced and not resectable (able to be surgically removed) at the time of diagnosis. Thus, the prognosis for pancreatic cancer is often poor. According to the American Cancer Society, the one-year survival for all stages of pancreatic cancer is 20%, while the 5-year survival rate is 5%. If the tumor is resectable, survival climbs slightly to 18 to 20 months at one year.
People with cancer not only face physical challenges, but also mental and emotional challenges. It is important to understand your illness and treatment as it can make you feel more in control. Taking care of your emotional health is also vital. Family and friends can be an important source of support for you during this challenging time.
In addition, it is helpful to consider the following:
There are no official recommendations from the U.S. Preventive Services Task Force to suggest that it is beneficial for pancreatic cancer screenings at the current time.
The first goal of pancreatic cancer treatment is removal of the cancer if possible. When this may not be an option, the next step is to prevent the cancer from progressing and making symptoms worse. Finally, if treatments are likely to not help, palliative treatment with effective pain control (via medications and nerve blocks) and symptom control may prove to be the best path for the individual.
Potential treatment options include:
Surgery – to remove all or part of the pancreas. If the tumor is located in the head of the pancreas, your surgeon may perform a Whipple procedure, also known as a pancreatoduodenectomy). During this surgery, the head of the pancreas, part of your small intestine (duodenum), gallbladder, bile duct, and possibly part of your stomach are removed. The remaining portions of the organs are re-connected (or anastomosed) to allow for digestion. This is a very involved surgery and carries many risks, such as bleeding, infection, nausea, and vomiting. If the pancreatic tumor is located in the tail or body of the pancreas, he or she may elect to perform a distal pancreatectomy, which may involve removing your spleen as well.
Radiation – this treatment involves high energy x-rays focused on a specific site to kill cancer cells. The efficacy of radiation is cumulative; so multiple sessions of radiation are necessary for optimal treatment. Side effects of radiation include fatigue, skin damage, and necrosis of nearby structures to the cancer.
Chemotherapy – uses medication via oral or intravenous routes to kill rapidly diving cells (which is characteristic of cancer cells, but other cells in the body divide quickly as well and may be killed by the chemotherapy, such as hair cells leading to baldness during chemotherapy). High-grade tumors may respond well to chemotherapy and shrink the tumor prior to a possible surgery, which makes resection easier for the surgeon. Besides the aforementioned baldness, chemotherapy may also cause loss of appetite, nausea, vomiting, weight loss, lethargy, and an increased risk of infection.
Targeted – utilizes drugs to identify and attack only the cancer cells, while avoiding normal healthy cells. Targeted therapy with antiangiogenic agents are used in renal cancers to prevent the formation of blood vessels that are supplying nutrients and oxygen to growing cancers. Monoclonal antibodies and kinases inhibitors are two examples of this type of treatment.
As the definitive treatment for pancreatic cancer remains chemotherapy, radiation, and surgery, alternative treatments for this condition should only be considered after traditional interventions have been initiated or completed.
Complementary medicine, which refers to interventions performed in addition to traditional or standard treatment, are numerous and may provide additional symptom relief and improved quality of life for many patients. According to the National Center for Complementary and Integrative Health, these include:
Acupuncture – is particularly effective in alleviating treatment-related nausea and vomiting in cancer patients. It may even help control cancer pain. Although complications from acupuncture are rare, it is important to ensure that the needles are properly sterilized. Many cancer patients have weakened immune systems and more prone to infections.
Ginger – may help to control nausea secondary to cancer chemotherapy, especially when used along with standard anti-nausea medications.
Massage therapy – may help to alleviate symptoms experienced by many cancer patients, such as pain, nausea, anxiety, and depression. However, the massage therapist should be careful to avoid deep or too rigorous massage prior to physician approval, especially directly over a tumor or around sensitive skin, which is common following radiation treatments.
Mindfulness-based Stress Reduction – as a type of meditation, mindfulness-based stress reduction can help cancer patients by relieving anxiety, stress, fatigue, and general mood and sleep disturbances. As a result, this can lead to an overall improvement in quality of life.
Yoga – preliminary studies suggest that yoga may improve anxiety, depression, and stress in patients with cancer. It may also alleviate fatigue in breast cancer patients. However, additional studies need to be completed for better evidence and conclusions.
Hypnosis, relaxation therapies, and biofeedback – various studies are currently assessing the benefits of these activities in cancer patients.
Herbal supplements – a 2008 review of research regarding herbal supplements and cancer concluded that the scientific evidence is limited and many clinical trials were not well designed. Furthermore, there are specific concerns regarding some herbal supplements in terms of medication interactions. Thus, any use of herbal medications should be discussed thoroughly with your physician.
If you are experiencing any of the signs or symptoms of pancreatic cancer (see above), you should seek medical attention as soon as possible. The earlier a diagnosis can be made, the earlier treatment can begin, which generally leads to improved outcomes and better prognosis.
Unless the symptoms are life threatening, you can make an appointment within a reasonable time period and do not need to visit the emergency department.
Your medical team may consist of several healthcare professionals, including your primary care physician, gastroenterologist, oncologist, and an oncologic surgeon.
The National Cancer Institute offers a website where you can find a cancer center near you.
When you go to see your doctor, it’s good to have a list of the questions you’d like to have answered. Take a moment to write down some of the things you want to know. Your questions for your doctor might include some of these:
Useful resources for pancreatic cancer include:
The National Cancer Institute
The American Cancer Society
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