Pancreatic cancer

Pancreatic cancer

Author
David P Ryan, MD

Section Editor
Kenneth K Tanabe, MD

Deputy Editor
Diane MF Savarese, MD

Disclosures

 

INTRODUCTION — More than 42,000 Americans develop cancer of the pancreas each year; it is the fourth leading cause of cancer-related death in the United States. Two types of cancer can affect the pancreas:

The most common is cancer of the exocrine pancreas that originates in the pancreatic ducts (figure 1). The ducts are responsible for carrying pancreatic juice to the intestines. This type of pancreatic cancer, called pancreatic adenocarcinoma, is discussed in this article.
Another type of cancer consists of a group of tumors that originate from the cells that make hormones such as insulin. These tumors are called pancreatic endocrine tumors and are not discussed here.

More detailed information about pancreatic cancer is available by subscription. (See “Management of locally advanced and borderline resectable exocrine pancreatic cancer” and “Adjuvant and neoadjuvant therapy for exocrine pancreatic cancer”.)

PANCREATIC CANCER SYMPTOMS — Most people with pancreatic cancer have pain, weight loss, or jaundice (yellowing of the skin). (See “Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer”.)

Pain is common. It usually develops in the upper abdomen as a dull ache that wraps around to the back. The pain can come and go, and it might get worse after eating.
Weight loss. Some people lose weight because of a lack of appetite, feeling full after eating only a small amount of food, or diarrhea. The bowel movements might look greasy and float in the toilet bowl because they contain undigested fat.
Jaundice causes yellow colored skin and whites of the eyes. Bowel movements may not be a normal brown color, and instead have a grayish appearance.

PANCREATIC CANCER DIAGNOSIS — If you develop signs or symptoms that raise suspicion for pancreatic cancer, your doctor or nurse will order one or more tests. This might include blood tests and imaging tests, like an ultrasound or CT scan. These tests can show if there is a mass (a growth) in the pancreas and if surgery to remove the mass is possible.

Biopsy — In some cases, your doctor will recommend a biopsy to confirm the diagnosis of cancer. A biopsy is a test that removes a small piece of tissue from the mass. A physician examines the tissue under a microscope to see if there are signs of cancer.

To perform the biopsy, a doctor will use a CT scan or ultrasound to pinpoint the mass, then insert a needle into the mass and take a sample of tissue.

PANCREATIC CANCER STAGING — Once pancreatic cancer is diagnosed, the next step is to determine its stage. Staging is a system used to describe the aggressiveness and spread of a cancer. A pancreatic cancer’s stage is based on:

The size of the cancer.
If there are signs of cancer spread outside the pancreas on a physical exam, CT scan or MRI, chest x-ray, or other imaging tests.

The final staging of a pancreatic cancer often depends on what is found during surgery.

Pancreatic cancer stages range from stage I, the earliest stage, to stage IV, which means that the cancer has spread to distant organs, such as the brain. In general, lower stage cancers are less aggressive and require less treatment than do higher stage cancers.

PANCREATIC CANCER TREATMENT — Pancreatic cancer can be treated with several approaches. Early stage pancreatic cancer can often be treated and even cured with surgery. After surgery, further treatment, called adjuvant therapy, is often recommended. This might include chemotherapy or radiation therapy. In some cases, chemotherapy or radiation might be offered initially,(termed neoadjuvant therapy).

However, surgery is often not possible; pancreatic cancer is often advanced by the time it is diagnosed. If surgery is not possible, radiation therapy chemotherapy, or both are often used to shrink the cancer, reduce symptoms, and prolong life.

Laparoscopy — In some centers, a laparoscopy is recommended before an attempt to remove the cancer surgically to get more information about the location and size of the cancer. During a laparoscopy, the surgeon inserts a thin tube with a camera into small incisions in the belly to see the organs inside the abdomen.

Surgery for tumors in the head of the pancreas — The standard operation for tumors in the head of the pancreas (figure 1) is a Whipple procedure (also called a pancreaticoduodenectomy). (See “Surgery in the treatment of exocrine pancreatic cancer and prognosis”.)

In this procedure, the surgeon removes the pancreatic head, the duodenum (first part of the small intestine), part of the jejunum (the next part of the small intestine), the common bile duct, the gallbladder, and part of the stomach (figure 2). A modification of the Whipple procedure (a pylorus-preserving Whipple procedure) has been developed that preserves the part of the stomach (the pylorus) that is important for stomach emptying.

In the past, complications and deaths following the Whipple procedure were high, and cure rates were less than 10 percent. However, more recent results suggest better outcomes.

Better outcomes are possible in hospitals that perform a large number of Whipple procedures and when the surgeon is experienced with the procedure [1] (see ‘Adjuvant therapy after surgery’ below).

Surgery for tumors in the body or tail of the pancreas — Because tumors in the body or tail of the pancreas do not cause the same symptoms as those in the head of the pancreas, these cancers tend to be discovered at a later stage, when they are more advanced.

If the tumor can be removed with surgery, a laparoscopy is usually done first to make sure the cancer has not spread. If surgery is an option, part of the pancreas is removed, usually along with the spleen.

Adjuvant therapy after surgery — Adjuvant (additional) therapy refers to chemotherapy, radiation, or a combination of both that is recommended for people who are thought to be at high risk of having cancer reappear (termed a recurrence or a relapse) after a tumor has been removed surgically. (See “Adjuvant and neoadjuvant therapy for exocrine pancreatic cancer”.)

Even if the tumor has been completely removed, tiny cancer cells may remain in the body and grow, causing relapse after surgery. Adjuvant therapy can prolong survival by eliminating the tiny cancer cells before they have a chance to grow [2-4].

In people with stage II or III pancreatic cancer, there are two ways to give adjuvant therapy after surgery for pancreatic cancer:

Give chemotherapy alone
Give a combination of chemotherapy and radiation therapy, usually followed by several months of chemotherapy alone. This strategy is called chemoradiotherapy.

In the United States, chemoradiotherapy is recommended for most patients. Outside of the United States, patients are frequently offered chemotherapy alone.

Treatment of locally advanced pancreatic cancer — Locally advanced pancreatic cancer is cancer that has not yet spread to distant locations in the body, but has spread into areas around the pancreas. The best treatment of locally advanced pancreatic cancer is not clear, but surgery is not usually possible. Options for treatment include chemotherapy alone or a combination of chemotherapy and radiation therapy (chemoradiotherapy). (See “Management of locally advanced and borderline resectable exocrine pancreatic cancer”.)

Chemoradiotherapy — Chemoradiotherapy often requires a central venous access catheter (often termed a port). This is placed during surgery into one of the large blood vessels in the chest. Chemoradiotherapy also requires a portable chemotherapy pump; this is a small, battery-operated pump that fits into a pack that can be worn around the waist. The pump gives the chemotherapy medicine into the port continuously for five to six weeks.

During this time, the patient is treated with radiation therapy five days per week. The radiation is delivered while the patient lies on a table underneath or in front of the machine. The treatment takes only a few seconds (similar to having an x-ray).

In some cases, the chemotherapy pump is not covered by health insurance. In this case, an oral (pill) form of chemotherapy can be substituted. This treatment is taken as a pill once per day, along with radiation therapy. Radiation therapy is given five days per week. This combination probably works as well as the chemotherapy pump plus radiation therapy, although studies have not been done.

Treatment of stage IV (metastatic) disease — For patients who are initially diagnosed with metastatic pancreatic cancer (stage IV) chemotherapy might be recommended to slow the spread of the cancer and relieve symptoms. (See “Chemotherapy for advanced exocrine pancreatic cancer”.)

Chemotherapy does not cure metastatic pancreatic cancer, but it can relieve symptoms, slow disease progression, and prolong life. Talk to your doctor about the benefits and risks of chemotherapy. Your doctor might suggest participating in a clinical trial that compares new chemotherapy medicines or new combinations of treatment. (See ‘Clinical trials’ below.)

Treating pancreatic cancer symptoms — Pancreatic cancer often causes bothersome symptoms like jaundice, blockage of the bowels, pain, and weight loss. Treatments are available to relieve these symptoms. (See “Exocrine pancreatic cancer: Palliation of symptoms”.)

Jaundice — Jaundice is caused by a blockage of the flow of bile through the common bile duct into the intestine (figure 1). The most common treatment is a stent, which is a small tube that is inserted into a duct to keep it open. The stent can usually be placed in a procedure called ERCP (endoscopic retrograde cholangiopancreatography). More information on this procedure is available separately. (See “Patient information: ERCP (endoscopic retrograde cholangiopancreatography)”.)

Bowel (duodenal) blockage — About 15 to 20 percent of people with pancreatic cancer will develop a blockage in the upper intestine (duodenum) caused by the tumor (figure 1). Surgery can be done to create a detour between the stomach and a lower part of the intestine. An alternative to bypass surgery is placement of a stent (a tube) in the duodenum. The stent helps to hold open the blocked area.

Pain — Pain is a common problem in people with pancreatic cancer. In some people, pain medicine alone is all that is needed. Radiation therapy can also help relieve pain by shrinking the tumor.

A procedure called celiac plexus block might also be a good option to control pain. This procedure uses injections of alcohol into nerves that transmit pain signals. The alcohol kills the nerves, preventing them from telling the brain to feel pain.

Weight loss — Weight loss is common in people with pancreatic cancer. Taking a pancreatic enzyme replacement can help your body to absorb fat. Enzyme replacements are usually taken in a capsule on a daily basis.

If nausea and vomiting is a problem, there are several medicines that can reduce these symptoms and improve the appetite.

END OF LIFE CARE — In many people with pancreatic cancer, the disease cannot be cured. Deciding when to stop treating the cancer can be difficult, and the decision should involve the patient, family, friends, and the healthcare team.

Ending cancer treatment does not mean ending care for the patient. Hospice care is frequently recommended when a person is unlikely to live longer than six months. Hospice care involves treatment of all aspects of a patient and family’s needs, including the physical (eg, pain relief), psychological, social, and spiritual aspects of suffering. This care may be given at home or in a nursing home or hospice facility, and usually involves multiple care providers, including a physician, registered nurse, nursing aide, a chaplain or religious leader, a social worker, and volunteers.

These providers work together to meet the patient and family’s needs and significantly reduce their suffering. For more information about hospice, see www.hospicenet.org. (See “Hospice: Philosophy of care and appropriate utilization”.)

CLINICAL TRIALS — Progress in treating cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. Ask for more information about clinical trials, or read about clinical trials at:

www.cancer.gov/clinicaltrials/learning/
www.cancer.gov/clinicaltrials/
file://clinicaltrials.gov/

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient Level Information:

Patient information: ERCP (endoscopic retrograde cholangiopancreatography)

Professional Level Information:

Adjuvant and neoadjuvant therapy for exocrine pancreatic cancer
Chemotherapy for advanced exocrine pancreatic cancer
Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer
Endoscopic ultrasound in the staging of exocrine pancreatic cancer
Exocrine pancreatic cancer: Palliation of symptoms
Pathophysiology and clinical manifestations of intraductal papillary mucinous neoplasm of the pancreas
Management of locally advanced and borderline resectable exocrine pancreatic cancer
Molecular pathogenesis of exocrine pancreatic cancer
Pathology of exocrine pancreatic neoplasms
Surgery in the treatment of exocrine pancreatic cancer and prognosis
Hospice: Philosophy of care and appropriate utilization

The following organizations also provide reliable health information.

 

National Cancer Institute

1-800-4-CANCER
(www.cancer.gov)

American Society of Clinical Oncology

(www.cancer.net/portal/site/patient)

National Comprehensive Cancer Network

(www.nccn.com)

Patient support — There are a number of online forums where patients can find information and support from other people with similar conditions.

About.com Cancer Forum

(file://cancer.about.com/forum)

REFERENCES
Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003; 349:2117.
Regine WF, Winter KA, Abrams RA, et al. Fluorouracil vs gemcitabine chemotherapy before and after fluorouracil-based chemoradiation following resection of pancreatic adenocarcinoma: a randomized controlled trial. JAMA 2008; 299:1019.
Neoptolemos JP, Stocken DD, Friess H, et al. A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer. N Engl J Med 2004; 350:1200.
Oettle H, Post S, Neuhaus P, et al. Adjuvant chemotherapy with gemcitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial. JAMA 2007; 297:267.
Yeo CJ, Cameron JL, Sohn TA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 1997; 226:248.
Moore MJ, Goldstein D, Hamm J, et al. Erlotinib plus gemcitabine compared with gemcitabine alone in patients with advanced pancreatic cancer: a phase III trial of the National Cancer Institute of Canada Clinical Trials Group. J Clin Oncol 2007; 25:1960.

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