Diagnosis, Treatment Of Pancreatic Cancer By Michael R. Thompson, M.D. Pancreatic cancer is the fourth leading cause of cancer death in both men and women. It accounts for only 2 percent of new cancers in the United States, but causes nearly 30,000 deaths annually. While this form of cancer is considered a disease of older Americans, a third of all cases involve people under the age of 65. It affects men and women equally, with increased incidence in African-Americans. Risk factors The only behavioral or environmental factor believed to increase the risk of pancreatic cancer is smoking. While consumption of coffee and alcohol has previously been associated with an increased risk, subsequent scientific data have not confirmed these relationships. Weakly positive associations have been found between this malignancy and dietary factors, diabetes, stomach surgery and a previous history of pancreatitis. Inherited and acquired chromosomal abnormalities are felt to play a central role. As with many other cancers that arise in the abdominal cavity, the earliest symptoms are not strongly suggestive of malignancy, which may delay definitive diagnosis by an average of two months. Symptoms may include: Upper abdominal and back pain Weight loss Persistent pain Yellow jaundice Loss of appetite Weakness New intolerance of certain foods Blood clots Depression Jaundice Jaundice is the most common physical finding on examination. It usually occurs in 75 percent of these patients. The most common cause is pressure on the main bile duct from a tumor in the head of the pancreas. However, it may also result from spread to the liver from a main tumor mass that arises from the body or the tail of the pancreas. Due to the cancer's deep location, physicians rarely feel the tumor itself. A swollen liver or gallbladder is more easily felt, but is only occasionally present early in the course of the disease. Routine blood tests are usually normal unless the patient is jaundiced. Role of imaging When physicians suspect cancer of the pancreas, they usually employ an ultrasound or CT scan to confirm the presence of a tumor mass. These tests can demonstrate involvement of surrounding structures such as blood vessels, lymph nodes, liver, bile duct and retroperitoneum, as well. Magnetic resonance imaging (MRI) and positron emission tomography (PET) may also provide information to help physicians determine whether surgery is appropriate. Dye studies of the bile ducts, performed either by endoscopy (ERCP) or from the outside (PTC), can help physicians determine whether the tumor is actually in the pancreatic head or elsewhere in the bile duct system. ERCP and PTC can provide information that is useful in placing stents to allow free flow of bile through the duct. Diagnosis Even when the symptoms, physical examination and imaging studies are consistent with pancreatic cancer, the diagnosis is not final until a biopsy is performed. For patients whose disease may not be surgically curable, the physician may order a fine needle aspirate biopsy using a CT scanner to guide placement of the needle. Most pancreatic cancers arise from the pancreatic duct and are classified as adenocarcinomas. Tumors that have extensive involvement in surrounding structures or have spread to the liver or other organs are not considered curable. Unfortunately, about 80 percent of patients are either incurable at diagnosis or are found to have a surgically inoperable disease when the abdomen is explored in the operating room. About 90 percent of those patients who have major surgery with a curative intent will die of recurrent cancer within two years. The poor prognosis of this disease is mainly due to early spread of the cancer before any symptoms occur. Surgery & chemotherapy Aggressive surgery for cancer of the pancreatic head classically involves surgery to remove the tumor mass, along with most or all of the first part of the small intestine, or duodenum. The surgeon then brings up the second part of the small intestine, or jejunum, and joins it to the remaining, non-cancerous pancreatic duct. Next, the surgeon joins the bile duct, which normally drains into the first part of the small intestine, to the jejunum to allow bile to drain from the liver. Lastly, he or she joins the jejunum either to the remaining part of the duodenum or to the stomach. More radical surgery can be performed if indicated. Tumors involving the body or the tail of the pancreas also can be approached surgically. However, anatomic considerations necessitate different techniques than those employed for tumors of the pancreatic head. As noted, patients who may be appropriate candidates for surgery based on CT scan findings frequently have an extensive, inoperable tumor, which a surgeon finds at exploration. When this occurs, the surgeon often diverts the bile duct by transplanting the end of the duct to another part of the small intestine. This may relieve, postpone or prevent jaundice and liver failure. Survival of people who are not cured by surgery is generally six months or less. Historically, chemotherapy has been unhelpful, with less than a 20 percent chance of meaningful tumor shrinkage and no impact on patient survival. The Food and Drug Administration has approved the use of gemcitabine as a first-line treatment for pancreatic cancer. While this chemotherapy agent does not generally shrink the tumor or dramatically prolong survival, more patients are alive at one year following diagnosis than with fluorouracil, the old standard drug. In addition, a patient's quality of life improves with the use of gemcitabine, as opposed to fluorouracil. People with inoperable disease require good supportive care. A team approach to pain control is particularly important. Nerve blocks can be utilized, but most of these patients ultimately require narcotic analgesics. A fighting chance Researchers are evaluating the combination of chemotherapy and radiation, given either before or after surgery, in hopes of improving survival. New chemotherapy agents are being tested alone and in combination with other drugs. Prevention is another area of active research, especially in relation to dietary influences. Presently, there is no "magic" bullet in the works. It is not clear whether a one- or two-month delay in the diagnosis of pancreatic cancer has an impact on survival. Pancreatic cancer is incurable once it has spread, though. For that reason, you should tell your doctor if you: Are losing significant amounts of weight for no apparent reason Notice a yellow color in the whites of your eyes Have persistent upper abdominal or mid-back pain. Early diagnosis of any malignancy gives you a better fighting chance. About the Author: Michael R. Thompson, M.D., is an oncologist/hematologist on the staff of Methodist Medical Center of Oak Ridge. He earned a medical degree from Hahnemann University in Philadelphia and completed an internal medicine residency at Reading Hospital and Medical Center in Reading, PA. In addition, Dr. Thompson completed a hematology/oncology fellowship at the Health Science Center in Syracuse, N.Y. He is board certified in medical oncology, hematology, and internal medicine and is a member of the American College of Physicians and the American Society for Hematology.

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