indiacancer.org - Pancreatic Cancer

Pancreatic Cancer

		What is the Pancreas?
		What is Pancreatic Cancer?
		How does Pancreatic Cancer present?
		How is Pancreatic Cancer detected?
		What are staging and grading?
		How is pancreatic cancer treated?
		What are the side effects of treatment for pancreatic cancer?
		Who is at a greater risk for developing pancreatic cancer?

What is the Pancreas?

Pancreas is a gland in the abdomen surrounded by the stomach, intestines and other organs. It is six inches long and shaped like a long, flattened pear, wide at one end (called the head) and narrow at the other (the tail). The middle section is the body of the pancreas.

Pancreas makes pancreatic juices to aid in digestion and also produces hormones such as insulin. Pancreatic juices contain enzymes that help digest foods. The pancreas releases these juices when they are needed through a system of ducts. The main pancreatic duct joins the common bile duct that comes from the liver and gall bladder. The common bile duct carries bile, a fluid that helps digest fats. The bile duct forms a short tube which empties into the duodenum, the first part of the small intestine.

The Pancreas with the Duodenum on the left

	What is Pancreatic Cancer?

The Pancreas with the Duodenum seen from the front.

Pancreatic cancer occurs when there is uncontrolled growth of abnormal cells in the pancreas or ducts. While normal pancreatic tissue consists of cells programmed by nature to reproduce and develop into a healthy, well formed pancreas, these abnormal cells reproduce rapidly and disrupt this natural programming. Tumors will then form and clog the pancreas or the pancreatic ducts, making it difficult for the pancreas to work properly.

Most pancreatic cancers begin in the pancreatic ducts, or in the area of the pancreas that produces digestive juices. This area is called the exocrine pancreas. About 95 per cent of all pancreatic cancers are found here.

However, a rare form of cancer begins in other cells of the pancreas, the endocrine pancreas, where cells produce insulin and other hormones. These cells are called islets of Langerhans, (named after the scientist who discovered them), and cancers that begin in these cells are called islet cell cancers. Depending upon which hormone production is disrupted by the cancer and the location of the tumor, islet cell cancers can be insulinoma, gastrinoma, VIPoma, glucagonoma, or somatostatinoma. These make up only about 5 per cent of pancreatic cancers.

Like most other cancers, pancreatic cancer can spread locally, and/or metastasize throughout the body, spreading to thebones, brain, liver or other organs. Cancers that spread are still considered part of the original cancer. In other words, if a tumor in the liver results from pancreatic cancer, is still called metastatic pancreatic cancer. Unfortunately, almost half of all pancreatic cancer patients have metastatic disease by the time they are diagnosed.

How does Pancreatic Cancer present?

Since the pancreas is hidden behind other organs like stomach, small intestine, bile ducts, gallbladder, liver, and spleen, cancers can grow in it for many years before they are detected. In fact, pancreatic cancers can easily spread outside the pancreas without causing any symptoms. Even when a major symptom appears, such as jaundice or pain in the upper abdomen or back, it is often mistaken for another condition (such as pancreatitis, a disease in which the pancreas becomes inflamed and digestive enzymes begin attacking the pancreas).

The signs of pancreatic cancer - nausea, loss of appetite, weight loss, pain, and/or jaundice - are like those caused by many other illnesses.

In brief, the symptoms of pancreatic cancer are:

Cancer of the Pancreas

Nausea.

Loss of appetite.

Weakness.

Unintentional weight loss.

Jaundice.

Pain in the upper abdomen or lower back.

Iching.

Dizziness and drowsiness.

Depression.

New onset diabetes.

These symptoms may appear in the early stages. More often, the cancer is detected after a growing tumor causes jaundice, itching, or pain in the abdomen and lower back.

If the tumor is in the head of the pancreas, and blocking the common bile duct, the skin and whites of the eyes can become yellow and urine may become dark. This is known as jaundice.

As the cancer grows and spreads, pain can develop in the upper abdomen and may also spread to the back. This pain can become worse either after a person lies down or after they have eaten. Cancers in the body of the pancreas are most likely to cause pain.

Cancerous tumour in an islet cell may result in bouts of dizziness and drowsiness due to the over production of insulin, which results in low blood sugar levels. Chills, muscle spasms and diarrhea are frequent symptoms of islet cell cancers as well.These symptoms may also be caused by other, less serious problems. Only a doctor will be able to tell what your symptoms mean.

Other symptoms also can occur from the metastases, or the spread of the cancer to other parts of the body. The symptoms will depend on which organs have been affected by the cancer.

In addition to pain or discomfort, cancer also changes the body's metabolism (the way your body uses food). People with cancer absorb less calories from the foods they eat, so they usually need to eat more to maintain their weight.

How is Pancreatic Cancer detected?

Periampullary Cancer (Cancer at the junction of Duodenum, CBD and Pancreatic Duct)

Usually, your doctor will want to get pictures of the pancreas and the areas around it by a series of X-rays of the area. These will include an upper GI series, CAT scan and MRI. X-rays reveal information about the size, shape, and location of a tumor. They do not, however, tell you whether a tumor is cancerous.

An upper GI series is a series of X-rays of the upper digestive system, taken after the patient has drunk a barium solution. The barium makes it possible for the outlines of the digestive organs to show up on the X-rays.

CAT (computer assisted tomography) scans are produced when the X-ray machine is linked to a computer. The X-ray machine is shaped like a large doughnut (Vada) with a hole. The patient lies on a bed which passes through this hole. As the patients body goes through it, the machine takes X-rays of different parts of the body. The computer then puts the X-ray pictures together to produce detailed, three dimensional pictures.

MRI(Magnetic Resonance Imaging) uses a powerful magnet linked to a computer. This large machine has space for the patient to lie in a tunnel inside the magnet. The machine measures the body's response to the magnetic field. The computer uses this information to create detailed, three dimensional pictures of areas inside the body. Because CAT scans and MRIs can show the pancreas, lymph nodes, or other parts of the body with much greater precision than X-rays, they can also pinpoint whether the cancer has spread from the pancreas to other organs or parts of the body.

ULTRASONOGRAPHY is the use of very high frequency sound waves that cannot be heard by the human ear. The ultrasound instrument sends sound waves into the patient's abdomen. The waves bounce off the internal organs and produce echoes that create a picture called a sonogram. Healthy tissues and organs produce different echoes from diseased tissues and organs.

You may also be asked to undergo an ERCP (Endoscopic Retrograde Cholangiopancreatography), an X-ray procedure in which the doctor passes a long, flexible tube (an endoscope) down the patient's throat, through the stomach, and into the small intestine. The doctor then injects dye through the tube into the ducts and takes X-rays of the common bile duct and pancreatic ducts.

In a PTC (Percutaneous Transhepatic Cholangiography), a thin needle is put into the liver through the skin on the right side of the abdomen. Dye is injected into the bile ducts in the liver so that X-rays will show blockages in the ducts.

ANGIOGRAPHY is a procedure where dye is injected into the blood vessels and then X-rays are taken of the blood vessels.

BONE SCAN can show abnormalities in your bones, and will tell you whether this is caused by some other problem, such as arthritis, or by the cancer itself.

BIOPSY is usually ordered when a tumor is suspected of being cancerous. For this test, tissue is removed from the tumor and examined under a microscope to see whether the tumor cells are cancerous and, if so, what type of cancer.

There are several ways to perform a biopsy.

In a fine needle biopsy, doctor inserts a long but very thin needle into the pancreas through the skin of the abdomen. X-rays or ultrasound waves guide the placement of the needle, which is used to draw out some cells from the tumor.

In a brush biopsy, the doctor inserts a tiny brush through the endoscope into the opening of the bile duct and main pancreatic duct, and the brush rubs the cells off and collects them.

Sometimes, a biopsy will be done during a laparoscopy, in which the doctor through a small incision or cut in the skin, passes a lighted instrument, shaped like a thin tube, into the abdomen. Tissue samples can then be obtained for microscopic examination; the doctor can also see inside the abdomen to determine the location and extent of the disease.

During laparoscopy, the doctor decides whether a larger operation, called a laparotomy, is needed to remove the tumor or relieve symptoms caused by the cancer. In some cases, a laparotomy is needed to make a diagnosis. If cancer is found, the doctor can then proceed with further surgery to remove it.

What are staging and grading?

These are terms with which you must become familiar, if you are dealing with any form of cancer.

When we stage a cancer, we try to establish carefully the degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs.

The grading of a cancer is a microscopic issue, in which the pathologist tells you how aggressive this particular type of cancer is; in which well differentiated means less aggressive, moderately differentiated intermediately aggressive, and poorly differentiated is more aggressive.

Stage I - Cancer is only in the pancreas, and has not begun to spread to the tissues next to the pancreas, such as the small intestine, stomach, or bile duct. This is the least advanced stage. The treatment recommended for stage I pancreatic cancer is surgical removal of the tumor. In addition, chemotherapy and/or radiation therapy may be recommended. This is successful for most patients. Unfortunately, most people are not diagnosed at this stage, as the symptoms are often not pronounced to suspect cancer.

Stage II - The cancer has spread to the nearby organs - the stomach, spleen, or colon - but has not yet entered the lymph nodes. Lymph nodes are small, bean-shaped structures found throughout the body, where infection-fighting cells are produced and stored. Nodes can trap cancer cells or bacteria travelling through the body.

Stage III - The cancer is found in the lymph nodes near the pancreas. The cancer may or may not have spread to nearby organs. A combination of chemotherapy with surgery or radiation offers the best possibilities if the cancer is still a single tumor, or mass, which has not spread to other organs, and occupies an area that can safely fit into a radiation field. Surgery is performed to relieve the actual or potential obstruction or the first part of the small intestine, duodenum, and/or the bile ducts. Surgery can improve quality of life by relieving the jaundice and intestinal obstructions.Usually, chemotherapy and radiation are used after or instead of surgery in order to shrink the tumor.

If the pancreatic cancer has spread to more than one area, most doctors would not recommend surgery. A combination of chemotherapy and radiation is usually of the greatest benefit.

Stage IV - This is the most advanced stage of pancreatic cancer, when the cancer has spread to a distant part of the body - for example, your bones, liver, lungs, or some other organ. For stage IV, most doctors are in agreement that chemotherapy is the most effective treatment. Often, different combinations of chemotherapy drugs will be tested, to see which will be the most effective on your particular form of cancer.

How is Pancreatic Cancer treated?

People with pancreatic cancer are often treated by a team of specialists, including surgeons, medical oncologists, radiation oncologists, endocrinologists and gastroenterologists. Choice of treatment depends on the type of cancer, the location and size of the tumor, the stage of the disease, the person's age and general health, and other factors.

Three kinds of treatment for cancer are most often used. Surgery, aimed at removing the cancer or relieving symptoms caused by the cancer; radiation therapy; or the use of high dose x-rays or other high-energy rays to kill cancer cells; and chemotherapy, the use of drugs to kill cancer cells.

Surgery to remove the tumor can take several forms, depending upon the size and location of the tumor and the stage of the cancer.

A Whipple Procedure takes out the head of the pancreas, part of the small intestine, and some tissue around it. Enough of the pancreas is left in the body to continue producing digestive juices and insulin.

A total pancreatectomy is an operation in which the entire pancreas, part of the small intestine and stomach, the bile duct, gallbladder, spleen and most of the lymph nodes in the area are removed. Because the entire pancreas has been removed, the patient becomes dependent on insulin given through injections, just as with someone who has diabetes. A patient who has had a total pancreatectomy will need to learn about enzyme use and diabetic care as part of post operative treatment.

A distal pancreatectomy is an operation where only the tail of the pancreas is removed.

Your doctor may also perform surgery to relieve symptoms of a tumor. If the cancer is blocking your small intestine, causing bile to build up in the gallbladder, you may receive biliary bypass surgery, where the doctor cuts the gall bladder or bile duct and sews it directly to the small intestine. Or, a catheter (tube) may be inserted into the body to allow excess bile to drain to a tube outside the body or directly to the small intestine. If the cancer is blocking the flow of food from the stomach, the stomach may be sewn to the small intestine, so you can continue to ear normally.

The recommended treatments for pancreatic cancer by stage are:

STAGE I - Recommended treatment: surgical removal of the tumor.

The surgery recommended at this stage may be any of the four options mentioned previously. A Whipple procedure, a total pancreatectomy, a distal pancreatectomy, or bypass surgery. Surgery may then be followed by courses of chemotherapy and/or radiation therapy to reduce the risk of recurrence.

STAGE II - Recommended treatment: surgical removal of the tumor and lymph nodes, followed by radiation and/or chemotherapy.

Surgery to remove all or part of the pancreas and /or to reduce symptoms will be performed. Again, one of the four procedures described above is typically used. Radiation and chemotherapy may be used before, during, or after surgery, depending on the characteristics of your cancer and your general health.

STAGE III - Recommended treatment: chemotherapy and radiation to shrink the tumor, which may or may not be followed by surgery to remove the remaining tumor.

Surgery at this stage is primarily done to help relieve symptoms, although it may be performed to remove all or part of the pancreas at the same time. There are numerous clinical trials in progress for patients at this stage of pancreatic cancer, involving various combinations of radiation, chemotherapy and surgery.

STAGE IV - Recommended treatment: a combination of chemotherapy drugs.

Because the cancer at this stage has spread to other parts of the body, chemotherapy is generally the preferred treatment, since it is a systemic therapy - that is, it travels through the blood stream to where it is needed. However, surgery and radiation are by no means ruled out at this stage and may be part of your doctors overall treatment plan, particularly where they can be effective in reducing or controllinng pain.

Chemotherapy is a general term for any treatment (not just cancer treatment) involving the use of drugs. (The prefix chemo comes from a Latin word meaning chemistry or drugs). When used to treat cancer, chemotherapy is usually a combination of drugs taken over a course of several weeks or months, depending on your general health, the kind of pancreatic cancer you have, and the extent to which it has spread in your body. Chemotherapy can be used to slow the cancer's growth, to prevent it from spreading, to relieve symptoms caused by the cancer, or to eliminate all cancer cells from the body.

Even when chemotherapy cannot cure you of cancer, it can help you live longer and more comfortably. Gemcitabine, for example, can improve the quality of life and increase the survival time of some people with advanced pancreatic cancer. Clinical studies are now being conducted to test additional drugs and to use known drugs more effectively.

Radiation therapy is where a beam of high energy rays is directed at a tumor, to slow or stop tumor growth,(in effect, the radiation "kills" the tumor cells). In some cases, radiation is used to shrink a tumor prior to surgical removal. After surgery, it can also be used to destroy any remaining cancer cells. Radiation and chemotherapy are often used together with, or in place of surgery.

Like chemotherapy, the amount of radiation you receive, and the schedule for your treatments, depends on your particular circumstances. First you will meet with a radiation oncologist who, with your doctor, will decide the kind, amount, and frequency of radiation you receive.

Your treatment schedule will depend upon the total amount of radiation you will need. This amount is divided into daily doses to make sure it works as well as possible, but delivers the least amount of damage to your normal cells. Radiation sessions normally go for several weeks at a time, followed by a rest period of a few weeks before the next round begins.

Note- If you are receiving radiation treatment, small tattoos will first be placed on the area to be treated to guide the x-ray instruments and ensure that the beams of radiation are targeted precisely at the cancer. Do not worry, these marks are not permanent. However, you must not wash them off until your entire series of radiation tretments is completed.

What are the side effects of treatment for Pancreatic Cancer?

	If you have either Stage I or Stage II pancreatic cancer, the surgery to remove your cancerous tumor is still a major operation, and it will probably take you many weeks, or even months, to regain your strength and energy. Recovery will vary from person to person, depending on your age, your health, and other factors. The muscles in your abdomen may become weak and require special exercises to regain strength. Unfortunately, some pain and discomfort are common after such a surgery. Your doctor or nurse can help you manage the pain with medicines and other means. When all or part of the pancreas is removed, a person with pancreatic cancer may no longer be able to produce enough pancreatic juices and hormones. As a result, problems with digestion are likely to occur. Your doctor can suggest an appropriate diet and prescribe medicine to help relieve the unpleasant symptoms (diarrhea, pain, cramping) created by the surgery. Patients who can no longer produce enough insulin may develop diabetes; doctors can treat this problem by injections of hormones to replace what the pancreas is no longer producing. Chemotherapy and/or radiation are used to kill cancer cells, but healthy cells and tissues can be affected leading to treatment related side effects or toxicity. Most, but not all, side effects can be lessened by medication and other methods of controlling symptoms. Unfortunately, some side effects of cancer treatment are difficult to control. You can learn to watch for warning signs, communicate with your doctor and take action quickly. The effects of radiation depend upon the dose of radiation, the size of the area radiated, and the number and size of each fraction. The commonest side effect is extreme fatigue. Although bed rest is good, most radiotherapists advise the patient to be as mobile as possible. Another common problem is that of radiation dermatitis in which the skin covering the radiated area becomes red, dry, itchy, and may show signs of scaling off. This will slowly settle down after radiation ceases, but there may be a permanent 'bronzing' of the skin. It is important to note here that this skin problem is associated only with teletherapy or external radiation therapy. Radiation also may cause nausea and vomiting, diarrhea, urinary discomfort. There may also be a fall in the white blood cells, which are needed by humans to fight infection. Usually the radiotherapist can suggest the drugs and diet necessary to alleviate such problems. The various drugs in chemotherapy cause a varied spectrum of side effects. The severity and variability of these symptoms are very individualistic, changing from patient to patient. Some of the common side effects are:
		Skin rashes.
		Loss of hair.
		Diarrhea.
		Vomiting.
		Tingling and numbness in the fingers and toes.
		Hearing loss.
	Most are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy. The medical oncologist will usually be able to reduce the severity and spectrum of these side effects. The psychology of the patient is very important during therapy. Better psychologically prepared the patient is, better are his chances of having decreased side effects. The patient should drink large quantities of water while the therapy is in progress, and preferably avoid uncooked or raw food. Water should be filtered or boiled. Any relative or person who has any sort of infection such as common cold should be asked to desist from coming close to the patient.

Who is at a greater risk for developing pancreatic cancer?

People with adult onset diabetes appear to be at a greater risk of developing pancreatic cancer. Also high-calorie diets, long-term exposure to certain chemical carcinogens, such as dry cleaning chemicals, gasoline fumes, or metallurgic fumes, may increase the risk of pancreatic cancer.

Though cancer of the pancreas accounts for only 1-2 percent of all cancer, it is the fifth most frequent cause of cancer deaths. Pancreatic cancer is more common among males than females, and it occurs most often around age 60.