Pancreatic Cancer

Pancreatic cancer occurs within the tissues of the pancreas, a vital endocrine organ located behind the stomach. The pancreas plays an essential role in digestion by producing enzymes the body needs to digest fats, carbohydrates, and proteins.

Pancreatic cancer starts when cells in the pancreas begin to grow out of control. The cells then cause tumors that lead to various health issues. There are two types of cells in the pancreas – exocrine and endocrine cells. Exocrine cells make up most of the pancreas and form exocrine glands and ducts. Glands make enzymes that help to digest food and ducts carry enzymes through the pancreas to the intestines.

Over 89% of pancreatic cancer patients are at least 55 years of age, making it rare in younger adults. Adenocarcinoma is the most common type of pancreatic cancer, followed by Pancreatic neuroendocrine tumors (NETs).

Pancreatic Cancer Symptoms

Cancer of the pancreas can begin in the three places, the head, body, or tail. If it starts in the head of the pancreas, it is closest to the bile duct and may press on the duct, causing jaundice throughout the body quickly.

If the cancer begins in the body or tail, jaundice is usually not seen until the cancer has spread to the tissues surrounding the pancreas. The liver is often the first place the cancer spreads beyond the pancreas. Despite jaundice being the most common first symptom pancreatic cancer patients experience, jaundice more often occurs in hepatitis, gallstones, or other liver and bile duct diseases.

Early signs of pancreatic cancer include:

• Back or abdominal pain
• Jaundice occurs when ducts are blocked, and bile builds up; whites of the eyes and the skin appear yellow
• Nausea or vomiting
• Bloating when eating small amounts of food

Late-stage symptoms of pancreatic cancer include:

• Change in stool or dark colored urine
• Weight loss
• Elevated blood sugar levels
• Persistent fatigue

What Causes Pancreatic Cancer?

Doctors do not know the exact cause of pancreatic cancer. However, observed changes in individual genes that are both inherited and developed over one’s lifetime do develop into cancer. Only a small number of cases develop from gene mutations inherited from family members. Most gene mutations attributed to pancreatic cancer occur after they are born. The common gene mutations seen in pancreatic cancer include:

• P16
• TP53
• KRAS
• BRAF
• DPC4 (SMAD4)

Pancreatic Cancer Diagnosis

There are a variety of tests that are used to diagnose pancreatic cancer. If patients are experiencing common symptoms of pancreatic cancer, they should schedule an appointment with their doctor to ensure they are screened appropriately.

Testing with certain imaging is used to help diagnose pancreatic cancer. Specific imaging includes:

• Ultrasonography: The pancreas can be examined in detail by ultrasonography method. Information about the masses in the region and the structure of these masses can be obtained.
• Computed tomography or MRI: With these two methods, any harmful mass in the pancreatic region and the structure of these masses can be diagnosed. These two methods, which can be used separately, can also be used together, and information about the status and stages of the cancer can be obtained.
• Laboratory tests: Pancreatic cancer can be diagnosed with certain tests used in the laboratory. The blood values of people with pancreatic cancer and the level of these values vary. With the data obtained, these changes can be analyzed and a diagnosis can be made.

Pancreatic Cancer Risk Factors

There are many other factors that increase the risk of pancreatic cancer. These include:

• Diabetes Disease
• Smoking
• Obesity
• Genetic Pancreatic Cancer
• Aging
• Diabetes

It has been observed that pancreatic cancer is more common in smokers and overweight people. Smoking, as the cause of pancreatic cancer is almost 30% of patients. Diabetes increases the rate of developing pancreatic cancer by two times compared to healthy individuals. Diabetes is observed in 60-80% of pancreatic cancer patients. It is also known that up to 10% of pancreatic cancers are familial or hereditary, for example in patients with history of BRCA 1 or 2 mutation running in their family.

Pancreatic Cancer Stages

After someone is diagnosed with pancreatic cancer, doctors will try to figure out if it has spread and if so, how far. This process is called staging. If early signs of pancreatic cancer are seen, tests will be done by your doctor to confirm the diagnosis such as an MRI, PET or CT scan, ultrasound, or blood chemistry study. Once the diagnosis is confirmed, additional testing is done to stage the disease.

The stages of pancreatic cancer are defined as:

• Stage 0: Cancer cells are found in duct cells and have not gone deep into the tissues. Carcinoma can be defined as in situ. No splashes to lymph nodes or distant parts of the body.
• Stage IA: Tumor smaller than 2 cm is seen in the pancreas. It has not yet spread out of the pancreas or to the lymph nodes.
• Stage IB: The tumor in the pancreas has reached between 2 cm and 4 cm. It is not seen outside the pancreas.
• Stage IIA: The tumor has become larger than 4 cm, but it is not found in lymph nodes.
• Stage IIB: The tumor has become larger than 4 cm and has spread to the lymph nodes. At this stage, tumors are found in at most 3 lymph nodes. It has not metastasized to other organs.
• Stage III: The tumor is seen in 4 or more regional lymph nodes or has spread to nearby arteries and veins. It is not seen in other organs.
• Stage IV: Cancer cells have spread to other organs such as liver, lungs and bones.

Pancreatic Cancer Treatment

Treatment of pancreatic cancer varies depending on the stage of the disease, the location of the cancer in the pancreas, the patient’s age, general condition, and the patient’s preferences. The first goal in treatment is to remove the cancerous tissue completely by surgery if possible. Since pancreatic cancer typically spreads early and is rarely diagnosed at an early stage, this is often not possible.

There are several options available for the treatment of pancreatic cancer, including surgery, radiation therapy, chemotherapy, targeted therapy, and immunotherapy. Available treatment options are determined by the type and stage of the cancer, possible side effects, the patient’s preferences, and general health status. The goals and expectations of each treatment are different.  Once discussed between the patient and the doctor, the most appropriate method is determined. Collaborative decision-making, regarding the treatment, is especially important for pancreatic cancer due to the limited treatment options for this type of cancer.

When detected early, pancreatic cancer has a much higher chance of being successfully treated. However, for patients with later stage pancreatic cancer, the goal of treatment is to help control and alleviate the symptoms.

Pancreatic Cancer Clinical Trials

Pancreatic cancer is one of the most challenging diseases due to its often-late diagnosis which results in limited therapeutic options and poor prognosis. Because the rate of survival and successful treatment options for pancreatic cancer are so low, there is motivation to research and develop new treatment options through clinical trials.

While pancreatic cancer clinical trials can be effective for some patients, surgical resection remains the only definitive option for patients, but is restricted to earlier disease stages and is applicable to less than one-third of newly diagnosed patients. Due to the lack of curative treatments and aggressiveness of pancreatic cancer, the treatment decision can be complicated for some patients. All patients are urged to consider clinical trials which have the following types of treatment available:

• Immunotherapy
• Targeted treatments
• New approaches of surgery
• Cancer vaccines
• Radiation therapy
• Combining chemotherapy with other treatments

Some of the promising drugs and combinations of treatments being researched are:

• GVAX
• FOLFIRINOX
• Gemcitabine
• Palbociclib
• FOLFOX

Clinical trials have specific eligibility criteria to target the patients that will likely be able to safely receive the treatment. Every individual is different, which is why you should consult your doctor to see if clinical trials may benefit you.