Recent diagnosis of pancreatic cancer in famous chief minister of one state has caused not only political flutter but also has caused increased awareness about the disease in the general public. This is a disease which has very poor prognosis but at the same time has some preventable causative factors like smoking. This article discusses the causes, symptoms, diagnosis and treatment options for pancreatic cancer.
What is Pancreas?
The pancreas is an elongated organ which is placed behind the stomach, deep inside the abdomen and anterior to the vertebral column. It has basically two important functions, First is to produce digestive juices required for digestion and second is to produce insulin hormone which controls the level of sugar in the blood. Thus, functionally pancreas is divided into exocrine and endocrine parts. All juices which are produced by pancreas are carried through a network of ducts to major pancreas duct which in turn drains into part of the intestine called as duodenum. Anatomically pancreas is divided into three parts called as head, body and tail.
Pancreas cancer:
Cancer is rapid, uncontrolled growth of cells which causes aggregation of cells and result in a tumour. Cancer formation is mainly due to mutations in genes which control cell division process. These abnormal cells spread locally in surrounding tissue or these cells spread through lymphatic and blood vessels to distant organs of the body which in medical term is called as metastasis. Cancer can arise from any cell of the body. Some tumours remain localised, grow slowly and don’t spread to distant organs called as benign tumours.
95 % of pancreatic cancers arise from exocrine cells of the pancreas. These cancers arise mainly from cells which lines pancreatic ducts. These types of cancer are called adenocarcinoma. Few percentages of cancers arise from the endocrine part of the pancreas which are called 'neuroendocrine' or 'islets cell cancer'. These types of cancers secrete hormones as per their cells of origin and cause symptoms accordingly. Generally, these cancers have better prognosis and different natural history than adenocarcinoma. Treatment of neuroendocrine tumours is different from adenocarcinoma. In this article, we will discuss mainly adenocarcinoma of the pancreas which are more common.
What are risk factors?
• The true cause of pancreatic cancer in patients is difficult to know. In many population-based studies, we have found a relation between some risk factors and cancer. Presence of these risk factors does not guarantee one will have cancer but exposure to these factors definitely increases the possibility of getting pancreas cancer.
• Age: Incidence of pancreatic cancer increases as age advances. Most of pancreatic cancer patients are between 60-80 age groups.
• Sex: Male tends to have a higher risk of pancreatic cancer but the recent trend has shown a decrease in gender gap possibly due to more smoking prevalence in the female population.
• Cigarette smoking: Tobacco smoking is a prominent cause of pancreatic cancer. 20-30% of cases are due to smoking. Smokeless tobacco like tobacco quid, pan masala also increases cancer risk.
• Obesity: Obese people have increased risk of pancreatic cancer
• Diabetes: Pancreatic cancer is more likely in those with diabetes but the actual relation between the two is not clear.
• Diet: Few medical studies have shown an increased risk of pancreatic cancer in patients who eat a high level of meat, a diet rich in fat.
• Alcohol: Recent studies have shown an association of alcohol intake and pancreatic cancer.
• Genetics: Pancreatic cancer can run in families due to genetic risk. Genetic factors are attributed for about 10% of pancreatic cancers. Few genetic syndromes like BRCA families, Lynch syndrome, Von Hippel Lindau syndrome, Peutz-Jeghers syndrome increases pancreatic cancer risk.
What are symptoms of pancreatic cancer?
Pancreatic cancer symptoms are generally nonspecific and vague, therefore early diagnosis requires high suspicion from patient and physician’s side.
• Pain: vague mid-abdominal pain is one of the first symptoms of pancreatic cancer. As the disease advances pain increases in severity and radiates to back.
• Bloating: Some patient will have sense of abdominal fullness after eating.
• Nausea
• Vomiting
• Jaundice: Pancreatic duct blocks bile duct which causes yellowish eyes, dark urine, light coloured stools and body itching. Jaundice occurs mainly in pancreatic head cancers as bile duct courses through pancreas head.
It is very important to know that having any of above symptom doesn’t mean you are having pancreatic cancer. These general symptoms can occur in many diseases.
As tumour grows and spreads in body following symptoms occurs
• Loss of appetite
• Loss of weight
• Diabetes
• Ascites (collection of fluid in abdominal cavity and distension)
• Fatigue
Diagnosis:
Unfortunately, most of the patients are diagnosed in the late stage as symptoms are nonspecific and occur at later stages. The doctor takes a clinical history, do a physical examination and advises blood tests. Based on this doctor advises the following imaging tests.
• CT scan
• MRI scan
• PET scan
• Ultrasound
These imaging tests confirm mass in the pancreas but the diagnosis is confirmed by biopsy which is performed under CT scan guidance or endoscopy guidance (ERCP). If a tumour is localised and resectable surgery is advised without a biopsy.
What are Treatment options?
Treatment of pancreas cancer depend on how much it has spread i.e. stage of disease. There are four stages, stage I to stage IV.
• Surgery: Surgery is only curative treatment in pancreatic cancer. Only about 15-20% of those individuals with pancreatic cancer will be found to be eligible for surgery. Surgery is possible only in early stages. The resection, known as the Whipple operation or pancreaticoduodenectomy is typically done for patients who have tumours which are located in the head of the pancreas or which are located in regions adjacent to the head of the pancreas. If a pancreatic tumour is located in the tail of the pancreas, often that portion of the pancreas will be removed along with the nearby spleen. If a tumour is not resectable then palliative surgery is done for intestinal obstruction, pain and jaundice.
• Chemotherapy: chemotherapy includes use of drugs to kill cancer cells, it is used after surgery as adjuvant treatment or in locally advanced disease to shrink tumour. In stage IV where disease spread in distant organs palliative chemotherapy is only treatment.
• Radiotherapy: radiotherapy uses x rays to kill cancer cells. It is used along with chemotherapy in locally advanced disease.
Dr Ashish Pokharkar
MS, MCh (surgical oncology)
Fellowship in minimally invasive gastrointestinal Oncosurgery
Consultant Oncosurgeon
Jupiter Hospital, Baner Pune.
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