Pancreatic Cancer Causes, Symptoms, Diagnosis, Treatment, Prevention

Pancreatic Cancer Causes, Symptoms, Diagnosis, Treatment, Prevention


The Pancreas


The pancreas is a gland located deep in the abdomen between the stomach and the spine (backbone). The liver, intestine, and other organs surround the pancreas.

The pancreas is about 6 inches long and is shaped like a flat pear. The widest part of the pancreas is the head, the middle section is the body, and the thinnest part is the tail.

The pancreas makes insulin and other hormones. These hormones enter the bloodstream and travel throughout the body. They help the body use or store the energy that comes from food. For example, insulin helps control the amount of sugar in the blood.

The pancreas also makes pancreatic juices. These juices contain enzymes that help digest food. The pancreas releases the juices into a system of ducts leading to the common bile duct. The common bile duct empties into the duodenum, the first section of the small intestine.

Read more: Pancreatitis Causes, Symptoms, Diagnosis, Treatment, Prevention

Understanding Cancer


Cancer is a group of many related diseases. All cancers begin in cells, the body's basic unit of life. Cells make up tissues, and tissues make up the organs of the body.

Normally, cells grow and divide to form new cells as the body needs them. When cells grow old and die, new cells take their place.

Sometimes this orderly process breaks down. New cells form when the body does not need them, or old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor.

Tumors can be benign or malignant:

  • Benign tumors are not cancer. Usually, doctors can remove them. In most cases, benign tumors do not come back after they are removed. Cells from benign tumors do not spread to tissues around them or to other parts of the body. Most important, benign tumors are rarely a threat to life.

  • Malignant tumors are cancer. They are generally more serious and may be life threatening. Cancer cells can invade and damage nearby tissues and organs. Also, cancer cells can break away from a malignant tumor and enter the bloodstream or lymphatic system. That is how cancer cells spread from the original cancer (primary tumor) to form new tumors in other organs. The spread of cancer is called metastasis.

Most pancreatic cancers begin in the ducts that carry pancreatic juices. Cancer of the pancreas may be called pancreatic cancer or carcinoma of the pancreas.

A rare type of pancreatic cancer begins in the cells that make insulin and other hormones. Cancer that begins in these cells is called islet cell cancer. This booklet does not deal with this rare disease. The Cancer Information Service can provide information about islet cell cancer.

When cancer of the pancreas spreads (metastasizes) outside the pancreas, cancer cells are often found in nearby lymph nodes. If the cancer has reached these nodes, it means that cancer cells may have spread to other lymph nodes or other tissues, such as the liver or lungs. Sometimes cancer of the pancreas spreads to the peritoneum, the tissue that lines the abdomen.

When cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if cancer of the pancreas spreads to the liver, the cancer cells in the liver are pancreatic cancer cells. The disease is metastatic pancreatic cancer, not liver cancer. It is treated as pancreatic cancer, not liver cancer.

What is pancreatic cancer?


Cancers that develop within the pancreas fall into two major categories: (1) cancers of the endocrine pancreas (the part that makes insulin and other hormones) are called "islet cell" or "pancreatic neuroendocrine" cancers and (2) cancers of the exocrine pancreas (the part that makes enzymes). Islet cell cancers are rare and typically grow slowly compared to exocrine pancreatic cancers. Islet cell tumors often release hormones into the bloodstream and are further characterized by the hormones they produce (insulin, glucagon, gastrin, or other hormones). Cancers of the exocrine pancreas develop from the cells that line the system of ducts that deliver enzymes to the small intestine and are commonly referred to as pancreatic adenocarcinomas. Adenocarcinoma of the pancreas comprises 95% of all pancreatic ductal cancers and is the subject of this review.

Pancreatic Cancer Causes, Symptoms, Diagnosis, Treatment, Prevention
Pancreatic Cancer

Cells that line the ducts in the exocrine pancreas divide more rapidly than the tissues that surround them. For reasons that we do not understand, these cells can make a mistake when they copy their DNA as they are reproducing to replace other cells. In this manner, an abnormal cell can be made. When an abnormal ductal cell begins to divide in an unregulated way, a growth can form that is made up of abnormal looking and functioning cells. The abnormal changes that can be recognized under the microscope are called "dysplasia." Often, dysplastic cells can undergo additional genetic mistakes over time and become even more abnormal. If these dysplastic cells invade through the walls of the duct from which they arise into the surrounding tissue, the dysplasia has become a malignant tumor (cancer).

What are pancreatic cancer causes and risk factors?


No one knows the exact causes of pancreatic cancer. Doctors can seldom explain why one person gets pancreatic cancer and another does not. However, it is clear that this disease is not contagious. No one can "catch" cancer from another person.

Research has shown that people with certain risk factors are more likely than others to develop pancreatic cancer. A risk factor is anything that increases a person's chance of developing a disease.

Studies have found the following risk factors:

Age 


The likelihood of developing pancreatic cancer increases with age. Most pancreatic cancers occur in people over the age of 60.

Smoking 


Cigarette smokers are two or three times more likely than nonsmokers to develop pancreatic cancer.

Diabetes


Pancreatic cancer occurs more often in people who have diabetes than in people who do not.

Being male


More men than women are diagnosed with pancreatic cancer.

Being African American


African Americans are more likely than Asians, Hispanics, or whites to get pancreatic cancer.

Family history


The risk for developing pancreatic cancer triples if a person's mother, father, sister, or brother had the disease. Also, a family history of colon or ovarian cancer increases the risk of pancreatic cancer.

Chronic pancreatitis


Chronic pancreatitis is a painful condition of the pancreas. Some evidence suggests that chronic pancreatitis may increase the risk of pancreatic cancer.

Other studies suggest that exposure to certain chemicals in the workplace or a diet high in fat may increase the chance of getting pancreatic cancer.

Most people with known risk factors do not get pancreatic cancer. On the other hand, many who do get the disease have none of these factors. People who think they may be at risk for pancreatic cancer should discuss this concern with their doctor. The doctor may suggest ways to reduce the risk and can plan an appropriate schedule for checkups.

What are the symptoms and signs of pancreatic cancer?


Pancreatic cancer is sometimes called a "silent disease" because often, early on, there are not any symptoms of cancer of the pancreas. But, as the cancer grows, pancreatic cancer symptoms may include:

  • Pain in the upper abdomen or upper back
  • Yellow skin and eyes, and dark urine from jaundice
  • Weakness
  • Loss of appetite
  • Nausea and vomiting
  • Weight loss

These symptoms are not sure signs of pancreatic cancer. An infection or other problem could also cause these symptoms. Only a doctor can diagnose the cause of a person's symptoms. Anyone with these symptoms should see a doctor so that the doctor can treat any problem as early as possible.

Diagnosis of Pancreatic Cancer


If a patient has symptoms that suggest pancreatic cancer, the doctor asks about the patient's medical history. The doctor may perform a number of procedures, including one or more of the following:

Pancreatic Cancer Causes, Symptoms, Diagnosis, Treatment, Prevention
Pancreatic Cancer

Physical exam


The doctor examines the skin and eyes for signs of jaundice. The doctor then feels the abdomen to check for changes in the area near the pancreas, liver, and gallbladder. The doctor also checks for ascites, an abnormal buildup of fluid in the abdomen.

Lab tests


The doctor may take blood, urine, and stool samples to check for bilirubin and other substances. Bilirubin is a substance that passes from the liver to the gallbladder to the intestine. If the common bile duct is blocked by a tumor, the bilirubin cannot pass through normally. Blockage may cause the level of bilirubin in the blood, stool, or urine to become very high. High bilirubin levels can result from cancer or from noncancerous conditions.

CT scan (Computed tomography)


An x-ray machine linked to a computer takes a series of detailed pictures. The x-ray machine is shaped like a donut with a large hole. The patient lies on a bed that passes through the hole. As the bed moves slowly through the hole, the machine takes many x-rays. The computer puts the x-rays together to create pictures of the pancreas and other organs and blood vessels in the abdomen.

Ultrasonography


The ultrasound device uses sound waves that cannot be heard by humans. The sound waves produce a pattern of echoes as they bounce off internal organs. The echoes create a picture of the pancreas and other organs inside the abdomen. The echoes from tumors are different from echoes made by healthy tissues.

The ultrasound procedure may use an external or internal device, or both types:

  • Transabdominal ultrasound: To make images of the pancreas, the doctor places the ultrasound device on the abdomen and slowly moves it around.
  • EUS (Endoscopic ultrasound): The doctor passes a thin, lighted tube (endoscope) through the patient's mouth and stomach, down into the first part of the small intestine. At the tip of the endoscope is an ultrasound device. The doctor slowly withdraws the endoscope from the intestine toward the stomach to make images of the pancreas and surrounding organs and tissues.

ERCP (endoscopic retrograde cholangiopancreatography)


The doctor passes an endoscope through the patient's mouth and stomach, down into the first part of the small intestine. The doctor slips a smaller tube (catheter) through the endoscope into the bile ducts and pancreatic ducts. After injecting dye through the catheter into the ducts, the doctor takes x-ray pictures. The x-rays can show whether the ducts are narrowed or blocked by a tumor or other condition.

PTC (percutaneous transhepatic cholangiography)


A dye is injected through a thin needle inserted through the skin into the liver. Unless there is a blockage, the dye should move freely through the bile ducts. The dye makes the bile ducts show up on x-ray pictures. From the pictures, the doctor can tell whether there is a blockage from a tumor or other condition.

Biopsy


In some cases, the doctor may remove tissue. A pathologist then uses a microscope to look for cancer cells in the tissue. The doctor may obtain tissue in several ways. One way is by inserting a needle into the pancreas to remove cells. This is called fine-needle aspiration. The doctor uses x-ray or ultrasound to guide the needle. Sometimes the doctor obtains a sample of tissue during EUS or ERCP. Another way is to open the abdomen during an operation.

How is pancreatic cancer staged?


When pancreatic cancer is diagnosed, the doctor needs to know the stage, or extent, of the disease to plan the best treatment for pancreatic cancer. Staging is a careful attempt to find out the size of the tumor in the pancreas, whether the cancer has spread, and if so, to what parts of the body.

The doctor may determine the stage of pancreatic cancer at the time of diagnosis, or the patient may need to have more tests. Such tests may include blood tests, a CT scan, ultrasonography, laparoscopy, or angiography. The test results will help the doctor decide which treatment is appropriate.

Pancreatic Cancer Treatment


Pancreatic cancer is treated in several ways, alone or in combination:

  • Surgery
  • Chemotherapy
  • Radiation therapy
  • Palliative care

Many people with pancreatic cancer want to take an active part in making decisions about their medical care. They want to learn all they can about their disease and their choices for pancreatic cancer treatment. However, the shock and stress that people may feel after a diagnosis of cancer can make it hard for them to think of everything they want to ask the doctor. Often it helps to make a list of questions before an appointment. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some patients also want to have a family member or friend with them when they talk to the doctor-to take part in the discussion, to take notes, or just to listen.

Cancer of the pancreas is very hard to control with current treatments. For that reason, many doctors encourage patients with this disease to consider taking part in a clinical trial. Clinical trials are an important option for people with all stages of pancreatic cancer.

At this time, pancreatic cancer can be cured only when it is found at an early stage, before it has spread. However, other treatments may be able to control the disease and help patients live longer and feel better. When a cure or control of the disease is not possible, some patients and their doctors choose palliative therapy. Palliative therapy aims to improve quality of life by controlling pain and other problems caused by this disease.

The doctor may refer patients to an oncologist, a doctor who specializes in treating cancer, or patients may ask for a referral. Specialists who treat pancreatic cancer include surgeons, medical oncologists, and radiation oncologists. Treatment generally begins within a few weeks after the diagnosis. There will be time for patients to talk with the doctor about treatment choices, get a second opinion, and learn more about the disease.

What to Expect From Pancreatic Cancer


Pancreatic cancer is a serious condition. Most cases of pancreatic cancer have already spread at the time of diagnosis, making a full cure unlikely. Treatments can allow people to live longer with pancreatic cancer and improve their quality of life. Clinical trials are ongoing to discover more effective ways of treating pancreatic cancer.

Can pancreatic cancer be prevented?


At this time there is no known surveillance strategy to reduce the risk of pancreatic cancer for the general population. With only 40,000 new diagnoses a year occurring in a country with over 300 million people, screening blood tests or X-rays have never been proven to be cost effective or beneficial. Additionally, doctors do not routinely screen individuals with family members diagnosed with the disease aside from the rare instance where a known genetic risk factor is present.

Preparing for Treatment for Pancreatic Cancer


The doctor can describe treatment choices and discuss the results expected with each pancreatic cancer treatment option. The doctor and patient can work together to develop a treatment plan that fits the patient's needs.

Treatment depends on where in the pancreas the tumor started and whether the disease has spread. When planning treatment, the doctor also considers other factors, including the patient's age and general health.

These are some questions a person may want to ask the doctor before treatment begins:
  • What is the diagnosis?
  • Where in the pancreas did the cancer start?
  • Is there any evidence the cancer has spread? What is the stage of the disease?
  • Do I need any more tests to check whether the disease has spread?
  • What are my treatment choices? Which do you recommend for me? Why?
  • What are the expected benefits of each kind of treatment?
  • What are the risks and possible side effects of each treatment?
  • What is the treatment likely to cost? Is this treatment covered by my insurance plan?
  • How will treatment affect my normal activities?
  • Would a clinical trial (research study) be appropriate for me?

People do not need to ask all of their questions or understand all of the answers at one time. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information.

Methods of Pancreatic Cancer Treatment


People with pancreatic cancer may have several treatment options. Depending on the type and stage, pancreatic cancer may be treated with surgery, radiation therapy, or chemotherapy. Some patients have a combination of therapies.

Surgery


Surgery may be used alone or in combination with radiation therapy and chemotherapy.

The surgeon may remove all or part of the pancreas. The extent of surgery depends on the location and size of the tumor, the stage of the disease, and the patient's general health.

  • Whipple procedure: If the tumor is in the head (the widest part) of the pancreas, the surgeon removes the head of the pancreas and part of the small intestine, bile duct, and stomach. The surgeon may also remove other nearby tissues.
  • Distal pancreatectomy: The surgeon removes the body and tail of the pancreas if the tumor is in either of these parts. The surgeon also removes the spleen.
  • Total pancreatectomy: The surgeon removes the entire pancreas, part of the small intestine, a portion of the stomach, the common bile duct, the gallbladder, the spleen, and nearby lymph nodes.

Sometimes the cancer cannot be completely removed. But if the tumor is blocking the common bile duct or duodenum, the surgeon can create a bypass. A bypass allows fluids to flow through the digestive tract. It can help relieve jaundice and pain resulting from a blockage.

The doctor sometimes can relieve blockage without doing bypass surgery. The doctor uses an endoscope to place a stent in the blocked area. A stent is a tiny plastic or metal mesh tube that helps keep the duct or duodenum open.

After surgery, some patients are fed liquids intravenously (by IV) and through feeding tubes placed into the abdomen. Patients slowly return to eating solid foods by mouth. A few weeks after surgery, the feeding tubes are removed.

These are some questions a person may want to ask the doctor before having surgery:
  • What kind of operation will I have?
  • How will I feel after the operation?
  • How will you treat my pain?
  • What other treatment will I need?
  • How long will I be in the hospital?
  • Will I need a feeding tube after surgery? Will I need a special diet?
  • What are the long-term effects?
  • When can I get back to my normal activities?
  • How often will I need checkups?

Radiation therapy


Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. A large machine directs radiation at the abdomen. Radiation therapy may be given alone, or with surgery, chemotherapy, or both.

Radiation therapy is local therapy. It affects cancer cells only in the treated area. For radiation therapy, patients go to the hospital or clinic, often 5 days a week for several weeks.

Doctors may use radiation to destroy cancer cells that remain in the area after surgery. They also use radiation to relieve pain and other problems caused by the cancer.

These are some questions a person may want to ask the doctor before having radiation therapy:
  • Why do I need this treatment?
  • When will the treatments begin? When will they end?
  • How will I feel during therapy? Are there side effects?
  • What can I do to take care of myself during therapy? Are there certain foods that I should eat or avoid?
  • How will we know if the radiation is working?
  • Will I be able to continue my normal activities during treatment?

Chemotherapy


Chemotherapy is the use of drugs to kill cancer cells. Doctors also give chemotherapy to help reduce pain and other problems caused by pancreatic cancer. It may be given alone, with radiation, or with surgery and radiation.

Chemotherapy is systemic therapy. The doctor usually gives the drugs by injection. Once in the bloodstream, the drugs travel throughout the body.

Usually chemotherapy is an outpatient treatment given at the hospital, clinic, doctor's office, or home. However, depending on which drugs are given and the patient's general health, the patient may need to stay in the hospital.

Patients may want to ask these questions about chemotherapy:
  • Why do I need this treatment?
  • What will it do?
  • What drugs will I be taking? How will they be given? Will I need to stay in the hospital?
  • Will the treatment cause side effects? What can I do about them?
  • How long will I be on this treatment?

Side Effects of Treatment for Pancreatic Cancer


Because cancer treatment may damage healthy cells and tissues, unwanted side effects are common. These side effects depend on many factors, including the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. The health care team will explain possible side effects and how they will help the patient manage them.

Surgery for pancreatic cancer is a major operation. Patients need to stay in the hospital for several days afterward. Patients may feel weak or tired. Most need to rest at home for about a month. The length of time it takes to regain strength varies.

The side effects of surgery depend on the extent of the operation, the person's general health, and other factors. Most patients have pain for the first few days after surgery. Pain can be controlled with medicine, and patients should discuss pain relief with the doctor or nurse.

Removal of part or all of the pancreas may make it hard for a patient to digest foods. The health care team can suggest a diet plan and medicines to help relieve diarrhea, pain, cramping, or feelings of fullness. During the recovery from surgery, the doctor will carefully monitor the patient's diet and weight. At first, a patient may have only liquids and may receive extra nourishment intravenously or by feeding tube into the intestine. Solid foods are added to the diet gradually.

Patients may not have enough pancreatic enzymes or hormones after surgery. Those who do not have enough insulin may develop diabetes. The doctor can give the patient insulin, other hormones, and enzymes.

Radiation therapy may cause patients to become very tired as treatment continues. Resting is important, but doctors usually advise patients to try to stay as active as they can. In addition, when patients receive radiation therapy, the skin in the treated area may sometimes become red, dry, and tender.

Radiation therapy to the abdomen may cause nausea, vomiting, diarrhea, or other problems with digestion. The health care team can offer medicine or suggest diet changes to control these problems. For most patients, the side effects of radiation therapy go away when treatment is over.

The side effects of chemotherapy depend mainly on the drugs and the doses the patient receives as well as how the drugs are given. In addition, as with other types of treatment, side effects vary from patient to patient.

Systemic chemotherapy affects rapidly dividing cells throughout the body, including blood cells. Blood cells fight infection, help the blood to clot, and carry oxygen to all parts of the body. When anticancer drugs damage healthy blood cells, patients are more likely to get infections, may bruise or bleed easily, and may have less energy. Cells in hair roots and cells that line the digestive tract also divide rapidly. As a result, patients may lose their hair and may have other side effects such as poor appetite, nausea and vomiting, diarrhea, or mouth sores. Usually, these side effects go away gradually during the recovery periods between treatments or after treatment is over. The health care team can suggest ways to relieve side effects.

What is the treatment for locally advanced unresectable pancreatic cancer?


If a pancreatic cancer is found when it has grown into important local structures but not yet spread to distant sites, this is described as locally advanced, unresectable pancreatic cancer (stage III). The standard of care in the United States for the treatment of locally advanced cancer is a combination of low-dose chemotherapy given simultaneously with radiation treatments to the pancreas and surrounding tissues. Radiation treatments are designed to lower the risk of local growth of the cancer, thereby minimizing the symptoms that local progression causes (back or belly pain, nausea, loss of appetite, intestinal blockage, jaundice). Radiation treatments are typically given Monday through Friday for about 5 weeks. Chemotherapy given concurrently (at the same time) may improve the effectiveness of the radiation and may lower the risk for cancer spread outside the area where the radiation is delivered. When the radiation is completed and the patient has recovered, more chemotherapy often is recommended. Recently, newer forms of radiation delivery (stereotactic radiosurgery, gamma knife radiation, cyber knife radiation) have been utilized in locally advanced pancreatic cancer with varying degrees of success, but these treatments can be more toxic and are, for now, largely experimental.


What is the treatment for metastatic pancreatic cancer?


Once a pancreatic cancer has spread beyond the vicinity of the pancreas and involves other organs, it has become a problem through the system. As a result, a systemic treatment is most appropriate and chemotherapy is recommended. Chemotherapy travels through the bloodstream and goes anywhere the blood flows and, as such, treats most of the body. It can attack a cancer that has spread through the body wherever it is found. In metastatic pancreatic cancer, chemotherapy is recommended for individuals well enough to receive it. It has been proven to both extend the lives of patients with pancreatic cancer and to improve their quality of life. These benefits are documented, but unfortunately the overall benefit from chemotherapy in pancreatic cancer treatment is modest and chemotherapy prolongs life for the average patient by only a few months. Chemotherapy options for patients with pancreatic cancer vary from treatment with a single chemotherapy agent to treatment with as many as three chemotherapies given together. The aggressiveness of the treatment is determined by the cancer doctor (medical oncologist) and by the overall health and strength of the individual patient.

Pain Control


Pain is a common problem for people with pancreatic cancer. The tumor can cause pain by pressing against nerves and other organs.

The patient's doctor or a specialist in pain control can relieve or reduce pain in several ways:

  • Pain medicine - Medicines often can relieve pain. (These medicines may make people drowsy and constipated, but resting and taking laxatives can help.)
  • Radiation - High-energy rays can help relieve pain by shrinking the tumor.
  • Nerve block - The doctor may inject alcohol into the area around certain nerves in the abdomen to block the feeling of pain.
  • Surgery -The surgeon may cut certain nerves to block pain.

The doctor may suggest other ways to relieve or reduce pain. For example, massage, acupuncture, or acupressure may be used along with other approaches to help relieve pain. Also, the patient may learn relaxation techniques such as listening to slow music or breathing slowly and comfortably.

Nutrition for people with pancreatic cancer


People with pancreatic cancer may not feel like eating, especially if they are uncomfortable or tired. Also, the side effects of treatment such as poor appetite, nausea, or vomiting can make eating difficult. Foods may taste different. Nevertheless, patients should try to get enough calories and protein to control weight loss, maintain strength, and promote healing. Also, eating well often helps people with cancer feel better and have more energy.

Careful planning and checkups are important. Cancer of the pancreas and its treatment may make it hard for patients to digest food and maintain the proper blood sugar level. The doctor will check the patient for weight loss, weakness, and lack of energy. Patients may need to take medicines to replace the enzymes and hormones made by the pancreas. The doctor will watch the patient closely and adjust the doses of these medicines.

The doctor, dietitian, or other health care provider can advise patients about ways to maintain a healthy diet.

Support for People with Pancreatic Cancer


Living with a serious disease such as pancreatic cancer is not easy. Some people find they need help coping with the emotional and practical aspects of their disease. Support groups can help. In these groups, patients or their family members get together to share what they have learned about coping with their disease and the effects of treatment. Patients may want to talk with a member of their health care team about finding a support group.

People living with pancreatic cancer may worry about the future. They may worry about caring for themselves or their families, keeping their jobs, or continuing daily activities. Concerns about treatments and managing side effects, hospital stays, and medical bills are also common. Doctors, nurses, and other members of the health care team can answer questions about treatment, diet, working, or other matters. Meeting with a social worker, counselor, or member of the clergy can be helpful to those who want to talk about their feelings or discuss their concerns. Often, a social worker can suggest resources for financial aid, transportation, home care, emotional support, or other services.