Pancreatic Cancer: A Deadly silent disease. 1

What is pancreatic cancer and its types?

Pancreatic cancer begins in the tissues of the pancreas — an organ in the abdomen that lies horizontally behind the lower part of the stomach. The pancreas releases enzymes that aid digestion and hormones that help manage blood sugar – that is why it is one of the handful of “mixed” organs of the body. The incidence of pancreatic cancer in India is 0.5–2.4 per 100,000 men and 0.2–1.8 per 100,000 women. Globally, it causes more than a quarter of a million deaths annually. It is the 13th most common cancer, the eighth most frequent cause of death from cancer.

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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, and 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.

Causes and Risk Factors

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The biggest risk factor is increasing age; being over the age of 60 puts an individual at greater risk.

Rarely, there can be familial or hereditary genetic syndromes arising from genetic mutations that run in families and put individuals at higher risk, such as BRCA-2 and, to a lesser extent, BRCA-1 gene mutations. 

What are pancreatic cancer symptoms and signs?

  • jaundice,
  • dark urine
  • itchy skin,
  • light-colored stools,
  • pain in the abdomen or the back,
  • poor appetite and weight loss
  • digestive problems (pale and/or greasy stools, nausea and vomiting),
  • blood clots
  • enlarged gallbladder.
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How is the diagnosis of pancreatic cancer made?

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Most screening tests consist of CT scans, ultrasounds, magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography , or endoscopic ultrasounds.

A physical examination (usually normal), blood tests, X-rays, and an ultrasound. If pancreatic cancer is present, the likelihood of an ultrasound revealing an abnormality in the pancreas is about 75%. If a problem is identified or suspected, frequently a computed tomography (CT) scan is performed as the next step in the evaluation. A pancreatic mass and the suspicion of pancreatic cancer is then raised and a biopsy is performed to yield a diagnosis.

Treatment:

Treatment for pancreatic cancer depends on the stage and location of the cancer as well as on your age, overall health and personal preferences. The first goal of pancreatic cancer treatment is to eliminate the cancer, when possible. When that isn’t an option, the focus may be on preventing the pancreatic cancer from growing or causing more harm. When pancreatic cancer is advanced and treatments aren’t likely to offer a benefit, your doctor will help to relieve symptoms and make you as comfortable as possible.

  1. Surgery

Surgery may be an option if your pancreatic cancer is confined to the pancreas. Operations used in people with pancreatic cancer include:

  • Surgery for tumors in the pancreatic head. If your pancreatic cancer is located in the head of the pancreas, you may consider an operation called a Whipple procedure (pancreatoduodenectomy).

The Whipple procedure involves removing the head of your pancreas, as well as a portion of your small intestine (duodenum), your gallbladder and part of your bile duct. Part of your stomach may be removed as well. Your surgeon reconnects the remaining parts of your pancreas, stomach and intestines to allow you to digest food.

Whipple surgery carries a risk of infection and bleeding. After the surgery, some people experience nausea and vomiting that can occur if the stomach has difficulty emptying (delayed gastric emptying).

Expect a long recovery after a Whipple procedure. You’ll spend several days in the hospital and then recover for several weeks at home.

  • Surgery for tumors in the pancreatic tail and body. Surgery to remove the tail of the pancreas or the tail and a small portion of the body is called distal pancreatectomy. Your surgeon may also remove your spleen.
    • Radiation therapy

Radiation therapy uses high-energy beams, such as X-rays, to destroy cancer cells. You may receive radiation treatments before or after cancer surgery, often in combination with chemotherapy. Or, your doctor may recommend a combination of radiation and chemotherapy treatments when your cancer can’t be treated surgically.

  • Chemotherapy

Chemotherapy uses drugs to help kill cancer cells. Chemotherapy can be injected into a vein or taken orally. You may receive only one chemotherapy drug, or you may receive a combination of chemotherapy drugs.Chemotherapy can also be combined with radiation therapy (chemoradiation). Chemoradiation is typically used to treat cancer that has spread beyond the pancreas, but only to nearby organs and not to distant regions of the body. This combination may also be used after surgery to reduce the risk that pancreatic cancer may recur.In people with advanced pancreatic cancer, chemotherapy may be used alone or it may be combined with targeted drug therapy.

  • Targeted therapy

Targeted therapy uses drugs that attack specific abnormalities within cancer cells. The targeted drug erlotinib (Tarceva) blocks chemicals that signal cancer cells to grow and divide. Erlotinib is usually combined with chemotherapy for use in people with advanced pancreatic cancer.

What is the treatment for resect able pancreatic cancer?

If a pancreatic cancer is found at an early stage (stage I and stage II) and is contained locally within or around the pancreas, surgery may be recommended (resect able pancreatic cancer). Surgery is the only potentially curative treatment for pancreatic cancer. The surgical procedure most commonly performed to remove a pancreatic cancer is a Whipple procedure (pancreatoduodenectomy).

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 (inoperable) pancreatic cancer (stage III). The standard of care 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 is often recommended.

What is the treatment for metastatic pancreatic cancer?

 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.

What are the side effects of pancreatic cancer treatment?

Side effects of treatment for pancreatic cancer vary depending on the type of treatment. For example, radiation treatment (which is a local treatment) side effects tend to accumulate throughout the course of radiation therapy and include fatigue, nausea, and diarrhea. Chemotherapy side effects depend on the type of chemotherapy given (less aggressive chemotherapy treatments typically cause fewer side effects whereas more aggressive combination regimens are more toxic) and can include fatigue , loss of appetite, change in taste, hairloss  (although not usually), and lowering of the immune system with risk for infections (immunosuppression). While these lists of side effects may seem worrisome, radiation doctors (radiation oncologists) and medical oncologists have much better supportive medications than they did in years past to control any nausea, pain, diarrhea, or immunosuppression related to treatment. The risks associated with pancreatic cancer treatment must be weighed against the inevitable and devastating risks associated with uncontrolled pancreatic cancer and, if the treatments control progression of the cancer, most patients feel better on treatment than they otherwise would.

Pancreatic cancer is not common in India, but it can be lethal

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KEY POINTS

  1. Pancreatic cancer typically spreads rapidly and is seldom detected in its early stages, which is a major reason why it’s a leading cause of cancer death.
  2. The first goal of pancreatic cancer treatment is to eliminate the cancer, when possible. When that isn’t an option, the focus may be on preventing the pancreatic cancer from growing or causing more harm.

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