Pancreatic cancer is a disease in which malignant cells form in the tissues of the pancreas. The pancreas is a gland about 6 inches long that is shaped like a thin pear lying on its side. The wider end of the pancreas is called the head, the middle section is called the body, and the narrow end is called the tail. The pancreas lies behind the stomach and in front of the spine.

The pancreas has two main jobs in the body:

• To produce juices that help digest (break down) food.
   
• To produce hormones, such as insulin and glucagon, that help control blood sugar levels. Both of these hormones help the body use and store the energy it gets from food.
   
• The digestive juices are produced by exocrine pancreas cells and the hormones are produced by endocrine pancreas cells. About 95% of pancreatic cancers begin in exocrine cells.
   
• Smoking and health history can affect the risk of developing pancreatic cancer.

The following are possible risk factors for pancreatic cancer:

• Smoking.
   
• Long-standing diabetes.
   
• Chronic pancreatitis.
   
• Certain hereditary conditions, such as hereditary pancreatitis, multiple endocrine neoplasia type 1 syndrome, hereditary nonpolyposis colon cancer (HNPCC; Lynch syndrome), von Hippel-Lindau syndrome, ataxia-telangiectasia, and the familial atypical multiple mole melanoma syndrome (FAMMM).

Possible signs of pancreatic cancer include jaundice, pain, and weight loss.
These symptoms can be caused by pancreatic cancer or other conditions. A doctor should be consulted if any of the following problems occur:

Jaundice (yellowing of the skin and whites of the eyes).
Pain in the upper or middle abdomen and back.
Unexplained weight loss.
Loss of appetite.
Fatigue.
 

Pancreatic cancer is difficult to detect (find) and diagnose early. Pancreatic cancer is difficult to detect and diagnose for the following reasons:

• There aren’t any noticeable signs or symptoms in the early stages of pancreatic cancer.
   
• The signs of pancreatic cancer, when present, are like the signs of many other illnesses.
   
• The pancreas is hidden behind other organs such as the stomach, small intestine, liver, gallbladder, spleen, and bile ducts.

Tests that examine the pancreas are used to detect, diagnose and stage pancreatic cancer.
Pancreatic cancer is usually diagnosed with tests and procedures that produce pictures of the pancreas and the area around it. The process used to find out if cancer cells have spread within and around the pancreas is called staging. Tests and procedures to detect, diagnose, and stage pancreatic cancer are usually done at the same time. In order to plan the best treatment, it is important to know the stage of the disease and whether or not the pancreatic cancer can be removed by surgery. The following tests and procedures may be used:

Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.

Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.

CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. A spiral or helical CT scan takes detailed pictures of areas inside the body as it scans the body in a spiral path.

MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).

PET scan (positron emission tomography scan): A procedure to find malignant tumour cells in the body. A small amount of radionuclide glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumour cells show up brighter in the picture because they are more active and take up more glucose than normal cells.

Endoscopic ultrasound (EUS): A procedure in which an endoscope (a thin, lighted tube) is inserted into the body. The endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure is also called endosonography.

Laparoscopy: A surgical procedure to look at the organs inside the abdomen to check for abnormal areas. An incision (cut) is made in the abdominal wall and a laparoscope (a thin, lighted tube) is inserted into the abdomen. Tissue samples and lymph nodes may be removed for biopsy.

Endoscopic retrograde cholangiopancreatography (ERCP): A procedure used to x-ray the ducts (tubes) that carry bile from the liver to the gallbladder and from the gallbladder to the small intestine. Sometimes pancreatic cancer causes these ducts to narrow and block or slow the flow of bile, causing jaundice. An endoscope (a thin, lighted tube) is passed through the mouth, oesophagus, and stomach into the first part of the small intestine. A catheter (a smaller tube) is then inserted through the endoscope into the pancreatic ducts. A dye is injected through the catheter into the ducts and an x-ray is taken. If the ducts are blocked by a tumour, a fine tube may be inserted into the duct to unblock it. This tube (or stent) may be left in place to keep the duct open. Tissue samples may also be taken.

Percutaneous transhepatic cholangiography (PTC): A procedure used to x-ray the liver and bile ducts. A thin needle is inserted through the skin below the ribs and into the liver. Dye is injected into the liver or bile ducts and an x-ray is taken. If a blockage is found, a thin, flexible tube called a stent is sometimes left in the liver to drain bile into the small intestine or a collection bag outside the body. This test is done only if ERCP cannot be done.

Biopsy: The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. There are several ways to do a biopsy for pancreatic cancer. A fine needle may be inserted into the pancreas during an x-ray or ultrasound to remove cells. Tissue may also be removed during a laparoscopy (a surgical incision made in the wall of the abdomen).

Certain factors affect treatment options and prognosis (chance of recovery).
The treatment options and prognosis (chance of recovery) depend on the stage of the cancer (the size of the tumour and whether the cancer has spread outside the pancreas to nearby tissues or lymph nodes or to other places in the body) and the patient’s general health. Lymph nodes are small, bean-shaped structures found throughout the body. They filter substances in a fluid called lymph and help fight infection and disease.

Pancreatic cancer can be controlled only if it is found before it has spread, when it can be removed by surgery. If the cancer has spread, palliative treatment can improve the quality of life by controlling the symptoms and complications of this disease.

Tests and procedures to stage pancreatic cancer are usually done at the same time as diagnosis.

The following stages are used for pancreatic cancer:

Stage I

In stage I, cancer is found in the pancreas only. Stage I is divided into stage IA and stage IB, depending on where the cancer has spread.

• Stage IA: Cancer is found only in the pancreas and is 2 centimetres or less in size.
• Stage IB: Cancer is found only in the pancreas and is greater than 2 centimetres in size.

Stage II

In stage II, cancer may have spread to nearby tissue and organs, and may have spread to lymph nodes near the pancreas. Stage II is divided into stage IIA and stage IIB, depending on where the cancer has spread.

• Stage IIA: Cancer has spread to nearby tissue and organs but has not spread to nearby lymph nodes.
• Stage IIB: Cancer has spread to nearby lymph nodes and may have spread to nearby tissue and organs.

Stage III

In stage III, cancer has spread to the major blood vessels near the pancreas, such as the celiac axis (the junction where the celiac artery branches off from the aorta, just below the diaphragm) and the superior mesenteric vein (the vein that returns blood from the rectum and colon to the heart) and aorta, and may have spread to nearby lymph nodes.

Stage IV

In stage IV, cancer may be of any size and has spread to distant organs, such as the liver, lung, and peritoneal cavity (the body cavity that contains most of the organs in the abdomen (such as the lungs). It may have also spread to organs and tissues near the pancreas or to lymph nodes.

There are different types of treatment for patients with pancreatic cancer.

Different types of treatment are available for patients with pancreatic cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the “standard” treatment, the new treatment may become the standard treatment.

Three types of standard treatment are used:

Surgery

One of the following types of surgery may be used to take out the tumour:

• Whipple procedure: A surgical procedure in which the head of the pancreas, the gallbladder, part of the stomach, part of the small intestine, and the bile duct are removed. Enough of the pancreas is left to produce digestive juices and insulin.
• Total pancreatectomy: This operation removes the whole pancreas, part of the stomach, part of the small intestine, the common bile duct, the gallbladder, the spleen, and nearby lymph nodes.
• Distal pancreatectomy: The body and the tail of the pancreas and usually the spleen are removed.

If the cancer has spread and cannot be removed, the following types of palliative surgery may be done to relieve symptoms:

• Surgical biliary bypass: If cancer is blocking the small intestine and bile is building up in the gallbladder, a biliary bypass may be done. During this operation, the doctor will cut the gallbladder or bile duct and sew it to the small intestine to create a new pathway around the blocked area.
• Endoscopic stent placement: If the tumour is blocking the bile duct, surgery may be done to put in a stent (a thin tube) to drain bile that has built up in the area. The doctor may place the stent through a catheter that drains to the outside of the body or the stent may go around the blocked area and drain the bile into the small intestine.
• Gastric bypass: If the tumour is blocking the flow of food from the stomach, the stomach may be sewn directly to the small intestine so the patient can continue to eat normally.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly in the spinal column, a body cavity such as the abdomen, or an organ, the drugs mainly affect cancer cells in those areas. The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Other types of treatment are being tested in clinical trials.

Biologic therapy

Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defences against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

There are treatments for pain caused by pancreatic cancer.

Pain can occur when the tumour presses on nerves or other organs near the pancreas. When pain medicine is not enough, there are treatments that act on nerves in the abdomen to relieve the pain. The doctor may inject medicine into the area around affected nerves or may cut the nerves to block the feeling of pain. Radiation therapy with or without chemotherapy can also help relieve pain by shrinking the tumour.

Patients with pancreatic cancer have special nutritional needs.

Surgery to remove the pancreas may interfere with the production of pancreatic enzymes that help to digest food. As a result, patients may have problems digesting food and absorbing nutrients into the body. To prevent malnutrition, the doctor may prescribe medicines that replace these enzymes.

Treatment Options By Stage
Stage I Pancreatic Cancer
Treatment of stage I pancreatic cancer may include the following:

Surgery alone.
Surgery with chemotherapy and radiation therapy.
A clinical trial of surgery followed by radiation therapy with chemotherapy. Chemotherapy is given before, during, and after the radiation therapy.

Stage IIA Pancreatic Cancer
Treatment of stage IIA pancreatic cancer may include the following:

Surgery with or without chemotherapy and radiation therapy.
Radiation therapy with chemotherapy.
Palliative surgery to bypass blocked areas in ducts or the small intestine.
A clinical trial of surgery followed by radiation therapy with chemotherapy. Chemotherapy is given before, during, and after the radiation therapy.
A clinical trial of radiation therapy combined with chemotherapy and/or radiosensitizers (drugs that make cancer cells more sensitive to radiation so more tumor cells are killed), followed by surgery.
A clinical trial of chemotherapy.
A clinical trial of radiation therapy given during surgery or internal radiation therapy.

Stage IIB Pancreatic Cancer
Treatment of stage IIB pancreatic cancer may include the following:

Surgery with or without chemotherapy and radiation therapy.
Radiation therapy with chemotherapy.
Palliative surgery to bypass blocked areas in ducts or the small intestine.
A clinical trial of surgery followed by radiation therapy with chemotherapy. Chemotherapy is given before, during, and after the radiation therapy.
A clinical trial of radiation therapy combined with chemotherapy and/or radiosensitizers (drugs that make cancer cells more sensitive to radiation so more tumor cells are killed), followed by surgery.
A clinical trial of chemotherapy.
A clinical trial of radiation therapy given during surgery or internal radiation therapy.
Stage III Pancreatic Cancer
Treatment of stage III pancreatic cancer may include the following:

Surgery with or without chemotherapy and radiation therapy.
Radiation therapy with chemotherapy.
Palliative surgery or stent placement to bypass blocked areas in ducts or the small intestine.
A clinical trial of surgery followed by radiation therapy with chemotherapy. Chemotherapy is given before, during, and after the radiation therapy.
A clinical trial of radiation therapy combined with chemotherapy and/or radiosensitizers, followed by surgery.
A clinical trial of chemotherapy.
A clinical trial of radiation therapy given during surgery or internal radiation therapy.

Stage IV Pancreatic Cancer
Treatment of stage IV pancreatic cancer may include the following:

Chemotherapy.
Palliative treatments for pain, such as nerve blocks, and other supportive care.
Palliative surgery or stent placement to bypass blocked areas in ducts or the small intestine.
Clinical trials of chemotherapy or biological therapy.
Treatment Options for Recurrent Pancreatic Cancer
Treatment of recurrent pancreatic cancer may include the following:

Chemotherapy.
Palliative surgery to bypass blocked areas in ducts or the small intestine.
Palliative radiation therapy.
Other palliative medical care to reduce symptoms, such as nerve blocks to relieve pain.
Clinical trials of chemotherapy or biological therapy.

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