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Cancer Types

Pancreatic Cancer

Pancreatic Cancer Facts

What is Pancreatic Cancer?

What is Pancreatic Cancer?

The pancreas is a pear-shaped gland located in the abdomen between the stomach and the spine. It is about 6 inches in length and it makes hormones and enzymes that help the body digest and break down food. One of the hormones the pancreas produces is insulin, which is an important substance that helps control the amount of sugar in the blood.

Pancreatic cancer is a disease in which normal cells in the pancreas malfunction and begin to grow out of control. If not treated or removed, these cancerous cells will eventually form a growth or tumor, which can interfere with proper functioning of the pancreas and spread to cause cancer in other parts of the body.

The enzymes produced by the pancreas are released into ducts, which lead to the common bile duct and then into the small intestine. It is in these ducts that most pancreatic cancers begin and this type of cancer is referred to as pancreatic cancer or carcinoma of the pancreas. Most of the cancers that occur in these cells are called adenocarcinomas. Other cancers that occur in these cells are adenosquamous carcinomas, squamous cell carcinomas, and giant cell carcinomas.

In some cases, cancer will begin in the cells of the pancreas that produce insulin and other hormones. This is referred to as islet cell cancer. Tumors that are not cancerous also occur in these cells and they are known collectively as neuroendocrine tumors, or more specifically, islet cell tumors.

However, most cases of pancreatic cancer are not detected until the cancer has metastasized or spread beyond the pancreas to other areas of the body, such as the liver, the lungs or the peritoneum, which is the tissue lining the abdomen. At this stage, pancreatic cancer can be very difficult to treat because medications and surgical procedures are not very effective at stopping the cancer once it has spread beyond the pancreas.

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.


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

Cancers of the exocrine pancreas are a very serious health issue in the United States where approximately 27,000 patients are diagnosed annually with pancreatic cancer while about the same number die annually from this disease. Due to difficulties in diagnosis, the intrinsic aggressive nature of pancreatic cancers, and the sparse systemic treatment options available, only approximately 4% of patients diagnosed with pancreatic adenocarcinoma will be alive five years after diagnosis. Pancreatic cancer is the fifth leading cause of cancer deaths following breast cancer; lung cancer, colon cancer, and prostate cancer. Because of the extremely poor prognosis for the majority of individuals with pancreatic cancer, it is very important that patients be offered the opportunity to participate in clinical trials. If you or someone you love has been diagnosed with pancreatic cancer, speak with your physician regarding any trials in which you or your loved one may be eligible to participate.

Risk Factors

The risk of developing cancer of the pancreas is usually low before the age of 40, but the risk subsequently increases sharply, with most people diagnosed between their sixties and eighties. Risk factors for the development of this disease include environmental factors, medical/surgical factors, genetic factors, and occupational exposures.

The presence of a risk factor does not necessarily mean that an individual will develop cancer, nor does the absence of risk factors mean that an individual will not develop cancer. Some risk factors for developing pancreatic cancer are:

Age: The incidence of pancreatic cancer is relatively low in individuals up to age 50, after which it increases significantly. The age group 65 - 79 has the highest incidence of cancer of the pancreas.

Smoking: Smokers develop pancreatic cancer more than twice as often as nonsmokers.

Diet: Frequency of pancreatic cancer may be associated with high intakes of meat and fat.

Medical factors: Pancreatic cancer is more common among individuals with histories of the following conditions: cirrhosis (a chronic liver disease), chronic pancreatitis, diabetes and a history of surgery to the upper digestive tract.

Environmental factors: Long-term exposure to certain chemicals, such as gasoline and related compounds, as well as certain insecticides, may increase the risk of developing cancer of the pancreas.

Genetic predisposition: Possibly 3% of cases of pancreatic cancer are related to genetic disorders.


Am I at Risk For Pancreatic Cancer?

The incidence of pancreatic cancer is highest between 60 and 80 years of age, and is only rarely seen in people under 40. It is seen about equally in men and women, although the rates in women have risen in recent years, which may be due to higher rates of smoking in women. Cigarette smokers are two to three times more likely to develop pancreatic cancer. It is slightly more common in blacks and members of the Jewish community. It is seen more commonly in people who have diabetes, but this link is not yet well understood. Certain occupational exposures are thought to put a person at higher risk. These include chemists, coal, gas, and metal industry workers, and industries where pesticides are used more frequently. A person's risk triples if their mother, father, or siblings have had the disease. A family history of breast or colon cancer also increases risk. This increased risk is due to inherited mutations in cancer causing genes (changes that allow cancer to develop). The actual cause of this disease is not known, but is thought to be a result of a combination of inherited genetic changes and changes caused by environmental exposures.

What to Look For

The diagnosis of pancreatic cancer is usually delayed because symptoms are nonspecific. Jaundice, which causes yellowing of the skin, is present in approximately 50% of patients at the time of diagnosis and may be associated with less-advanced disease. Other symptoms include weight loss, fatigue, discomfort in the abdomen, loss of appetite, and glucose intolerance.

In addition, the patient may experience pain in the abdomen and back. The pancreas may produce too much insulin, causing such symptoms as dizziness, weakness, diarrhea, chills, or muscle spasms.

The patient may not even notice the gradual onset of these relatively nonspecific symptoms. The doctor may interpret them as being caused by something else.

If a physician suspects pancreatic cancer, the first step is to evaluate the patient with a series of tests. Imaging tests produce a picture of a patient's organs and tissues. If an abnormality is noted and the patient appears to have resectable disease (see the Staging section) surgery is often the next step. Additional tests which may be of benefit in the work-up include the tumor marker CA 19-9 (cancer antigen).

Tests

To diagnose pancreatic cancer, the doctor does a complete physical exam and asks about the patient's personal and family medical history. In addition to checking general signs of health (temperature, pulse, blood pressure, and so on), the doctor usually orders blood, urine, and stool tests. The doctor may also ask for a "barium swallow," or "upper GI series." For this test, the patient drinks a barium solution before x-rays of the upper digestive system are taken. The barium shows an outline of the pancreas on the x-rays.

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 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 makes a series of very detailed pictures of areas inside the body using an x-ray machine that 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 tumor 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 tumor 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 signs of disease. Small incisions (cuts) are made in the wall of the abdomen and a laparoscope (a thin, lighted tube) is inserted into one of the incisions. Other instruments may be inserted through the same or other incisions to perform procedures such as removing organs or taking tissue samples 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, esophagus, 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 tumor, 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).

Stages

When the physicians talk about staging, they are referring to determining the size of the tumor and if it has spread or not. This information is then used to determine the best treatment. In the case of pancreatic cancer, the size of the tumor and if it involves important blood vessels determines if it can be surgically removed. Pancreatic cancer is staged on the TNM system (also called tumor - node - metastasis system). This describes the size of the tumor (T), if the lymph nodes are involved (N), and if it has spread to other areas of the body (M).

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 I-A and Stage I-B, based on the size of the tumor.

Stage IA: The tumor is 2 centimeters or smaller

Stage IB: The tumor is larger than 2 centimeters

– 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 II-A and Stage II-B, based on where the cancer has spread.

Stage II-A:Cancer has spread to nearby tissue and organs but has not spread to nearby lymph nodes.

Stage II-B: 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 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. It may have also spread to organs and tissues near the pancreas or to lymph nodes.

Types of Treatment

The prognosis (chance of recovery) and treatment options depend on the following:
  • Whether or not the tumor can be removed by surgery.
  • The stage of the cancer (the size of the tumor and whether the cancer has spread outside the pancreas to nearby tissues or lymph nodes or to other places in the body).
  • The patient’s general health.
  • Whether the cancer has just been diagnosed or has recurred (come back).

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 patient's quality of life by controlling the symptoms and complications of this disease.

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.


Types of standard treatment used are:

– Surgery

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

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 tumor 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 tumor 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 into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Treatment of Pain

In pancreatic cancer, as well as in other cancers, the growth of tumors can result in abnormal levels of pressure on nerves. Therefore, pain is a major concern for patients. Cancer treatments can result in pain reduction when the reduction of the tumor relieves pressure on the nerves.

The doctor can prescribe pain-relief medications, which can be successful singly or in combination. The most common side effects of pain medications are fatigue and constipation. Rest and laxatives can moderate these side effects.

In cases where pain medication alone is not enough to make the patient comfortable, the treatment team may decide on treatments that affect the nerves directly. These include alcohol injection in a nerve to inhibit pain response and surgically severing nerves to prevent transmission of pain impulses.

Follow-up Treatment

In pancreatic cancer cases, it is essential that the patient receive effective follow-up care. Regular examinations are necessary to determine whether the cancer has returned or has advanced.

Many of the same methods used to diagnose the cancer may be used to evaluate the patient's recovery. These may include CAT scans, MRI tests, and X-rays, among others.

In addition, the treatment team will need to monitor the patient's hormone replacement therapy or other ongoing treatments.

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
  • A clinical trial of surgery followed by chemotherapy

Stage II-A Pancreatic Cancer

Treatment of Stage II-A 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 surgery followed by chemotherapy
  • A clinical trial of biologic therapy with radiation therapy and/or chemotherapy
  • 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

Stage II-B Pancreatic Cancer

Treatment of Stage II-B 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 surgery followed by chemotherapy
  • A clinical trial of biologic therapy with radiation therapy and/or chemotherapy
  • A clinical trial of radiation therapy combined with chemotherapy and/or radiosensitizers, followed by surgery
  • 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 surgery followed by chemotherapy
  • A clinical trial of biologic therapy with radiation therapy and/or chemotherapy
  • A clinical trial of radiation therapy combined with chemotherapy and/or radiosensitizers, which may be followed by surgery
  • 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 biologic therapy

Pancreatic Cancer Risk Factors

The risk of developing cancer of the pancreas is usually low before the age of 40, but the risk subsequently increases sharply, with most people diagnosed between their sixties and eighties. Risk factors for the development of this disease include environmental factors, medical/surgical factors, genetic factors, and occupational exposures.

The presence of a risk factor does not necessarily mean that an individual will develop cancer, nor does the absence of risk factors mean that an individual will not develop cancer. Some risk factors for developing pancreatic cancer are:

Age: The incidence of pancreatic cancer is relatively low in individuals up to age 50, after which it increases significantly. The age group 65 - 79 has the highest incidence of cancer of the pancreas.

Smoking: Smokers develop pancreatic cancer more than twice as often as nonsmokers.

Diet: Frequency of pancreatic cancer may be associated with high intakes of meat and fat.

Medical factors: Pancreatic cancer is more common among individuals with histories of the following conditions: cirrhosis (a chronic liver disease), chronic pancreatitis, diabetes and a history of surgery to the upper digestive tract.

Environmental factors: Long-term exposure to certain chemicals, such as gasoline and related compounds, as well as certain insecticides, may increase the risk of developing cancer of the pancreas.

Genetic predisposition: Possibly 3% of cases of pancreatic cancer are related to genetic disorders.


Am I at Risk For Pancreatic Cancer?

The incidence of pancreatic cancer is highest between 60 and 80 years of age, and is only rarely seen in people under 40. It is seen about equally in men and women, although the rates in women have risen in recent years, which may be due to higher rates of smoking in women. Cigarette smokers are two to three times more likely to develop pancreatic cancer. It is slightly more common in blacks and members of the Jewish community. It is seen more commonly in people who have diabetes, but this link is not yet well understood. Certain occupational exposures are thought to put a person at higher risk. These include chemists, coal, gas, and metal industry workers, and industries where pesticides are used more frequently. A person's risk triples if their mother, father, or siblings have had the disease. A family history of breast or colon cancer also increases risk. This increased risk is due to inherited mutations in cancer causing genes (changes that allow cancer to develop). The actual cause of this disease is not known, but is thought to be a result of a combination of inherited genetic changes and changes caused by environmental exposures.

What to Look for

The diagnosis of pancreatic cancer is usually delayed because symptoms are nonspecific. Jaundice, which causes yellowing of the skin, is present in approximately 50% of patients at the time of diagnosis and may be associated with less-advanced disease. Other symptoms include weight loss, fatigue, discomfort in the abdomen, loss of appetite, and glucose intolerance.

In addition, the patient may experience pain in the abdomen and back. The pancreas may produce too much insulin, causing such symptoms as dizziness, weakness, diarrhea, chills, or muscle spasms.

The patient may not even notice the gradual onset of these relatively nonspecific symptoms. The doctor may interpret them as being caused by something else.

If a physician suspects pancreatic cancer, the first step is to evaluate the patient with a series of tests. Imaging tests produce a picture of a patient's organs and tissues. If an abnormality is noted and the patient appears to have resectable disease (see the Staging section) surgery is often the next step. Additional tests which may be of benefit in the work-up include the tumor marker CA 19-9 (cancer antigen).

Pancreatic Cancer Tests

To diagnose pancreatic cancer, the doctor does a complete physical exam and asks about the patient's personal and family medical history. In addition to checking general signs of health (temperature, pulse, blood pressure, and so on), the doctor usually orders blood, urine, and stool tests. The doctor may also ask for a "barium swallow," or "upper GI series." For this test, the patient drinks a barium solution before x-rays of the upper digestive system are taken. The barium shows an outline of the pancreas on the x-rays.

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 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 makes a series of very detailed pictures of areas inside the body using an x-ray machine that 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 tumor 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 tumor 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 signs of disease. Small incisions (cuts) are made in the wall of the abdomen and a laparoscope (a thin, lighted tube) is inserted into one of the incisions. Other instruments may be inserted through the same or other incisions to perform procedures such as removing organs or taking tissue samples 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, esophagus, 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 tumor, 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).

Stages of Pancreatic Cancer

When the physicians talk about staging, they are referring to determining the size of the tumor and if it has spread or not. This information is then used to determine the best treatment. In the case of pancreatic cancer, the size of the tumor and if it involves important blood vessels determines if it can be surgically removed. Pancreatic cancer is staged on the TNM system (also called tumor - node - metastasis system). This describes the size of the tumor (T), if the lymph nodes are involved (N), and if it has spread to other areas of the body (M).

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 I-A and Stage I-B, based on the size of the tumor.

Stage IA: The tumor is 2 centimeters or smaller

Stage IB: The tumor is larger than 2 centimeters

– 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 II-A and Stage II-B, based on where the cancer has spread.

Stage II-A:Cancer has spread to nearby tissue and organs but has not spread to nearby lymph nodes.

Stage II-B: 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 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. It may have also spread to organs and tissues near the pancreas or to lymph nodes.

Types of Treatment for Pancreatic Cancer

The prognosis (chance of recovery) and treatment options depend on the following:
  • Whether or not the tumor can be removed by surgery.
  • The stage of the cancer (the size of the tumor and whether the cancer has spread outside the pancreas to nearby tissues or lymph nodes or to other places in the body).
  • The patient’s general health.
  • Whether the cancer has just been diagnosed or has recurred (come back).

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 patient's quality of life by controlling the symptoms and complications of this disease.

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.


Types of standard treatment used are:

– Surgery

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

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 tumor 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 tumor 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 into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Treatment of Pain

In pancreatic cancer, as well as in other cancers, the growth of tumors can result in abnormal levels of pressure on nerves. Therefore, pain is a major concern for patients. Cancer treatments can result in pain reduction when the reduction of the tumor relieves pressure on the nerves.

The doctor can prescribe pain-relief medications, which can be successful singly or in combination. The most common side effects of pain medications are fatigue and constipation. Rest and laxatives can moderate these side effects.

In cases where pain medication alone is not enough to make the patient comfortable, the treatment team may decide on treatments that affect the nerves directly. These include alcohol injection in a nerve to inhibit pain response and surgically severing nerves to prevent transmission of pain impulses.

Follow-up Treatment

In pancreatic cancer cases, it is essential that the patient receive effective follow-up care. Regular examinations are necessary to determine whether the cancer has returned or has advanced.

Many of the same methods used to diagnose the cancer may be used to evaluate the patient's recovery. These may include CAT scans, MRI tests, and X-rays, among others.

In addition, the treatment team will need to monitor the patient's hormone replacement therapy or other ongoing treatments.

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
  • A clinical trial of surgery followed by chemotherapy

Stage II-A Pancreatic Cancer

Treatment of Stage II-A 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 surgery followed by chemotherapy
  • A clinical trial of biologic therapy with radiation therapy and/or chemotherapy
  • 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

Stage II-B Pancreatic Cancer

Treatment of Stage II-B 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 surgery followed by chemotherapy
  • A clinical trial of biologic therapy with radiation therapy and/or chemotherapy
  • A clinical trial of radiation therapy combined with chemotherapy and/or radiosensitizers, followed by surgery
  • 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 surgery followed by chemotherapy
  • A clinical trial of biologic therapy with radiation therapy and/or chemotherapy
  • A clinical trial of radiation therapy combined with chemotherapy and/or radiosensitizers, which may be followed by surgery
  • 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 biologic therapy

Side Effects of Pancreatic Cancer

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