Alex Trebeck. Steve Jobs. Ruth Bader Ginsburg. Patrick Swayze. All these famous personalities died of the same disease: pancreatic cancer.
This malignancy is steadily increasing in incidence and is currently the third leading cause of cancer-related death in the United States (behind lung and colon cancer), with projections to become the second leading cause by 2030.
This year, an estimated 62,210 Americans will be diagnosed and an equally grim 49,830 will die from the disease. Kentucky’s age-adjusted pancreatic cancer incidence rate is slightly higher than the national average.
Despite these unfavorable statistics, overall patient survival has improved and doubled over the past two decades. For all stages, the 5-year survival rate is 11%, and for local disease in which patients receive a multimodal therapy of surgery and chemotherapy, the 5-year survival rate is 42%. The majority of this progress is attributed to improving the effectiveness of systemic chemotherapy options, particularly in converting patients into candidates for surgery with curative intent.
Dr. Brent Xia
Although being diagnosed with pancreatic cancer as a patient or becoming a caregiver for someone newly diagnosed may seem like a death sentence, there are treatment options available, particularly if the disease is detected at an early stage. with a more favorable prognosis and the possibility of treatment.
• What are the risk factors for pancreatic cancer?
The use of tobacco products, obesity and diabetes are modifiable factors that remain the most important risk factors for developing the disease compared to the general population. Some risk factors, such as age (>60% in patients aged 65 years and over) and family history or genetic predisposition to pancreatitis cannot be changed. The majority of patients have no family history, but 5-10% may be linked to inherited mutations, such as BRCA1 or BRCA2 (hereditary breast and ovarian cancer syndrome), PALB2 (hereditary cancer of the breast), p16/CDKN2A (atypical familial multiple mole melanoma), PRSS1 (familial pancreatitis) or mismatch repair mutations (Lynch syndrome).
• What are the symptoms of pancreatic cancer?
Symptoms can vary from abdominal/back pain, weight loss, onset of new diabetes or insulin requirements in a patient who already has diabetes, to nausea and early satiety. If the cancer grows large enough to push on nearby structures, patients may experience obstructive jaundice which is accompanied by a constellation of symptoms such as dark urine, clear or greasy stools (steatorrhea) and itchy skin (pruritus) . By the time a patient shows symptoms, the tumor has most likely been present for several years. The transition from a benign cell to a malignant mass takes years.
• Is there screening available to detect pancreatic cancer early?
Currently, there are no general population-level screening guidelines, such as those available for colon cancer or breast cancer. However, individualized screening protocols are available for high-risk individuals with familial syndromes that predispose to a higher likelihood of developing the disease. A discussion with a genetic counselor can help determine which individuals will benefit most from screening with radiological imaging modalities.
• How often is pancreatic cancer detected at an early stage?
Only 20% of patients at the time of diagnosis have early resectable disease (capable of being removed by surgery). Another 20% have borderline resectability – disease that can be resected but leaves an increased chance of a positive margin (tumor left behind). The remaining cases are locally advanced unresectable or metastatic. The determination of resectability is based on the relationship of the tumor to nearby critical vasculature – the veins and arteries that are necessary to maintain organ perfusion and gastrointestinal function.
• Does treatment differ by stage?
Previously, initial surgery was recommended for early resectable pancreatic cancers, followed by six months of adjuvant chemotherapy (after surgery). The problem with this paradigm is that 50% of patients do not complete the recommended dose of chemotherapy due to post-surgery complications, delayed initiation of adjuvant therapy, or prolonged post-surgery recovery.
Recently, another acceptable option is neoadjuvant chemotherapy (before surgery), followed by surgery if there is no evidence of metastatic disease on repeat imaging. This has gained popularity because it allows time and tumor biology to be tested. Pancreatic cancer is a systemic disease, and a patient whose tumor progresses or metastasizes during chemotherapy would not have benefited from initial surgery and would have been spared the potential morbidity and mortality of major surgery.
Resectable borderline cancers benefit from neoadjuvant treatment. Tumor involvement of the major vasculature nearby – portal or superior mesenteric veins – is not a contraindication to curative resection after systemic treatment, as these can be resected and reconstructed.
Locally advanced unresectable cancers and metastatic disease are treated with systemic therapy only, with the role of palliative radiotherapy defined on an individual basis.
• Who treats pancreatic cancer?
Due to its aggressive nature, multimodal therapy is required. Pancreatic cancer is treated in a multidisciplinary manner by many collaborating providers – surgical oncologists, medical oncologists, radiation oncologists, gastroenterologists, genetic counselors, nurse navigators, radiologists and interventional radiologists, and pathologists. Discussions are held during the tumor board conference in order to obtain a consensual opinion on the sequencing of the treatment, because no two patients and tumors are identical.
Patients whose survival is optimal benefit from the combination of chemotherapy and surgery, with the involvement of radiotherapy on a case-by-case basis. This multi-pronged approach is superior to chemotherapy or surgery alone in terms of disease-free and overall survival.
• Is there a role for precision medicine in pancreatic cancer?
About 5% of pancreatic cancers harbor a genetic mutation that can be targeted by specific therapies. Immunotherapies may be appropriate in certain situations based on genetic mutations. The role of immunotherapy is limited compared to other cancers such as melanoma due to differences in tumor biology. Currently, national guidelines recommend that all patients undergo genetic testing and meet with a genetic counselor.
• What are some great resources that patients and caregivers can use?
There are many resources on the Internet, but not all of them are reliable or go through a rigorous verification process. The National Comprehensive Cancer Network (NCCN) is a trusted resource for providers, patients, and caregivers. Their website has a patient-caregiver section with guidelines as well as webinars and advocacy/support. Additional local resources include the Greater Cincinnati/Northern Kentucky Cancer Support Communitya national non-profit organization with local chapters that provides free counseling, support groups, resources and courses/programs for patients and caregivers.
A common misconception is that there is no role for holistic medicine or that it works against conventional medicine. Integrative oncology is a patient-centered, evidence-based specialty that addresses holistic aspects in partnership with conventional treatments. Another common misunderstanding is the confusion between palliation and hospice. Palliative care is an important specialty that focuses on improving the quality of life for patients and their families throughout the cancer treatment journey, by addressing the symptoms of the disease as well as the adverse effects of treatment. Patients receiving palliative care can still receive treatment with curative intent.
Although a diagnosis of pancreatic cancer is understandably overwhelming for patients and their families, they are not alone in the fight and are surrounded by a multidisciplinary team of providers as well as community awareness and support programs. Because of its aggressive biology, to fight effectively against the disease and increase the chances of long-term survival, a multimodal approach, over several months, is necessary. The course of care is equivalent to a marathon. To support this mentally and physically, staying informed is an essential part of preparation and allows for more meaningful discussions during cancer care visits.
Dr. Brent Xia, MD, is a Surgical Oncologist – Gastrointestinal and Hepato-Pancreato-Biliary – at St. Elizabeth Cancer Center. He graduated from Thomas Jefferson Medical College in Philadelphia and completed his general surgery residency at the University of Cincinnati. He received a Fellowship in Complex General Surgical Oncology at the Moffitt Cancer Center in Tampa, Florida.
