Pancreatic (Pancreas) Cancer Symptoms and Treatment Alternatives

Every year some 34,200 people die from pancreatic cancer, making it the fourth leading cause of cancer death in the United States.

What is the Pancreas?

The pancreas is a glandular organ in the digestive and endocrine system which is responsible for producing many important hormones such as insulin, Somatostatin (growth hormone inhibiting hormone) and Glucagen (important for carbohydrate metabolism).

As an exocrine gland (secretes hormones into ducts), the pancreas excretes juices which contain digestive proteins that pass into portions of the small intestine and breakdown carbohydrates, fats and proteins in the chyme (half-digested food).

What is Pancreatic Cancer?

The endocrine and exocrine glands of the pancreas form different types of tumors:
 

Exocrine tumors

The most common type of pancreatic cancer.  Cystadenomas are benign (non-cancerous) cysts and tumors, however, most types of exocrine tumors are cancerous.  Around 95% of the cancer of the exocrine gland in the pancreas are cancerous.  Cancers which develop from the cells that release pancreatic enzymes are called acinar cell carcinomas.  The less common forms of ductal cancers of the exocrine pancreas include the following; adenosquamous carcinomas, squamous cell carcinomas and giant cell carcinomas.  The type of cancer presenting can only be distinguished by examination under a microscope.  A less common form of cancer in the pancreas is called ampullary cancer or cancer of the ampulla of Vater.  The location where the bile duct and pancreatic duct joins, and empties into the duodenum is called the ampulla of Vater.  

Endocrine tumors

While uncommon, tumors of the endocrine gland can happen.  Tumors of the endocrine gland as a group are called neuroendocrine tumors or islet cell tumors.  There are several subtypes of islet cell tumors and each is named according to the type of hormone cell from which it originates.  This includes the following:

• Insulinomas: originate in insulin making cells
• Glucagonomas: come from cells that make glucagon
• Gastrinomas: happen in cells that manufacture gastrin
• Somatostatinomas:  occur in cells that make Somatostatin
• VIPomas:  occur from cells that produce vasoactive intestinal peptides (VIP)

Endocrine tumors are referred to as “functioning,” if they make hormones, and “non-functioning” if they do not.  For the most part, functioning islet cell tumors are usually benign, while non-functioning tumors are likely to be malignant.  Malignant pancreatic endocrine tumors are called islet cell cancers or islet cell carcinomas. 

What are the Risk Factors Associated with Pancreatic Cancer?

Each type of cancer has its own risk factors, which means a person has an increased risk of getting the disease.  Researches have determined that there are many risk factors associated with a persons chance of developing pancreatic cancer, which include the following:

• Age increases a persons likelihood of developing pancreatic cancer.  Most patients diagnosed are around the age of 45, 90% are over the age of 50 and 70% are older than 70 years old.  The median age for diagnosis is 72 years old.
• Males are more likely to develop pancreatic cancer than females, this may be a result of males having higher rates of tobacco use.
• African Americans are more prone to developing pancreatic cancer than Caucasians.  The reasons for the increase of risk factors in race are unknown, but researchers speculate it could be because of higher rates of tobacco use and diabetes in males and  the  higher obesity rate among females.
• People who smoke cigarettes are 2-3 times more likely to develop pancreatic cancer, and scientists attribute this to the cancer-causing chemicals found in cigarettes.  Around 20-30% of pancreatic cancer diagnosed are believed to be caused directly by cigarette smoking. 
• Obese people are more likely to develop pancreatic cancer and the increased risk is also associated with people who do not get enough exercise.
• The risk of pancreatic cancer increases in people with diabetes, however, the reason is unknown.  The risk factors increase with people who have type II diabetes, in some cases pancreatic cancer can actually cause people to get diabetes.
• People who have cirrhosis (scarring of the liver due to drinking or hepatitis) have a higher risk of developing pancreatic cancer.
• Pancreatic cancer does have the propensity to run in families, some people at high risk have what is called genetic syndromes (caused by abnormality of the genes or chromosomes), in some cases the gene which causes the increased risk is unknown.
• Having chronic stomach infections caused by Helicobacter pylori (H. pylori) also increases the risk of developing pancreatic cancer.  It is thought that the increase of stomach acid is the culprit.
• Some scientific studies have found a definitive link between a diet high in fat and an increased risk of pancreatic cancer.  On the other end of the spectrum, diets higher in fruits and vegetables seem to lower the risk factors for pancreatic cancer.  Ongoing research is being done to find the exact role that diet plays in relation to pancreatic cancer.
• Occupational exposure to certain types of pesticides, chemicals and dyes used in metal refineries has been associated with an increased risk of developing pancreatic cancer.
• Heavy alcohol use can raise the risk of developing diabetes and chronic pancreatitis, which are  factors that relate directly to the development of pancreatic cancer.

What Causes Pancreatic Cancer?

While scientists have not identified the exact cause of pancreatic cancer, several risk factors have been discovered, and these factors increase the chance of a person developing the disease. Recent scientific research has uncovered some of the risk factors involved can affect the deoxyribonucleic acid (DNA)  in pancreatic cells which in turn causes abnormal cellular growth and results in tumors.

Science has also discovered several cancer family syndromes in inherited DNA, which puts a person at higher risk.  Most commonly, DNA mutations of tumor suppressor genes related to the formation of pancreatic cancer occur after birth, not because of something inherited.

How is Pancreatic Cancer Diagnosed?

If one or more of the signs or symptoms described in the following list are present, there are certain medical tests and examinations that can be performed to determine whether or not pancreatic cancer is the cause.

Signs and symptoms include:

• Jaundice, yellowing of the skin and in the whites of the eyes, presents in at least half of all cases of pancreatic cancer and in all cases of ampullary cancer.
• Pain in the abdomen or back, this is common in cases of advanced pancreatic cancer. 
• Unintentional or unexplained weight loss, poor appetite and fatigue are common in people with pancreatic cancer.
• If pancreatic juice is blocked from getting released into the intestines, it will inhibit the body's ability to digest fatty foods, this could signal a tumor within the pancreas.  The undigested fats will cause stools to be greasy, bulky, pale and watery.  If the cancer is wrapped around the end of the stomach and cause a partial blockage which can lead to nausea, vomiting and pain after eating.
• When cancer is blocking the bile duct, it can lead to a buildup in the gallbladder and cause it to become enlarged.  During a physical examination a doctor might feel the enlargement and it may also be detected during an imaging test.
• A blood clot or fatty tissue abnormality is oftentimes the first clue of pancreatic cancer. Another sign of pancreatic cancer might be an uneven texture in the fatty tissue under the skin, this is a result of the release of pancreatic enzymes that digest fat.
• Because exocrine cancers destroy the cells that make insulin, diabetes can develop.  This can be detected by using certain blood tests.

When examining a patient who possibly has pancreatic cancer, a physician will take a thorough medical history to check for certain risk factors, find out how long the pain has been present, ask questions about appetite, weight loss, fatigue and other symptoms.

A complete physical exam will involve manually manipulating the abdomen to check for swelling, tenderness and any masses.  The physician will check the skin and eyes for signs of jaundice and the gallbladder for enlargement.  If the cancer has spread to the liver, causing it to enlarge, this can also be felt during manipulation of the abdomen.  Lymph nodes above the collarbone and other areas will also be checked to indicate whether or not the cancer has spread.

A computed tomography scan (CT), is an x-ray that produces a detailed cross-sectional image of the  body.  Unlike an x-ray which takes only one picture, a CT scan takes several pictures as it rotates around the body.  A computer will then combine the pictures into images that resemble “slices” of the portion of the body that is being studied.

CT scans are a useful tool for detecting and diagnosing pancreatic cancer and can also assist in staging the cancer.  A CT scan will show the pancreas clearly and confirm the location of the cancer, also shown are the organs around the pancreas, as well as the lymph nodes.  A scan can help determine what type of treatment option would work best.

Magnetic resonance imaging (MRI) uses magnets and strong radio waves to make pictures of the body.  Generally, a CT scan is more preferred over an MRI when looking at the pancreas, but at times an MRI may yield more information.

Positron emission tomography (PET) scan is a procedure that involves giving the patient a glucose (form of sugar) injection which releases a radioactive atom into the bloodstream.  Because cancer cells grow rapidly, they absorb more of the glucose than a normal cell.  A PET scan is a useful test to check if cancer has spread into the lymph nodes, the test is also good for allowing a physician to find out if cancer has spread to other parts of the body.

When a PET and CT scan are combined, it is even easier to pinpoint the location of a tumor.  The test is useful for locating cancer that might have spread to another part of the body and may not be treatable with surgery.  A combined scan can also be used to stage the cancer and may be able to spot early forms of cancer in the body.

Ultrasonography (US) utilizes sound waves to produce a picture of internal organs such as the pancreas.  A wand probe, called a transducer is placed over the abdomen and it emits sound waves and detects the echo produced as the sound waves bounce off internal organs.  The pattern of echoes is processed by a computer to produce an image, the echoes made by tumors of the pancreas are different from those of normal tissue of the pancreas.

An endoscopic ultrasound is done under sedation (medicine to make the patient drowsy),and is more accurate than one done on the abdomen, making it a better way to diagnose pancreatic cancer.  The test is performed using an ultrasound probe attached to the end of an endoscope, which is a lighted, thin, flexible tube with fiber optics.  A physician will use the probe to enter through the patients mouth or nose, and view the inside of the intestines.  An endoscopic ultrasound is a good way to peer inside the pancreas and is better than a CT scan for spotting smaller tumors and if one is seen, it can be biopsied during the procedure.

Endoscopic retrograde cholangiopancreatography (ERCP) uses an endoscope which is passed down the throat, through the esophagus and stomach, into the upper portion of the small intestine.  A physician can then see through the endoscope to locate the ampulla of Vater (where the bile duct connects to the small intestine).  A catheter (small, flexible tube) is then threaded into the bile duct and a small amount of dye is injected and x-rays are taken.  The dye helps to outline the bile duct and pancreas duct, the image may show narrowing or enlargement of the organ which could indicate the presence of cancer.  An ERCP  is usually done while the patient is under sedation and a biopsy may also be done during the  procedure.

An angiography is an x-ray procedure which looks at the blood vessels using a small amount of contrast dye which is injected into an artery.  The procedure will show whether blood flow in any particular area is blocked or compressed due to a tumor.  It may also show any blood vessels which are abnormal and might be feeding the cancer.  An angiography can assist surgeons in deciding whether the cancer can be removed without causing damage to vital blood vessels.

There are several types of blood tests which a physician can use to detect or help diagnose pancreatic cancer, or it can help determine which treatment options would work best. There are blood tests that check levels of different types of billirubin (a chemical manufactured by the liver).  Other types of blood tests are used to evaluate the overall health of a patient and can be used to determine if the patient is strong enough to withstand major surgery.

If a patients blood tests or imaging results strongly suggest the presence of pancreatic cancer, a physician may want to remove a small sample of the tumor to study under a microscope.  The procedure is called a biopsy and there are several different types.  A fine needle aspiration  (FNA) biopsy is the procedure most often done to diagnose pancreatic cancer.  A surgical biopsy is called a laparotomy, which involves making a large incision into the skin of the abdomen to examine the internal organs.  A patient undergoing a laparotomy will have to be put under general anesthesia and spend time in the hospital to recover.

Another option is a laparoscopy, which involves putting the patient under sedation and a surgeon makes several tiny incisions and inserts small telescopic instruments into the abdominal cavity.  One of the instruments is connected to a video monitor and the surgeon can view the organs and take a tissue sample if necessary.

How is Pancreatic Cancer Staged?

Staging pancreatic cancer is the most important factor when deciding upon which treatment protocols are available.  Using a staging system is the way an oncology team describes the extent that a cancer has spread.  Pancreatic cancer staging is done using the American Joint Committee on Cancer, TNM system  (T describes the size of the tumor; N describes the spread of the pancreatic cancer into nearby lymph nodes; M is used to denote whether the cancer has metastasized or spread to other parts of the body).

Treatment Options for Pancreatic Cancer

The are three ways in which pancreatic cancer can be treated, surgery, radiation therapy and chemotherapy.  Depending upon which stage the cancer is in, some of these treatment options might be combined.

Two types of surgery used for treating pancreatic cancer:

Potentially curative surgery:  used when an imaging test determines that it is likely all the cancer can be removed.

Palliative surgery:  can be done if image testing determines the tumor is too widespread to be completely removed.  Surgery of this type is done to alleviate symptoms or to prevent certain types of complications (blockage of the bile duct or intestines).

Surgery to remove only a portion of the pancreatic cancer does not result in the patient living longer.  This kind of surgery is very grueling for a patient and one of the most difficult a surgeon can perform, if the surgery is not done correctly there are possible complications which could result in a longer recovery period.

There are three procedures a physician can use to remove pancreatic cancer tumors:

1. Pancreaticoduodenectomy (Whipple procedure):  the most common type of operation performed to remove tumors of the exocrine pancreas.  The procedure involves removing the head and sometimes the body of the pancreas, part of the small intestine, stomach and lymph nodes.  A part of the bile duct and gallbladder are also removed, with the remaining bide duct attached to the small intestine.  This is done so that bile from the liver can continuing entering the small intestine.   The operation is very complicated and patients can end up suffering complications as a result of the surgery, such as: leaking from the connections made by the surgeon, infection, bleeding and stomach problems.
2. Distal pancreatectomy:  an operation that involves removing the tail or a small portion of the body of the pancreas, it is common for the spleen to be removed at this time as well. 
3. Total pancreatectomy:  the surgery was once used for tumors in the body or head of the pancreas.  This involves removing the entire pancreas and spleen, and is now seldom used as a treatment option for exocrine cancers of the pancreas.

External beam radiation therapy is the most common type of radiation therapy used to treat pancreatic cancer.  The treatment involves focusing the radiation on the cancer, using a machine from the outside of the body.  A regimen of radiation is usually performed 5 days a week for a period weeks or months.

Radiation treatment can be done before or after surgery has been performed.  If a patient has to have surgery, it is preferable to do preoperative radiation therapy because any therapy taking place after the operation would have to be done after the patient has fully recovered, which may take several weeks.

At times, radiation therapy is combined with chemotherapy, for use in patients with tumors that are too widespread to be removed by surgery alone.

The side effects of radiation can include; mild skin changes that look like a sunburn, nausea, diarrhea, vomiting and fatigue.  When on a radiation regimen it is common for patients to lose their appetite and experience weight loss, however, these side effects usually go away within a few weeks of completing treatment.  Radiation can compound the side effects of chemotherapy, so it may be necessary to ask the physician for advice on side effects and how to avoid, prevent or relieve them.

Chemotherapy is sometimes referred to as “chemo”, this method of treatment involves using anti-cancer drugs injected into a vein or taken orally.  The medication enters the bloodstream and reaches all areas of the body, making the treatment useful for cancers that have spread beyond the organ of origin.

Chemotherapy treatment can be used at any stage for treating pancreatic cancer, and is the favored treatment for people with advanced cancer.  Chemotherapy is often used after surgery to kill off any remaining cancer cells that the surgery might have missed.  For patients who are having surgery, a combination of chemotherapy and radiation is often used to shrink the tumors and make the removal easier.

Gemcitabine and 5-fluourouracil, are the most common chemotherapy medications used to treat pancreatic cancer.  At times other medications may be used in conjunction with these medications, such drugs include; cisplatin, irinotecan, paclitaxel, docetaxel, capecitabine and oxaliplatin. 

One of the disadvantages of using chemotherapy treatment is while it kills cancer cells, it also damages normal cells in the process.  This can lead to serious side effects such as; hair loss, mouth sores, appetite loss, nausea, vomiting  and low blood cell counts.

Researchers are now studying newer drugs that target specific parts of cancer cells, the medications work differently than traditional chemotherapy and often produce fewer side effects.

Alternative and Complementary Treatment for Pancreatic Cancer

When a person is diagnosed with cancer, they are likely to hear about the many different ways to treat the cancer or relieve the symptoms and side effects.  Some of these methods vary greatly from the standard protocols for cancer treatment.  Alternative or complementary methods can include the use of vitamins, herbal supplements, special diets, acupuncture or massage therapy. 

The terms alternative and complementary can be confusing because not everyone uses the terms in the same manner.  According to the American Cancer Society the term complementary refers to methods or medicines that are used in conjunction with regular medical treatment.  Alternative medicine is a form treatment used in place of regular medical treatment.

Complementary methods:  are not used as a “cure” for cancer, most often used to alleviate the symptoms and side effects patient experience as a result of standard cancer treatment.  Some complementary methods used include meditation for stress reduction, acupuncture for pain relief and peppermint tea for relief of nausea, along with several others.  Complementary methods are used to make a cancer patient feel better and to improve quality of life.

Alternative treatments:  used in lieu of standard medical treatment and have not been proven to be safe or effective during clinical trials.  Alternative methods could be extremely dangerous and have life-threatening consequences.  Any type of delay or interruption of standard medical treatment could cause the cancer to spread to other parts of the body.

Decisions regarding how to treat and manage cancer are the responsibility of the patient.  When considering whether to use complementary or alternative methods, it is best to consult with the cancer care team prior to beginning.  A physician can answer questions and provide a patient with useful information about the advantages and disadvantages associated with alternative and complementary treatments.

Prognosis

The survival rates for people with pancreatic cancer have been improving from decade to decade, however the disease is still considered incurable.  The American Cancer Society reports the survival rate at one year is 20%, with all stages of pancreatic cancer combined, and the  five year survival rate at 4%.  Low survival rates are attributed to the fact that less than 10% of pancreatic tumors are confined to one area, in most instances the malignancy has progressed to a  stage where it is inoperable.

It is recommended to increase the odds of survival and improve outcome, a patient seek out a major medical center with extensive experience in treating pancreatic cancer, preferably the institutions that perform more than 20 Whipple procedures each year.