Pancreatic Cancer Diagnosis
The pancreas is a fish-shaped organ located in the abdomen, tedious the stomach. The pancreas contains two different types of glands (exocrine and endocrine). The exocrine glands make pancreatic fluid, and the enzymes in this fluid breaks down proteins and fats in foods so that the body is able to employ them. Most of the pancreas is composed of exocrine cells. The remaining endocrine cells are grouped in clusters called islets. These islets make hormones (insulin) that regulate the level of sugar in the blood.
Types of Pancreatic Tumors
Tumors of the exocrine cells are much more common than tumors of the endocrine cells. While most are malignant (cancerous), a small number are benign (non-cancerous). It is imperative to know whether the malignancy is caused form the exocrine or endocrine cells. Each type of cancer has its own symptoms, diagnostic procedures, treatments and prognosis.
Exocrine Tumors
Tumors that begin from the exocrine cells are usually malignant, and are called adenocarcinimas. There is also ampullary cancer, which originates where the bile duct and the pancreatic duct empty into the small intestine. This type of cancer may cause jaundice (yellowing) of the skin and eyes.
Endocrine Tumors
Tumors that launch from the endocrine cells are less well-liked, and are usually benign. These tumors are called islet cell or neuroendocrine tumors, and have several sub-types. Malignant endocrine tumors do occur, but are rare.
How Celebrated is Pancreatic Cancer?
Pancreatic cancer affects about 1 in 72 people. The American Cancer Society’s 2009 estimates for pancreatic cancer cases in the United States are:
1) 42,470 newly diagnosed cases of pancreatic cancer
2) 35,240 deaths from pancreatic cancer
Causes of Pancreatic Cancer
Despite years of research, the exact causes(s) of pancreatic cancer remains unknown. Scientists do know that some risk factors have been linked to the disease, and that some of these risk factors affect DNA in the cells of the pancreas. “DNA is is the substance in each cell that carries our genes-the instructions for how our cells work.” (American Cancer Society). This can lead to abnormal cell growth, and tumor formation.
Risk Factors for Pancreatic Cancer
Age: Your risk increases with age. 90% of patients are older than 55, and the average age of patients diagnosed with this type of cancer is 72.
Gender: Men have only a slightly higher risk for developing this type of cancer than do women.
Race: African Americans have an increased risk for developing pancreatic cancer as compared to Caucasians.
Family History: This type of cancer tends to accelerate in families.
Genetics: Inherited gene mutations may contribute to pancreatic cancers. Genetic testing is helpful in identifying these mutations.
Smoking: Smokers have a 2 to 3 times higher risk for developing pancreatic cancer than do non-smokers. People who use chewing tobacco are also at an increased risk for developing the disease.
Diabetes: Patients with type 2 diabetes are at an increased rick for developing pancreatic cancer. Some patients are diagnosed with pancreatic cancer, and later create diabetes.
Stomach Problems: Patients diagnosed with H. pylori bacteria or increase amounts of stomach acid show an increased risk for developing this cancer.
Obesity: Morbidly obese (very overweight) people are more likely to develop pancreatic cancer.
Lack of Exercise: Sedentary (inactive) people are at an increased risk for developing this type of cancer.
Exposure: Long-term or heavy exposure to pesticides or chemicals increases the risk for the disease.
Chronic Pancreatitis: Chronic pancreatitis is inflammation of the pancreas (long-term). Patients with this condition have a slightly higher risk for developing pancreatic cancer, however most of these patients do not develop the disease.
Cirrhosis of the Liver: Cirrhosis(scarring) of the liver is caused from hepatitis and alcohol abuse. Patients diagnosed with cirrhosis have a higher risk of developing pancreatic cancer.
Symptoms of Pancreatic Cancer
Jaundice: 50% of patients with pancreatic cancer have jaundice of the skins and/or eyes. This is caused by a build-up of bilirubin(bile pigment made in the liver) in the bloodstream.
Pain: Pain in the abdomen or middle of back is common in advanced stages of pancreatic cancer.
Weight Loss: Unexplained weight loss and loss of appetite (with or without fatigue) are approved in patients with this disease.
Digestive Problems: The pancreatic tumor may block the the release of pancreatic fluid into the intestine, which makes digesting fatty foods difficult. As a result, nausea, vomiting and increased pain after eating are common symptoms.
Diabetes: Since the pancreas’ main function is to regulate blood sugar, cancer of this organ may cause diabetes.
Diagnosing Pancreatic Cancer
History and Physical
Your physician will want to get information about your past /present medical history and perform a thorough physical examination. Particular attention will be directed to the abdominal area (belly). Your physician will check for swelling of the lymph nodes and liver, as pancreatic cancer frequently spreads to these areas. Assessment of your skin color and whites of the eyes will be performed, as pancreatic cancer may cause jaundice(yellow color).
Diagnostic Imaging Tests (X-Rays)
Your physician is likely to order some of these imaging tests to aid in his or her differential diagnosis. Your physician and a radiologist (physician who reads X-rays) will likely confer regarding your films.
Computerized Tomography (CT Scan)
CT scans are useful in diagnosing and detecting the spread of many cancers. A CT scan provides a cross-sectional view of the pancreas, lymph nodes, and surrounding organs. The physician can pinpoint where the cancer is located and if it is operable. CT scans may be performed with a contrast dye that is injected into the veins. The contrast helps outline the details of the organs. Make sure that you inform your physician and the radiology technician if you have allergies to shellfish or iodine. People who are allergic to these, may be allergic to the contrast dye as well.
The CT scan takes longer than a regular X-ray. You will lie on a table, and the table will slowly move through a doughnut-shaped scanner. The test is painless, but you have to remain still during the procedure.
Magnetic Resonance Imaging (MRI)
MRI scans exhaust magnetic fields and radio waves to produce images. The patient is enclosed in a narrow tube during the procedure, and the machine makes loud thumping and clicking noises. Newer scanners are more “patient-friendly”, and are better tolerated than some of the older models (more open on both ends). However, some patients still require mild sedation for anxiety, especially if they are claustrophobic.
Positron Emission Tomography (PET Scan)
PET scans use radioactive glucose (sugar) which shows up in colors on the film. The glucose in injected into a vein in the arm, and because cancer cells are so active, they absorb large amounts of the sugar. A special camera is ragged to visualize the organs, and the colored images are easily seen. PET scans actually scan the entire body, so its particularly estimable in determining if the cancer has spread to the lymph nodes or other organs.
PET/CT Scan
The combination of PET/CT scans is helpful to better pinpoint a tumor. It is used to spot cancer that has spread beyond the pancreas, stage the cancer(we’ll discuss this later), and can even spot early cancers.
Ultrasound
Ultrasound utilizes high-frequency sound waves to visualize the organs. This test can tell what kind of tumor is in the pancreas. Sometimes, an endoscopic ultrasound is performed with a scope inserted through the nose or mouth into the stomach. The scope can be directed toward the pancreas, and sometimes gives a better picture than the CT scan. Patients are usually sedated if an endoscopic procedure will be performed.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
An ERCP is an endoscopic procure where a scope in passed down the throat, to the stomach, and into the small intestine. This allows the physician to see where the celebrated bile duct opens into the small intestine. Sometimes, contrast dye is pushed into these ducts to allow better visualization of the organs on X-rays. Narrowing or blocked bile ducts may indicate pancreatic cancer. The physician can also take a brushing of these cells and have them analyzed to see if they stare like cancer. If a tumor is present and compressing the bile duct, a stent (small tube) is placed to keep it open.
Angiography
Angiography is an X-ray that uses a dye to look at blood vessels. It can show if a tumor is blocking or slowing blood flow in a particular area, or if there are abnormal vessels present. Angiography helps the physician decide if and how the tumor can be safely removed.
The blueprint involves inserting a catheter into the femoral artery( by the inner thigh) and threading it up to the pancreas. Local anesthetic is administered to numb the area prior to inserting the catheter, and the dye in quickly injected while the X-rays are being taken.
Blood Tests
Blood tests may or may not be qualified in providing a diagnosis of pancreatic cancer. Sometimes, high blood levels of the tumor markers CA19-9 and carcinoembryonic antigen (CEA) may indicate exocrine pancreatic cancer. These tests are are not always suitable, and the only way to accurately diagnose pancreatic cancer is by performing a biopsy.
Biopsy
There are two different ways that biopsies may be performed.
FNA
A fine needle aspiration (FNA) is most commonly used, and involves inserting a thin needle through the skin and into the pancreas to remove little pieces of pancreatic tissue. Ultrasound may be conventional during the procedure to help pinpoint the tumor plot. Patients tolerate this plan well, and side effects are infrequent.
Laparoscopy
A laparoscopy (keyhole surgery) may be performed to derive biopsy samples. The patients is sedated, and the surgeon makes tiny cuts in the abdomen and inserts small telescope-like instruments into the area. One of the scopes has a camera that is connected to a large video screen. This allows the surgeon to see how large the tumor is, and if it has spread. Several tissue biopsies are usually taken during the laparoscopy.
Most surgeons will not manufacture surgery on pancreatic cancer patients unless they feel that the cancer can be completely removed. If the surgery is performed, and the cancer has spread too far to be removed, biopsy samples are taken, but the surgery is stopped.
Staging of Pancreatic Cancer
All cancers are staged using Roman numerals I through IV. The lower the number, the less chance the cancer has spread. However, with pancreatic cancer, doctors often exercise a simpler staging system. This system divides cancers into groups based on whether or not they can be removed.
Resectable
This type of cancer is localized to the pancreas, and all of the tumor can be removed.
Locally Advanced (unresectable)
This type of cancer has spread to the blood vessels and surrounding tissue around the pancreas, but not to the distant organs. Surgery is not usually performed, unless it is for symptom relief.
Metastatic
The cancer has spread to one or more distant organs. Surgery is not an option, unless it is for relief of symptoms or other complications.
Pancreatic Cancer Treatment
There are three types of treatment for pancreatic cancer: surgery, radiation therapy and chemotherapy. The oncologist (physician specializing in cancer) will recommend which option (s) are best for each patient. Sometimes, all three treatments may be used.
Surgery
There are two types of surgical interventions passe for cancer of the pancreas:
1) Potentially curative surgery is performed when it looks as though all of the tumor can be removed. This complex surgery is called a Whipple device, which has an extremely high complication risk (including death).
2) Palliative surgery may be done if the cancer has spread and can not be completely removed. Surgery is done to relieve symptoms or complications, such as blockage of the intestines or bile ducts by the tumor.
Other Surgery
Ablative techniques may be used when pancreatic cancer has spread to a few other locations. These procedures may improve symptoms and help the patient live longer.
Radiofrequency ablation (RFA) uses radio waves to heat and kill tissues (cancer cells).
Microwave thermotherapy uses microwaves to heat and end cancer cells.
Cryosurgery (or cryablation) involves the insertion of a probe into a tumor to freeze the tissue with liquid nitrogen or carbon dioxide. The cells that are frozen are destroyed.
Embolization involves the insertion of a catheter into the blood vessel that is feeding the tumor. Radioactive or chemotherapy microspheres (tiny beads) are placed in the blood vessel, cutting off the blood supply. This caused the tumor to die.
Radiation Therapy
Radiation therapy involves treatment with high energy x-rays to kill cancer cells. The process is similar to receiving X-rays, but takes longer. The patient is usually treated 5 times per week for several weeks or months. Radiation may be administered before or after surgery and/or along with chemotherapy.
Side effects of radiation therapy include sunburn, nausea, diarrhea weight loss, and fatigue. These usually subside after treatment ends.
Chemotherapy
Chemotherapy (chemo) involves the use of drugs that abet to kill cancer cells. The drugs may be given orally in a pill form, or intravenously.
Chemo is often used after surgery to ensure that any remaining cancer cells are killed. Sometimes chemo and radiation therapies are ragged before pancreatic cancer surgery to help shrink the tumor.
Sides effects of chemotherapy vary, depending on which type, how much, and how long chemo drugs are used. Typical side effects are hair loss, nausea, vomiting, diarrhea, loss of appetite, fatigue, and mouth sores. Low blood cells count may cause an increased risk for infection or bleeding/bruising from minor cuts.
These side effects usually subside once treatment is completed.
Advances in Chemotherapy
Tarceva (erlotinib) is a newer chemo drug that has helped many patient with advanced pancreatic cancer. When combined with Gemzar (gemcitabine), the effects are even better. The side effects are similar to other chemotherapy drugs.
Improving Quality of Life
Palliative care helps patients manage their devastating diagnosis of pancreatic cancer. Whatever helps to wait on symptoms and improve their quality of life are essential goals in the treatment of pancreatic cancer.
Eating may be difficult for patients diagnosed with pancreatic cancer. Sometimes they develop bile duct or intestinal blockages, and lose their appetite. They may feel weak or have a rapid weight loss. Sometimes the chemo or radiation causes nausea, vomiting, or loss of appetite. These patients should try to eat high- energy foods. Many pancreatic cancer patients need to take pancreas enzymes to abet in digestion. Occasionally, the physician will suggest inserting a feeding tube to improve nutrition and energy levels.
Pain management is a huge impart for patients with this type of cancer. Medications are available to back control the pain and keep your healthcare provider updated about your damage level. The important thing to remember is to keep your pain under control by taking your pain medication regularly. Don’t wait until the afflict gets really awful to take your pain relievers. There are long-acting morphines that only need to be taken once or twice a day.
Survival Rates/Prognosis
About 2 out of 10 people live at least one year after their cancer is diagnosed. However, less than 4% will be alive after 5 years.
Emotional Aspects
Receiving a cancer diagnosis is probably some of the most devastating news that a person will get in their lifetime. You may feel overwhelmed, scared, depressed, or alone. Maybe you are worrying about how this will affect your family, friends, or career.
This is the time to seek out emotional and social support. Turn to your family, friends, church, cancer support groups, online support, or a counselor. If you need assistance, call the American Cancer Society at 1-800-227-2345 and they can help you locate the proper resources (American Cancer Society, 2010).
Remember, you still have today and the rest of your life. Like Tim McGraw’s song says: “Live Like You Were Dying.”
Sources:
Overview: Pancreatic Cancer, (2010). No Author. Retrieved from http://www.cancer.org
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