Pancreatic cancer

Pancreatic cancer is a disease in which cancerous cells forms in the tissues of pancreas. Pancreatic cancer is one of the leading cause of cancer deaths in the world and it’s incidence is on the rise in developing countries like India. Incidence of pancreatic cancer in India is 0.5-2.4 per 100000 men and it is 0.2-1.8 per 100000 women.

Signs and symptoms:

Pain in the upper abdomen and back
Loss of appetite and weight
Yellowish discolouration of eye andskin (jaundice)
Itching
Fatigue

Risk factors:

Smoking
Alcohol
Chronic pancreatitis
Obesity
Old age ( >65 yrs)
Family history of pancreatic cancer

Diagnosing pancreatic cancer

Physical examination : Your doctor will examine your eyes and skin to look for signs of jaundice. Your doctor will also examine your abdomen to look for changes caused by the cancer.
Blood tests : Complete blood count, liver function test, renal function test, coagulation profile, CA19-9 (Tumor marker)
Radiological imaging: CT scan, MRI scan, PET-CT, Ultrasound of the abdomen, ERCP. In case of severely jaundiced patient, doctor might refer you to medical gastroenterologist for a ERCP and stenting to decompress the bile duct prior to the surgery. Plastic or metal stents will be placed in your bile duct to relieve the obstructive jaundice.
Biopsy: Biopsy is not mandatory to diagnose the pancreatic cancer. Most of the times diagnosis is confirmed by imaging tests. However, a small subset of patients with pancreatic cancer may present without jaundice. In these patients biopsy is required to confirm the diagnosis.

Treatment Options

Treatment options available for pancreatic cancer

Surgery

Surgery for a pancreatic cancers depends on the location of the tumour Surgery for pancreatic head cancer: If the cancer is located in the head of pancreas then the patient will require a Whipple’s procedure (pancreaticoduodenectomy). A close look at the scans will help the surgeon understand of the tumor is resectable or not. Often the main blood vessels going to the liver or intestines are affected by the cancer rendering it inoperable. Tumors in the body or tail of the pancreas need a distal or subtotal pancreatectomy. This is often done by laparoscopy or robotic techniques to minimize stay and enable faster recovery.

Chemotherapy

Chemotherapy has been shown to extend life for people with pancreatic cancer. It is often combined with surgery or radiation therapy for tumors confined within the pancreas. It used as a primary treatment for inoperable cancers of the pancreas due to local vessel invasion or distant spread. At times , chemotherapy is used for borderline resectable cases to shrink the tumor and enable a better surgery.

Radiotherapy for pancreatic cancer

Radiation therapy in pancreatic cancer is used as a neoadjuvant treatment in order to shrink the cancer to enable safer surgery. It is used in a post operative setting in cases where the margins are positive.

Combination of the above treatments

Whipple’s pancreaticoduodenectomy

Whipple’s procedure is a technically very demanding surgery for cancers of the head of the pancreas , lower bile duct, duodenum or the periampullary region.

The surgeon will remove the head of the pancreas, duodenum, gall bladder, common bile duct and regional lymph nodes.

Following the removal surgeon reconnects the remaining pancreas, bile duct and stomach with the small intestine(jejunum) . This is one of the most complex operations . At times , the portal vein is also resected and joined back when affected. Post surgery patient may be kept in icufor monitoring .. Recovery period is usually between 6-10days after surgery. Whipple’s procedure is at times associated with complications. Complications include a pancreatic joint leak or bleeding, infection, fluid collection inside the abdomen, which might increase the hospital stay and expenses. Complication rates have come down with better understanding of the disease and improved technical skills. Complication are fewer when its done by a experienced surgeon and in a high volume centre.

Distal or subtotal pancreatectomy

This is a resection of the body or tail of the pancreas for a tumor in any of these regions. It may need an associated splenectomy. Your doctor may recommend a vaccination prior to or afterthe surgery. This is a shorter surgery as compared to theWhipples . we often do this by robotic or laparoscopy when feasible.

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Related FAQ's

1. Can pancreatic cancers be prevented?

You may not be able to prevent pancreatic cancer, but you can lower the risk rates by practicing a healthy diet, physical exercise, maintaining proper weight, avoiding smoking and alcohol.

2. What causes pancreatic cancer?

Currently, it isn’t known what causes pancreatic cancer, however, we do know that cancer occurs when cells develop mutations in their DNA. These mutations cause the cells to grow rapidly and uncontrollably, eventually forming a tumor. Conditions such as chronic pancreatitis are known to be risk factors.

3. What is the life expectancy of a person post whipple’s procedure?

Life expectancy after a Whipple's procedure depends on the exact stage of the disease. Inoperable Periampullary cancer in node-positive disease 5 yr survival is 40% and in node-negative disease, 5-years survival is 60%. In cancers involving the head and uncinate process of the pancreas, the survival rate is less compared to periampullary cancers. 5-years survival in an operable node-positive pancreatic head and uncinate cancer is about 20% and in node-negative disease, it's 40-45%.

4. Is there a screening test for pancreatic cancer?

Despite being one of the leading causes of cancer deaths around the world, there is no reliable screening test for pancreatic cancer.

5. Is there a relationship between diabetes and pancreatic cancer?

There is no association between type1 diabetes and pancreatic cancer, but there is mounting evidence regarding the association between type 2 diabetes and pancreatic cancer.

6. What is the mortality and morbidity rate after whipple’s procedure?

Mortality and morbidity rates of Whipple’s procedure are the least when it is done in a high volume center and by an experienced surgeon. Whipple’s procedure has a mortality rate of 1-3% and a morbidity rate of 10-20% in most of the centers around the world. In our center the mortality rate is less than 2% and morbidity rate of 15 - 20%.