Introduction

Cancer of the pancreas is responsible for about 4% of all cancer deaths in the UK; it is slightly more common in men than in women, and it occurs more frequently with age. As with some other cancers (e.g. stomach, ovary), the diagnosis is often made fairly late, when the condition is advanced. A recent article in the British Medical Journal reviews the signs and symptoms, the risk factors, steps to diagnosis, treatment, and likely outcome for pancreatic of cancer.

Risk factors

The known risk factors for cancer of the pancreas are: smoking, partial gastrectomy (removal of part of the stomach), excessive fat in the diet, and a family history of this type of cancer. It's interesting to know that the following are NOT risk factors for cancer of the pancreas: alcohol consumption, pancreatitis (inflammation of the pancreas), diabetes, or coffee drinking.

Symptoms & signs

The pancreas gland has a head, neck, body, and tail. Most cancers arise in the head or neck regions, and thus compress the common bile duct that empties the gallbladder. This leads to a back-up of bile, causing obstructive jaundice -- dark urine, pale feces, and an itchy skin.

Most frequently, the first symptoms are painless progressive jaundice, with some discomfort in the upper part of the abdomen, and dull back pain. If the tumor is in the body or tail of the pancreas, the symptoms are more vague -- no jaundice, just loss of appetite, nausea, weight loss, and pain going through into the back. If there is jaundice, the physician is likely to be able to feel an enlarged gallbladder. (In the case of jaundice due to gallstones, the gallbladder cannot usually be felt, as it is likely to be shrunken and fibrotic. Sometime secondary tumor masses (metastases) can be felt in the liver. There may be anemia, and quite extreme weight loss (cachexia).

Investigations

Blood tests are very helpful. The degree of jaundice (amount of bile, or bilirubin, in the blood), the type of jaundice (serum alkaline phosphatase level), and possible involvement of the liver (serum transaminases - SGPT, SGOT) can be determined with a high degree of confidence. There are some specific blood tests -- so-called tumor marker antigen tests (e.g. CA 19.9, or carcinoembryogenic antigen); however, these are more useful for monitoring progress than for diagnosis.

An ultrasound exam can show the differences between various causes of jaundice. Further procedures such as endoscopy or CAT scan (computed tomography) are usually reserved for preoperative assessments. Although chronic pancreatitis is normally excluded in the absence of a history of alcohol abuse, when in doubt a biopsy (fine-needle aspiration) can be done to settle the question.

Treatment

As with other tumors that are often detected rather late, surgery provides the only real hope of a cure, but only a low proportion of patients qualify for the radical removal of the cancerous gland; the tumor must be no more than a few centimeters in diameter, and there can be no metastases. The procedure is quite formidable, but mortality rates have fallen to less than 5% in experienced hands.

Postoperative chemotherapy is helpful after surgical removal of the pancreas, and new specific agents are being developed for this purpose. Radiotherapy is not usually helpful.

Palliative interventions to make life more comfortable for patients where the tumor has progressed include placing a stent (a firm tube) in the bile duct to relieve its obstruction, a surgical procedure to relieve obstruction of the duodenum, and nerve blocks for severe pain. Palliative care is recommended, using a hospice-based team approach.

The outlook

Few patients with cancer of the pancreas survive more than a year from the time of their diagnosis -- it's a rapidly fatal cancer. Surgical techniques have improved, however, so that 5 years after surgical removal of the pancreas between 10% and 20% of patients are still alive. With periampullary tumors (those situated around the point of entry of the common bile duct into the duodenum) this figure rises to 50%.

While this may be slightly encouraging, real progress will only result if risk factors are reduced (e.g. not smoking, less fat in the diet), and attention is paid to symptoms that cannot be cleared up rapidly with simple treatments. The rapidity of death following diagnosis makes this one type of tumor worth fighting vigorously.