Pancreatic cancer: Diagnosis, Staging, Treatment, Side effects of treatment, Palliative care and Support team
Pancreatic cancer is highly lethal because it grows and spreads rapidly and often is diagnosed in its late stages.
Some screening steps might help detect a problem early for people with pancreatic cysts or a family history of pancreatic cancer. Squamous, pancreatic progenitor, aberrantly differentiated endocrine exocrine (ADEX), and immunogenic are subtypes of pancreatic cancer.
The tests available for screening frequently are complex, risky, expensive, or insensitive in the early phases of the cancer. A set of factors that increase the risk for pancreatic cancer are pancreatic cysts, first degree relatives with pancreatic cancer, or a history of genetic syndromes associated with pancreatic cancer.
One or more of the following tests can be done to diagnose pancreatic cancer if it is suspected.
Imaging tests such as ultrasound, computerized tomography (CT) scans, magnetic resonance imaging (MRI) and, sometimes, positron emission tomography (PET) scans are used to visualize your internal organs, including the pancreas.
An ultrasound device is used in endoscopic ultrasound (EUS) to make images of your pancreas from inside your abdomen. The device is passed through a thin, flexible tube called endoscope down your esophagus and into your stomach in order to obtain the images.
A biopsy is a procedure to remove a small sample of tissue for examination under a microscope. A sample of tissue from the pancreas can be obtained by inserting a needle through your skin and into your pancreas called as fine-needle aspiration technique.
Biopsy also can be made via an endoscope put down the throat and into the intestines. A camera on the tip of the endoscope allows the endoscopist to guide the endoscope within the intestine. An ultrasound device at the tip of the endoscope locates the area of the pancreas to be biopsied. Then a biopsy needle is passed through a working channel in the endoscope to obtain tissue from the suspected cancer.
The elevation of a tumor marker, CA 19-9 can be found from a blood test which can be the indication of a pancreatic cancer. This is found abnormally high in people with pancreatic cancer. It is released often into the bloodstream by pancreatic cancer cells and may be elevated in patients newly found to have pancreatic cancer. Although the CA 19-9 test is cancer related, it is not specific for pancreatic cancer. Other cancers as well as some benign conditions can cause the CA 19-9 to be elevated.
The tumor marker is not perfect as in some cases the CA 19-9 will be at normal levels in the blood despite a confirmed diagnosis of pancreatic cancer. However, as its rise and fall may correlate with the cancer's growth, it can be helpful to follow during the course of illness to help guide appropriate therapy.
Once pancreatic cancer is diagnosed, the extent or stage of the cancer will be determined by the doctor. Information from staging tests helps determine what treatments are most likely to benefit to you.
There are four stages with stage 1 being the earliest stage and stage IV being the most advanced that is metastatic disease. Stage 0 is not counted. The following are the stages of pancreatic cancer according to the National Cancer Institute:
In this stage, cancer is found only in the lining of the pancreatic ducts. Stage 0 also is called carcinoma in situ.
In this stage, cancer has formed and is in the pancreas only. It is further classified in to two categories.
In this stage, cancer may have spread or advanced to nearby tissue and organs and lymph nodes near the pancreas. Again it is of two stages.
In this stage, cancer has spread or progressed to the major blood vessels near the pancreas and may have spread to nearby lymph nodes.
In this stage, cancer may be of any size and has spread to distant organs, such as the liver, lung, and peritoneal cavity. It also may have spread to organs and tissues near the pancreas or to lymph nodes. This stage has also been termed end stage pancreatic cancer.
Patients with stage I and stage II cancers will have local or resectable cancer where cancer can be completely removed with an operation. Patients with stage III cancers have locally advanced, unresectable disease. In this stage, cancer can not be cure, but local treatments such as radiation can be an option. Chemotherapy is most commonly recommended as a means of controlling the symptoms related to the cancer and extending life in patients with stage IV pancreatic cancer.
Treatment for pancreatic cancer depends on the stage and location of the cancer as well as on your overall health and personal preferences. The aim of pancreatic cancer treatment is to eliminate the cancer, if possible. When that isn't possible, the focus is on improving the quality of life and preventing the cancer from growing and spreading.
Treatment may include surgery, radiation, chemotherapy or a combination of these. Palliative care will be recommended by the doctor which makes you as comfortable as possible when pancreatic cancer is in advance stage and these treatments aren't likely to offer a benefit.
If a pancreatic cancer is found at an early stage that is stage I and stage II and is contained locally within or around the pancreas, surgery may be recommended. These are called as resectable pancreatic cancer.
Operations used in people with pancreatic cancer include:
A Whipple procedure or pancreaticoduodenectomy is considered if your cancer is located in the head of the pancreas. It often comprises removal of the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and part of the bile duct.
In some situations, part of the stomach and nearby lymph nodes may be removed as well. The remaining parts of your pancreas, stomach and intestines will be reconnecetd by your surgeon to allow you to digest food.
Surgery invloves the removal of left side (body and tail) of the pancreas and is called distal pancreatectomy. Your surgeon may also remove your spleen in this case.
The entire pancreas may need to be removed in some cases. This is called total pancreatectomy. You can live relatively normal without a pancreas but do need lifelong insulin and enzyme replacement.
Many people with advanced pancreatic cancer, if their tumors involve nearby blood vessels are not considered eligible for the Whipple procedure or other pancreatic surgeries. In this condition, highly specialized and experienced surgeons will safely perform these operations with removal and reconstruction of parts of blood vessels in select patients.
As these operation are very critical, it is important to be evaluated at a hospital with lots of experience performing pancreatic cancer surgery. Experienced surgeons can better select people who will get through the surgery safely and also better judge who will most likely benefit from the operation.
All of these surgeries carries the risk of bleeding and infection. After surgery some people experience nausea and vomiting if the stomach has difficulty emptying or delayed gastric emptying. Complications from the surgery can include blood loss (anemia), leakage from the reconnected intestines or ducts, or slow return of bowel function. Recovery to pre-surgical health after any of these procedures often can take several months.
Chemotherapy uses drugs to help kill cancer cells. These drugs can be injected into a vein or taken orally. You may receive one chemotherapy drug or a combination of them.
Chemotherapy can also be combined with radiation therapy which is known as chemoradiation. Chemoradiation is typically used to treat cancer that has spread beyond the pancreas, but only to nearby organs and not to distant regions of the body. This is described as locally advanced, unresectable (inoperable) pancreatic cancer or stage III cancer. A combination of low dose chemotherapy given simultaneously with radiation treatments to the pancreas and surrounding tissues in these cases. Radiation treatments are designed to lower the risk of local growth of the cancer, thereby minimizing the symptoms that local progression causes such as back or belly pain, nausea, loss of appetite, intestinal blockage and jaundice.
Radiation treatments are typically given five days a week for about 5 weeks. Chemotherapy given concurrently may improve the effectiveness of the radiation and may lower the risk for cancer spread outside the area where the radiation is delivered. More chemotherapy often is recommended after the radiation is completed and the patient has recovered.
Chemotherapy is also given to a patient after he recover from a Whipple procedure for pancreatic cancer. This treatment is referred to as adjuvant therapy and has proven to lower the risk of recurrent cancer. Typically 6 months of adjuvant chemotherapy is recommended in combination of radiation.
This combination may be used before surgery to help shrink the tumor. Sometimes it is used after surgery to reduce the risk that pancreatic cancer may recur. In people with advanced pancreatic cancer, called as metastatic pancreatic cancer, chemotherapy is often used to control cancer growth and prolong survival.
Chemotherapy travels through the bloodstream and goes anywhere the blood flows. It can attack a cancer that has spread through the body wherever it is found and treats most of the body.
Chemotherapy options for patients with pancreatic cancer vary from treatment with a single chemotherapy agent to treatment with as many as three chemotherapy agents given together. The aggressiveness of the treatment is determined by the oncologist and is based on the overall health and strength of the individual patient.
Radiation therapy uses high energy beams, such as those made from X-rays and protons, to destroy cancer cells. The treatments can be used either before or after cancer surgery, often in combination with chemotherapy. A combination of radiation and chemotherapy treatments is recommended when your cancer can't be treated surgically.
Radiation usually comes from a machine that moves around you, directing it to specific points on your body. This is called as external beam radiation. In specialized medical centers, radiation therapy may be delivered during surgery which is known as intraoperative radiation.
Proton beam radiation therapy, may be a treatment option for some people with advanced pancreatic cancer. Newer forms of radiation delivery such as stereotactic radiosurgery, gamma knife radiation and cyber knife radiation have been utilized in locally advanced pancreatic cancer with varying degrees of success.
Side effects of treatment for pancreatic cancer vary depending on the type of treatment. For example, side effects of radiation treatment tend to accumulate throughout the course of radiation therapy and include fatigue, nausea, and diarrhea.
The side effects of chemotherapy depend on the type of chemotherapy given. Less aggressive chemotherapy treatments typically cause fewer side effects whereas more aggressive combination regimens are more toxic and can include fatigue, loss of appetite, change in taste, hair loss, and lowering of the immune system with risk for infections (immunosuppression). There are supportive medications that can control nausea, pain, diarrhea, or immunosuppression related to treatment.
Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an extra layer of support that complements your ongoing care. Palliative care can be used along with aggressive treatments, such as surgery, chemotherapy and radiation therapy. People with cancer may feel better and live longer when palliative care is used along with other appropriate treatments . This can be used soon after diagnosing the disease.
Many hospitals provide support networks utilizing the expertise of trained social workers with experience in caring for people with cancer. Additionally, the Pancreatic Cancer Action Network (PANCAN) and the American Cancer Society both provide information and support for people living with pancreatic cancer. You can visit their web sites at http://www.pancan.org and http://www.cancer.org. Diet recommendations can be found at ACS Guidelines on Nutrition and Physical Activity for Cancer Prevention.