Pancreatic Cancer

Pancreatic cancer is the 11th most common cancer globally. In 2018, there were 458,918 new cases and 432,242 deaths worldwide.

TYPES OF PANCREATIC CANCER

There are various ways in which a doctor may classify pancreatic cancer:

• Based on the cells that the cancer originates from:
  • Adenocarcinoma: It is the most common type of pancreatic cancer that arises from cells lining the ducts (hollow tubes) of the pancreas.
  • Cystic tumours: This type of cancer leads to the development of a fluid-filled sac called a cyst.
  • Acinar cell cancer: This type of cancer develops in the acinar cells, which lie at the ends of the ducts that produce enzymes.
• Based on the spread of cancer
  • Localised pancreatic cancer: The cancer is contained within the pancreas and has not spread anywhere else in the body.
  • Locally advanced pancreatic cancer: The cancer has spread to the tissues around the pancreas, to the nearby lymph nodes, or nearby blood vessels, but has not spread to other parts of the body.
  • Metastatic pancreatic cancer: The cancer has spread to another part or parts of the body, also known as metastases.

STAGING OF PANCREATIC CANCER

If you are diagnosed with pancreatic cancer, your doctor will run more tests to determine the extent (stage) of your cancer. The stage of your cancer is based on the size and spread of the tumour and helps your doctor decide which treatments are optimum.

• • Stage 0: Cancer is confined to the top layers of pancreatic duct cells and sometimes referred to as carcinoma in situ.
  • Stage I: Cancer restricted to the pancreas with no spread to lymph nodes or distant organs. It has two sub-stages: Stage IA (The cancer is confined to the pancreas and is no bigger than 2 cm across), Stage IB (The cancer is confined to the pancreas and is larger than 2 cm (0.8 inches) but no more than 4 cm across)
  • Stage II: The cancer has spread to nearby lymph nodes with no spread to distant organs. It has two sub stages. Stage IIA (Cancer is confined to the pancreas and is bigger than 4 cm across) Stage IIB (Cancer is confined to the pancreas and is less than 2 cm across and has spread to 1 to 3 nearby lymph nodes OR is 2-4 cm across and has spread to 1-3 lymph nodes OR is larger than 4 cm and has spread to 1-3 lymph nodes).
  • Stage III: The cancer has spread to nearby lymph nodes with no spread to distant organs. It may be less than 2 cm and spread to 4 or more lymph nodes OR is 2-4 cm across and has spread to 4 or more lymph nodes OR has grown outside the pancreas to nearby blood vessels.
  • Stage IV: The cancer has spread to distant sites such as the liver, the lining of the abdominal cavity, the lungs or the bones.

Sources: Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018; European Society of Medical Oncology (ESMO) ; American Cancer Society

DIAGNOSTIC TESTS FOR PANCREATIC CANCER

• • Clinical History and examination: The doctor will ask for symptoms such as yellowing of the skin, abdominal pain, weight loss and symptoms of diabetes, such as thirst, frequent urination and fatigue. An abdominal examination is also done to palpate the abdomen for any abnormalities.
  • Radiological Imaging: Computed tomography (CT) scan: CT scans use X-rays to visualise the internal organs in cross-section. It is useful to diagnose and stage pancreatic cancer. Ultrasound: An ultrasound scan uses high-frequency sound waves to create an image of the inside of the body, and is useful to visualise the pancreases and other organs in the abdomen. Magnetic resonance imaging (MRI) uses magnetic fields and radio waves to produce images and is used for staging of pancreatic cancer.
  • Endoscopic ultrasound scan (EUS): In an EUS, an ultrasound scanner is attached to the end of an endoscope and is passed into the stomach through the mouth. This means that images can be taken from inside the body. Samples of tissue and lymph nodes can also be taken during the procedure to be tested later by the pathologist.
  • Biopsy: It is the removal of a tissue sample for testing under the microscope by a pathologist. It may be obtained by inserting a needle through the skin and into the pancreas (also known as fine-needle aspiration) or during an endoscopic ultrasound scan, mentioned above.
  • Blood tests: Certain blood tests are useful to detect pancreatic cancer. There are specific proteins that are detectable in cases of certain genetic mutations. These are known as band are produced by some pancreatic cancers. Examples include cancer antigen 19-9 (or CA 19-9). An increase in the levels of this protein in the blood can help the clinical team decide how best to treat the cancer. CA 19-9 measurements alone are not used to make therapy decisions.
  • Germline testing: Familial pancreatic cancer (FPC) is a term to describe families with an abnormally high rate of pancreatic cancer where at least two members of the family, who are first-degree relatives, suffer from pancreatic cancer. In these suspected families, genetic testing is conducted to detect certain mutations known as germline mutations. If found to be positive, the family is referred to a genetic counsellor to explain the diagnosis and future risks of developing cancer as well as to create a plan for follow up and screening.

TREATMENT OF PANCREATIC CANCER

• • Surgery: Operations used in people with pancreatic cancer include the following:
    • Tumours in the head of the pancreas: In these cases, a procedure known as Whipple procedure (pancreaticoduodenectomy) may be conducted. The procedure is technically challenging and involves the removal of the first part of the small intestine, the gallbladder, part of the bile duct and, in some cases, part of the stomach and lymph. A reconstruction surgery is then done to reconnect the remaining parts of your pancreas, stomach and intestines.
    • Tumours in the body and tail of the pancreas: These surgeries involve the removal of the left side of the pancreas and is called distal pancreatectomy.
    • Surgery to remove the entire pancreas: Removal of the entire pancreas is known as total pancreatectomy. The patient will be prescribed lifelong insulin and digestive enzymes.
    • Tumours affecting nearby blood vessels: In advanced cases involving the blood vessels, patients are ineligible for Whipple procedure or other pancreatic surgeries. These surgeries are performed by highly specialized and experienced surgeons which involve removal of the tumour and reconstruction of parts of blood vessels.

Side effects: Each surgery carries the risk of bleeding and infection. Other side effects include nausea, vomiting, leakage of stomach content into the abdomen etc.

• • Chemotherapy: Chemotherapy involves drugs which kill cancer cells taken through the mouth or injected into a vein. It may be combined with radiation therapy, also known as chemoradiation. This is typically used to treat cancer that has spread beyond the pancreas to nearby organs. Chemotherapy is used to control cancer growth and prolong survival in patients with advanced pancreatic cancer.
  • Radiation therapy: Radiotherapy uses high-energy beams to destroy cancer cells. It is typically prescribed when cancer can't be treated surgically. In most cases, external beam radiation is considered, which uses radiation from a machine outside the body. In some cases, intraoperative radiation therapy is considered which is delivered during surgery.
  • Endoscopic retrograde cholangiopancreatography (ERCP): ERCP is a procedure used to obtain pictures of the digestive tract and the pancreas. A dye is injected through a thin tube and multiple X-rays are taken, which allows doctors to diagnose pancreatic cancer or to treat its symptoms. It is useful to detect pancreatic cancer, get a biopsy (tumour samples), to identify if the tumour is blocking the pancreas or bile ducts which transport digestive enzymes and to treat jaundice by unblocking these tubes.
  • Percutaneous Transhepatic Cholangiogram (PTC): The PTC method is similar to ERCP. A dye is used to identify the obstruction on X-ray but rather than a tube being inserted through an endoscope, a needle will be inserted through the skin and a guide-wire passed through the liver and into the blocked bile duct. A stent is then passed along this wire and this stent helps relieve symptoms of jaundice and try and prevent a future block.
  • PEG Tube: This is a tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs, food and liquids. This form of feeding is called enteral nutrition and is used in end stage cancers.
  • Palliative care: This is specialized medical care by nurses and doctors that focuses on providing relief from pain and other symptoms of pancreatic cancer. Palliative care is prescribed in patients undergoing aggressive treatments, such as surgery, chemotherapy and radiation therapy. Palliative care aims to improve the quality of life for cancer patients and their families.

Sources: European Society of Medical Oncology (ESMO); Mayo Clinic; Cancer.Net; Pancreatic Cancer Action Network; National Cancer Institute

MULTI-DISCIPLINARY TEAM (MDT): Unlike most other diseases, cancer treatment requires an integrated approach from several specialists, each with their own expertise. This team of specialists who would work together on your cancer, is referred to as the Multi-Disciplinary Team (MDT). Many global organisations have recognized the importance of a MDT for cancer treatment, as it improves coordinated care to you, as a patient. Your MDT would include specialists from the following:

• • Gastroenterologist: Specialist dealing with diseases of the gastrointestinal tract. Performs the endoscopic procedures.
  • Surgeon or surgical oncologist: Specialist in operating on various types of cancer
  • Medical oncologist: Specialist who decides the optimum schedule and agent for chemotherapy
  • Radiation oncologist: Specialist in administering radiation therapy to treat cancer
  • Pathologist: Examines biopsies and other samples under the microscope
  • Radiologist: Specializes in using imaging tests to diagnose diseases such as gall bladder cancer
  • Palliative care specialist: Specialist in palliative and end-of-life care
  • Nutritionists: To customize diet during treatments.

Some hospitals that take an organ-based approach to cancer, have a separate department for Hepatobiliary Cancers (Liver, Gall bladder and also pancreas). These teams comprise of specialists who have dedicated training in cancers of the Hepatobiliary system.

TUMOR BOARD: A tumor board is a meeting where a Multi-Disciplinary Team discusses cancer cases and share knowledge. The board’s goal is to determine the best possible cancer treatment and care plan for an individual patient. Having fresh perspectives from other doctors makes it much easier to come up with that plan.

In some hospitals, all cancer cases are discussed at the Tumor Board, while in other hospitals the Tumor Board focuses on cases where a doctor seeks inputs from other specialists on the patient's case. It’s OK to ask your doctor if or why your case was discussed at a tumor board. Or if it wasn’t, why not? In some cases, a patient’s treatment plan is very straightforward using standard treatment guidelines, and the doctor may feel a tumor board review isn’t needed. However, you can request that one be done.

SUPPORT GROUPS: These are offline or online groups that connect patients suffering from cancer. Do find out about a support group around you. The hospital where you are being treated may have a support group that you could join.

Sources:  Mayo Clinic; 

Choosing your oncologist and hospital is a very important decision, we recommend you make the time to research your options. We profile doctors and hospitals based on range of services they offer to treat pancreatic cancer. Use our search tools to guide your selection of a medical provider. You may call us for any assistance during making a selection and booking.  

If you’ve been diagnosed with cancer, you need to find an oncologist to begin your treatment. An oncologist is a doctor who specializes in treating cancer. For pancreatic cancer, you can start by visiting a surgical oncologist or a medical oncologist. Choose someone you are not only confident about but also comfortable with.

TIPS TO FIND AN ONCOLOGIST 

1. 1. Look for Specialists: Look for doctors who treat your specific type of cancer - pancreatic cancer or hepatobiliary cancers (liver, gallbladder, bile ducts and pancreas). You may need to work with more than one type of oncologists – surgical, medical or radiation oncologists.
   2. Gather Feedback: Discuss with friends and family, especially those who’ve taken similar treatment before. Online communities are a quick way to get feedback from others who’ve experienced your type of cancer before.
   3. Check the doctor’s credentials: Find out if the doctor has received any advanced training. There may be super-specialists available for hepatobiliary cancers, who have received dedicated training on treating pancreatic If doctor’s credentials are not available easily, you have the right to ask for it from the doctor directly.
   4. Review doctor’s experience: Check how long the doctor has been practicing after completion of formal oncology education. How many patients with your type of cancer – pancreatic cancer – does the doctor see every year? In case of surgeons, studies have proven that higher volumes of surgeries lead to better outcomes. Organ-specific surgeons are also available in some hospitals, they have advance training and experience in operating cancers in specific organs.
   5. Find out hospital affiliations: Which hospitals does the doctor practice in? The availability of a multiple types of doctors at the hospital where you get treated is important. Find out what support staff is available at the hospital e.g. dietitian, counselor, home healthcare facilities etc.

TIPS TO FIND A HOSPITAL 

1. 1. Lookout for hospitals with lot of experts: Look for hospitals that offer a multi-disciplinary approach to hepatobiliary cancer treatment. This means each you receive inputs from many cancer experts. You will be helped by specialists including surgeons, medical oncologists, radiation oncologists, oncology nurses and other supporting staff. Find out if the hospital has surgeons with dedicated training for hepatobiliary cancers? Does the hospital have Tumor Board reviews – how often are they conducted and will your case be discussed there if you wish?
   2. Work with a major cancer hospital, even if it is far: Most experts in high-volume centers are willing to work with your local doctors. Usually, part of the treatment (for example, surgery) can be executed in the major center and the post-surgery treatment is executed locally.
   3. Research hospital’s Hepatobiliary Cancer volumes: How many cases of hepatobiliary cancer are treated in the hospital every year? High volume centers with multiple specialists available for hepatobiliary cancers may have better expertise and specialized medical infrastructure required.
   4. Consider Clinical Trials Availability: Ask whether the doctor or hospital has access to clinical trials and if you are eligible for any. Clinical trials are research studies that test new ways to treat cancer that you can be involved with. By being involved, you can help improve treatments and outcomes for future patients.
   5. Insurance Acceptance: Check if the hospital accepts your insurance. Check if the hospital has a desk that can assist you with claims.

Sources: Rogel Cancer Center; Cancer.Net