Are we making any progress in the management of pancreatic cancer?

"We can learn a lot from trees: they're always grounded but never stop reaching heavenward." -Everett Mamor
"We can learn a lot from trees: they're always grounded but never stop reaching heavenward." -Everett Mamor

Some years ago, my sister died of pancreatic cancer. She was only 60-years old. Not long ago, a friend of mine died of the same illness. Over the years, as a general surgeon, I have looked after many patients with pancreatic cancer. None of them lived more than six to 12 months after diagnosis.

Most common pancreatic cancer is pancreatic adenocarcinoma and this represents more than 90 per cent of diagnoses.

Long-term prognosis for pancreatic cancer depends on the size and type of the tumor, lymph node involvement and degree of metastasis at the time of diagnosis. The earlier pancreatic cancer is diagnosed and treated, the better the prognosis. Is this possible?

Unfortunately, pancreatic cancer usually shows little or no symptoms until it has advanced and spread. Therefore, most cases (up to 80 percent) are diagnosed at later, more difficult-to-treat stages.

Compared with many other cancers, the combined five-year survival rate for pancreatic cancer – the percentage of all patients who are living five years after diagnosis – is very low at just five to 10 per cent. This is because far more people are diagnosed as stage IV when the disease has metastasized.

With this information in my mind, I was curious to read an article on this subject in the Canadian Medical Association Journal (Advances in the management of pancreatic ductal adenocarcinoma, CMAJ June 7, 2021).

The article says the incidence of pancreatic carcer is rising and is projected to become the third leading cause of cancer death in Canada. The reason for this is not known. Observational studies have shown that smoking, obesity and a prolonged history of diabetes, are associated with a higher risk of developing pancreatic cancer. A family history of pancreatic cancer in a first degree relative is reported in about 10 per cent of patients.

Surgical resection remains the only opportunity to cure pancreatic cancer, and only about 20 per cent of patients present with resectable disease.

The CMAJ article has five recommendations for the management of pancreatic cancer:

  1. Germline testing is now recommended for all patients with pancreatic cancer. Pancreatic cancer is associated with numerous hereditary syndromes and the results of germline testing can help guide treatment selection.
  2. In suitable patients, modified FOLFIRINOX is the adjuvant chemotherapy regimen of choice, after surgical resection.
  3. Neoadjuvant approaches for resectable disease are increasingly common and should be considered in patients with high-risk features such as an elevated carbohydrate antigen 19.9 level at diagnosis.
  4. Patients with borderline resectable or locally advanced pancreatic cancer should have induction combination chemotherapy, when possible, before consideration of surgical resection or a local therapy.
  5. If resources allow, patients with advanced pancreatic cancer should have molecular profiling of their tumours to detect uncommon but therapeutically targetable somatic alterations.

These five treatment options are not easy to understand for people who are not involved in the management of pancreatic cancer. And cure for pancreatic cancer is nowhere in sight. Cure is only possible if the cancer is diagnosed early. Only up to 10 per cent of patients who receive an early diagnosis become disease-free after treatment. For rest of the pancreatic cancer patients the prognosis is poor.

If the tumour is resectable and there are no metastases then the person can live for 2.5 years after their diagnosis and have a five-year survival rate of 20 to 30 percent.

For early detection of cancer, we put many individuals through screening tests like pap smears, mammograms, colonoscopies etc. Should we put individuals age 60-years and older to go through ultrasound, computerized tomography (CT) scans, magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS) to pick up early pancreatic cancer? Can the health care system afford the cost of it? How many people will benefit? How many lives will be saved? Something for us to think about.

Be safe. Take care.

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