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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More About Steve Jobs and Pancreatic Cancer

Dear Dr. B: I read your column on Steve Jobs and pancreatic cancer. I am puzzled. You say that most people with pancreatic cancer survive only few months after the diagnosis. So how did Jobs, who was diagnosed in the fall of 2003 – and who revealed it publicly in 2004 – manage to survive for eight years? Is it because he could afford to buy good health care?

Answer: That is what it looks like. But the real story is different. Jobs had a rare form of pancreatic cancer, known as neuroendocrine cancer, which grows more slowly and is easier to treat. It is not unusual for patients to survive several years with this type of cancer.

Most common cancer of the pancreas is adenocarcinoma.. My sister had adenocarcinoma. So did Nobel Prize winner immunologist Ralph Steinman, actor Patrick Swayze and football great Gene Upshaw. They all died within a few months of diagnosis. Jobs, with his vast fortune, and Steinman, with his use of experimental immunological treatments, could not forestall indefinitely the dismal outcome of the disease. In the end, both kinds of pancreatic cancers are incurable.

What is the difference between adenocarcinomas and neuroendocrine (NE) tumours?

The pancreas has two distinct kinds of tissue, hence two very different types of cancer. About 95 per cent of pancreatic cancers are adenocarcinomas arising from exocrine glands of the pancreas. These glands produce enzymes to digest fat in our diet.

Scattered in that larger organ are thousands of tiny islands. These are islands of endocrine tissue which makes hormones like insulin that are secreted into the blood. Tumours in these cells are known as islet cells tumours or NE tumours. Jobs had NE cancer.

Approximately half of NE tumours are functioning and half are nonfunctioning. That means patients who have functioning tumours exhibit characteristic syndromes caused by the uncontrolled secretion of insulin, gastrin and other hormones. Consequently, functioning tumours are typically diagnosed when they are smaller than nonfunctioning tumours.

Unfortunately, most patients who have NE carcinomas have locally advanced or metastatic disease. Treatment is directed towards the metastatic disease of the liver. Surgery, chemotherapy, radiotherapy and immunotherapy have been tried. None of them are curative. But palliation and prolongation of life can be gained by few years.

Patients who have locally advanced disease have a median survival of about five years. One form of treatment that is not recommended for most pancreatic cancer is a liver transplant. There is speculation that the liver transplant Jobs received in 2009 had been necessary because the cancer had spread to his liver. In Jobs’ case, did liver transplant prolong his life?

Medical research suggests that patients should be considered for liver transplant if all or most (more than 90 per cent) of NE liver metastases can be resected. Liver resection is safe (operative mortality less than six per cent) and effectively palliates pain and hormonal symptoms in most patients.

Liver transplant may prolong survival but it is not curative because the disease recurs in most patients despite apparent complete resection. Patients who receive liver transplants must take immunosuppressant drugs for the rest of their lives to limit their risk for rejection. But while these drugs serve their purpose, a compromised immune system can leave patients vulnerable to other diseases. Liver transplantation must therefore be considered with great caution.

Steve Jobs was a controversial and complex man when he was alive. After his death, he continues to create speculation and controversy. May his soul rest in peace!

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Steve Jobs – a Victim of Pancreatic Cancer

Pancreatic cancer has taken another life. The prognosis for pancreatic cancer is dismal. The overall five year survival rate is less than two percent, the worst of any cancer. Only 20 percent of the patients will be diagnosed at a stage where surgery may offer hope.

Last time I wrote about pancreatic cancer was in 1996. That was the year my sister, Gulshan, age 60, passed away within three months of diagnosis of pancreatic cancer. Steve Jobs was 56. He lived for four years after having had a diagnosis of pancreatic cancer. He also received a liver transplant.

It has been 15 years since my sister died. Has anything changed to improve the prognosis of patients diagnosed with pancreatic cancer?

Before we look into that, let us look at some numbers. The Canadian Cancer Society’s document “Canadian Cancer Statistics 2010” says that in 2010, Canada will continue to see an increase in the number of individuals diagnosed with and dying from cancer. Every hour of every day, an average of 20 people will be diagnosed with some type of cancer and eight people will die from cancer.

Fifty per cent of the newly diagnosed cancer patients will be suffering from lung, colorectal, prostate and breast cancers. Cancer of the pancreas is 12th on the list of estimated number of new cases. About 4,000 new cases will be diagnosed – this will be equally divided amongst males and females. Almost the same number of people will die of pancreatic cancer each year. Death from pancreatic cancer is fifth on the list after lung, colorectal, breast and prostate.

An article in the Scientific American (January 2011) says that one of the reasons why the prognosis is so dismal in pancreatic cancer is that the disease is not typically diagnosed until 15 years after the first cancer-causing mutations appear, by which point the cancer has spread and become highly aggressive.

What does that mean? That means there may be plenty of time for doctors to intervene before pancreatic cancer becomes lethal. Then the tumour can be successfully removed and the prognosis can be improved with appropriate chemotherapy and radiotherapy, if indicated.

The article says researchers from John Hopkins found that cancer cells appear 10 years after the first cancer-causing mutation arises and that another five years pass before the cancer cells spread and become deadly. Research like this and many others gives hope for the future. In the last two years scientists have brought screening techniques for pancreatic cancer closer to reality.

The article says that these technologies are not available commercially but progress is expected to increase in the next decade. In the meantime, doctors should consider using CT and MRI scans to screen patients who are at high risk because of family history of the disease. Is that practical or economically feasible? There is no defined protocol for this and there are advantages and disadvantages of using CT or MRI scans as a screening tool in otherwise healthy individuals.

What causes pancreatic cancer? The precise cause is unknown. Smoking and chronic inflammation are suspected in the causation of the disease. An estimated 5-10 percent of pancreatic cancers are inherited and additional 10-20 percent may have other significant genetic influence. Most patients present with jaundice, abdominal pain, weight loss, or no appetite. By that time it is too late.

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Pancreatic Cancer

“Doc, few days ago, my neighbor’s wife, Yazmin, died of pancreatic cancer at the age of 59. Her husband, Yusuf, is devastated. He feels guilty. He thinks he could have done more to save her.”

Dave looks upset. I know when something is bothering him because normally he would say: What’s up doc? Busy today?

“Dave, here is some information which may help.”

Pancreatic cancer is the fifth leading cause of cancer death in North America. In 1992, 214 Albertans died of the disease (males 114, females 100). In 1993, 216 new cases were diagnosed in this province (males 98, females 118).

The prognosis is dismal. The overall 5 year survival rate is less than 2 percent, the worst of any cancer. Only 20 percent of the patients will be diagnosed at stage where surgery may offer hope.

The surgery is extensive with significant complications. Even those who survive the ordeal, the 5 year prognosis may not be better than 25 percent.

“Doc, why is it difficult to make an early diagnoses?”

Two main reasons: first, the pancreas is a long, narrow, transverse, deep seated organ behind the stomach in the upper abdomen; second, the initial symptoms are none or very vague. By the time ultrasound or CAT scan picks it up, it is too late.

Dave is surprised to hear that. He tells me about the difficulties Yusuf and Yazmin have overcome over the past 25 years. They had arrived penniless as refugees from Uganda with six children: the youngest, triplets, were about a year old.

Yusuf is a good watch repairer. After moving from few unsatisfactory jobs, he opened his own business: a jewelry shop. Yazmin did the “salesmanship” and Yusuf repaired watches. They were happy.

As parents, they had their share of problems raising children. Their oldest daughter has multiple sclerosis. Now, Yusuf has to deal with the tragedy of losing his wife.

Dave was almost in tears. “Doc, what causes pancreatic cancer?”

The precise cause is unknown. Smoking and chronic inflammation are suspected in the causation of the disease. An estimated 5-10 percent of pancreatic cancers are inherited and additional 10-20 percent may have other significant genetic influence (Current Oncology-July 1998).

“Doc, thanks for listening. I will go and see Yusuf. See if I can help him with the information I have.”

Good luck, Dave.

(This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems)

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