World Cancer Day is February 4th
"It's not a very common cancer," says Mark Trouti, M.D. , a surgical oncologist at the Mayo Clinic. "The lifetime risk of pancreatic cancer for any patient without any predisposing risk is only 1 to 3%."
According to the National Cancer Institute , pancreatic cancer accounts for 3.2% of all new cancer cases, but it causes about 8% of all cancer deaths. The 5-year survival rate for people with pancreatic cancer is only 10.8%.
Here are five things everyone should know about this deadly cancer:
- Pancreatic cancer is aggressive and causes nonspecific symptoms.
“In 50 percent of patients, when they are diagnosed, the cancer has spread beyond the pancreas to other organs, meaning they have reached stage 4 metastatic pancreatic cancer,” says Dr. Trotti.
This happens for two reasons. First, pancreatic cancer cells are very aggressive, accumulating and forming tumors and spreading to nearby organs at a rapid rate. Second, pancreatic cancer rarely causes symptoms before it spreads outside the pancreas. When it does cause symptoms, they are nonspecific, such as abdominal or back pain or weight loss, all of which may be caused by something other than pancreatic cancer.
"It's not worth screening everyone who has indigestion, gas, abdominal pain or back pain, because only a small percentage of them will develop this cancer," says Santi Swarup Vije, MD , a gastroenterologist at the Mayo Clinic.
"We only associate symptoms with pancreatic cancer when we see certain things such as: jaundice, yellowing of the skin, lighter stools, darker urine, or recent appearance of diabetes," Dr. Trouti continues.
Another specific symptom of pancreatic cancer is diabetes that is difficult to treat and appears suddenly.
- Diagnosing pancreatic cancer is a multistep process.
When a doctor suspects a patient has pancreatic cancer, the first step is imaging tests to visualize the internal organs. Computerized tomography (CT) scans are often used.
“We do what we call a protocol CT scan of the pancreas,” Dr. Figi explains. "If the radiologist confirms the presence of a mass in the pancreas, then we are 90 percent certain that it is pancreatic cancer." If for some reason a CT scan is not possible, or a CT scan is inconclusive, an MRI may be used. If imaging confirms a strong possibility of pancreatic cancer, the next step is a blood test.
“Once we do a CT scan that indicates pancreatic cancer, we do a blood test for a tumor marker called CA19-9, because 85% to 90% of people with pancreatic cancer have elevated values,” says Dr. Figi. "And if the blood test confirms high values of CA19-9, we use it as a baseline value test to follow up on the disease after we start treatment."
A blood test does not confirm the presence of pancreatic cancer, as some people with pancreatic cancer do not have elevated levels of CA19-9. A definitive diagnosis requires a biopsy (a sample of tissue for testing). "Cancer is not considered cancer until we have a biopsy to prove it," Dr. Figi adds.
At Mayo Clinic, a sample of tissue is often collected during an ultrasound endoscopy. During this procedure, an ultrasound device is passed through a thin, flexible tube (endoscope) through the esophagus and into the stomach, through which a needle can be inserted into the pancreas to collect tissue.
The tissue sample is then tested to confirm a diagnosis of pancreatic cancer. If the diagnosis is confirmed, the tissue is also analyzed for indications that may help determine the most effective treatment for that patient's cancer.
- The cause of most pancreatic cancers is not clear.
Doctors have identified some factors that may increase the risk of pancreatic cancer, including: smoking, diabetes, chronic pancreatitis, obesity, and family history, but the exact cause isn't clear.
"For the vast majority of patients, there is no predisposition associated with the disease other than behaviors such as smoking or diabetes," Dr. Trotte continues.
For his part, says Dr. Fiji: "Approximately 10% of pancreatic cancers have a genetic basis." And only about 8% of pancreatic cancers are familial, meaning that the patient has a first-degree or second-degree relative with pancreatic cancer.
Other pancreatic cancers are associated with a family history of genetic syndromes that may increase the risk of cancer, including: BRCA2 mutation, Lynch syndrome , and familial atypical multiple melanoma syndrome (FAMMM). "Only about 2% of pancreatic cancers are genetic syndromes of pancreatic cancer, and they are associated with inherited clinical syndromes," says Dr. Figi.
Research has shown that a combination of smoking, long-term diabetes, and a poor diet increases the risk of pancreatic cancer more than any of these factors alone.
- There is no good way to detect pancreatic cancer.
Doctors do not yet have a good way to screen large parts of the population for pancreatic cancer. “There is no good screening test that is cheap, effective, safe and feasible, such as a cervical cancer test, mammogram or colonoscopy,” says Dr. Fiji.
"For those who have a first-degree relative with pancreatic cancer - especially if they have two first-degree relatives with pancreatic cancer, we do some kind of MRI screening every year," Dr. Feiji continues. "And maybe we do an ultrasound every three years."
For those without a family history of pancreatic cancer, screening is not available.
Dr. Trotti, Dr. Fiji and other Mayo Clinic researchers are mining patient data for clues that can help them develop guidelines for pancreatic cancer screening. “We are looking at data from patients who have recently had diabetes and who have been diagnosed with pancreatic cancer,” says Dr. Fiji. "And for those who also have indigestion, abdominal symptoms, and elevated CA19-9 levels, we add the blood sugar levels over the previous three years and we can develop a risk estimate of approximately 50% to 74%."
The Mayo Clinic is a partner with the National Cancer Institute Pancreatic Cancer Detection Consortium to develop and test new methods for detecting early-stage pancreatic cancer for use in identifying people at risk for pancreatic cancer.
- Treatments and outcomes are improving.
For people whose pancreatic cancer has already spread to other organs at diagnosis, chemotherapy is the primary treatment. Also, patients whose cancer is confined to the pancreas may be candidates for radiation and surgery.
If a patient's tumor does not involve any important blood vessels or critical veins and arteries, patients usually have surgery to remove the tumor. "We've been doing this for several decades," says Dr. Trotti. "Unfortunately, the long-term results are poor. A large proportion of these patients develop early recurrent disease in distant sites, which means that the cancer has already spread and we were not aware of it."
To determine if surgery is the best option, Dr. Trouti looks at three questions:
- Is there evidence of cancer spreading?
- Can a tumor be removed without leaving any cancer cells?
- Is the patient fit enough to tolerate the surgery and recover enough to receive chemotherapy?
"We know that patients who have surgery to remove their tumors can live much longer than those who did not," Dr. Trotte explains. "But if we do the surgery and leave some cancer cells behind, or the patient has complications and can't tolerate chemotherapy, we're wasting the benefits."
Dr. Trotti and many other pancreatic cancer providers currently treat patients before surgery with a combination of chemotherapy, plus or without radiation. They also do more extensive operations.
“We have expanded our criteria for patients who qualify for surgery, and we currently operate on patients whose tumors involve large blood vessels, such as veins and arteries,” says Dr. Trotti. "Improved chemotherapy, appropriate radiation, and more complex operations all have significantly improved long-term outcomes."
Currently, Dr. Trotti and Dr. Fiji see some patients survive four to six years with this combination of treatments. "The goal is to extend the patient's life and maintain or improve the patient's quality of life," concludes Dr. Trouti. "And that's the outcome any cancer patient would want, and we're trying to get there using all the tools we have."
For more information, see the Mayo Clinic Cancer Center blog .
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Reporters: Dr. Trotti and Dr. Fiji discuss pancreatic cancer in a Mayo Clinic Q&A video in English.
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