USEFUL Information on Pancreatic Cancer

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Cancer of the pancreas is also called carcinoma of the pancreas, or

pancreatic cancer.

Cancer occurs when for some reason, cells begin to divide without order or

control.

Because of the location of the pancreas, cancer may grow for some time before

it causes symptoms.

Cancer of the pancreas can also cause nausea, loss of appetite, weight loss,

and weakness.

This disease can be cured only when it is found at an early stage, before it

has spread.

Various treatments can be considered for this disease.

Alternately You can check http://www.xtramsn.co.nz/health/0,,8065-3759276,00.htm

DescriptionWorld-wide, cancer of the pancreas is responsible for about five

percent of cancer deaths annually. It is often referred to as the " silent

disease " because symptoms are few and non-specific, leading to late diagnosis in

the majority of cases.

Cancer of the pancreas tends to affect people over the age of 50, and most

sufferers are aged 65 to 80 at the time of diagnosis. Men are at slightly higher

risk than women.

The pancreas is located in the central upper abdomen. It is surrounded by the

stomach, intestines and other organs. The pancreas is about six inches long and

is shaped like a long, flattened pear - wide at one end and narrow at the other.

It is divided into three parts - the wide part is called the head, the narrow

end is the tail, and the middle section is called the body. It has a duct

running down the centre.

The pancreas is a gland that has two main functions. It makes pancreatic juices

and it produces several hormones, including insulin. Pancreatic juices contain

proteins called enzymes that help digest food. The pancreas releases these

juices into a system of ducts, as they are needed. The main pancreatic duct

joins the common bile duct from the liver and gallbladder. (The common bile duct

carries bile, a fluid that helps digest fat.) Together these ducts form a short

tube that empties into the duodenum, which is the first section of the small

intestine.

Pancreatic hormones help the body use or store the energy that comes from food.

For example, insulin helps control the amount of sugar (a source of energy) in

the blood. The pancreas releases insulin and other hormones when they are

needed. They enter the bloodstream and travel throughout the body.

Cancer occurs when for some reason, cells begin to divide without order or

control. They may invade and destroy the tissue around them. Also, cancer cells

can break away from the primary (original tumour) and enter the bloodstream or

the lymphatic system. This process is the way cancer spreads to form new tumours

in other parts of the body. These new tumours are called metastases.

Several types of cancer can develop in the pancreas. Most pancreatic cancers

begin in the ducts that carry pancreatic juices, but a very rare type of

pancreatic cancer may begin in the cells that produce insulin and other

hormones. These cells are called islet cells, or the islets of Langerhans.

Cancers that begin in these cells are called islet cell cancers. As pancreatic

cancer grows, the tumour may invade organs that surround the pancreas, such as

the stomach or small intestine. Cells may also break off from the tumour and

travel to the lymph nodes or to other organs like the liver or lungs. This

usually only occurs when the cancer is quite large.

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Cause

Despite extensive studies, no definite cause for pancreatic cancer has been

identified. There are, however, several identifiable risk factors. A risk factor

is something which may increase a person's chances of contracting the cancer,

but which does not directly cause it. Several of these are mentioned below:

Smoking -- has a definite association with pancreatic cancer, and cigarette

smokers develop this disease two to three times more often than non-smokers.

Stopping smoking reduces the risk by about 30%.

Diet -- is important. Diets high in red meat and animal fats have been shown

to be associated with pancreatic cancer, while diets high in fresh fruit and

vegetables help to prevent the disease.

Diabetes -- having diabetes is another risk factor. People who have diabetes

develop pancreatic cancer about twice as often as non-diabetics. This refers

mainly to patients with insulin dependent diabetes, especially if it was

diagnosed before the age of 40.

Chronic inflammation -- of the pancreas and a previous history of upper

gastro-intestinal surgery have also been shown in some studies to predispose to

pancreatic cancer.

Occupational exposure to petroleum and certain chemicals -- some studies

suggest that this may increase the risk of pancreatic cancer. These possible

links have not been proven, but workers should follow the safety rules provided

by employers.

Sex -- men get pancreatic cancer more frequently than women

Race -- black people are more frequently affected than white, Hispanic or

Asian people.

Family history -- a first degree relative with the disease triples the risk.

Family history of colon or ovarian cancer also increases the risk.

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Symptoms

Because of the location of the pancreas, cancer may grow for some time before it

causes symptoms. When symptoms do appear, they may be so vague that they are

ignored at first. For these reasons, pancreatic cancer is hard to find early. In

many cases, the cancer has spread outside the pancreas by the time it is found.

When symptoms do appear, they depend on the location and size of the tumour. If

the tumour is located in the head of the pancreas, it may block the common bile

duct so that bile cannot pass into the intestines. This causes the skin and the

whites of the eyes to become yellow, and the urine to become dark. This

condition is called jaundice.

Cancer starting in the body or tail of the pancreas often causes no symptoms at

all until it grows and spreads. This causes pain, which may be felt in the upper

abdomen and sometimes spreads to the back. The pain may become worse after the

person eats or lies down. Leaning forward typically relieves the pain.

Cancer of the pancreas can also cause nausea, loss of appetite, weight loss, and

weakness.

Islet cell cancer can cause the pancreas to make too much insulin or other

hormones. When this happens, the person may feel weak or dizzy and may have

chills, muscle spasms, or diarrhoea.

All the symptoms mentioned above may be caused by cancer but are more commonly

caused by other, less serious problems. Persistence of any of these symptoms

should alert the patient to seek medical attention. Only special investigations

by a doctor can lead to the correct diagnosis.

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Diagnosis

To find the cause of a person's symptoms, the doctor will ask for a detailed

medical history and perform a physical exam. This may include blood, urine and

stool tests.

He or she may order various special investigations to be done, including:

An upper GI series (sometimes called a barium meal). -- is a series of X-rays

of the upper digestive system, taken after the patient has drunk a barium

solution. The barium shows an outline of the digestive organs on the X-rays.

A CT scan. -- This uses a computerised X-ray machine to show images of the

internal organs. The patient lies on a bed which moves through a circular hole

as the machine takes pictures. He or she may be asked to drink a special

substance prior to the scan - this will show up the bowel more easily.

An MRI scan. -- This uses a powerful magnet linked to a computer. The MRI

machine is very large, with space for the patient to lie in a tunnel inside the

magnet. The machine measures the body's response to the magnetic field, and the

computer uses this information to make detailed pictures of areas inside the

body.

Ultrasonography. -- This uses high-frequency sound waves that cannot be heard

by humans. A small instrument sends sound waves into the patient's abdomen.

These cannot be felt, but the echoes bounce off internal organs, creating a

picture called a sonogram. Healthy tissues and tumours produce different echoes.

This investigation is good for thin people, but fat may distort the signal.

ERCP. -- This is a method for taking X-rays of the common bile duct and

pancreatic ducts. The doctor passes a long, flexible tube (endoscope) down the

throat, through the stomach, and into the small intestine. Dye is then injected

into the ducts and X-rays are taken. This procedure is usually done under

sedation.

PTC. -- A thin needle is put into the liver through the skin on the right

side of the abdomen. Dye is injected into the bile ducts in the liver, so

blockages can be seen on X-rays.

Angiography. -- This involves injecting dye into blood vessels so that they

show up on the X-rays.

Biopsy may be done in some cases.

The information from all these tests is used to help make a diagnosis, and also

to provide information about how advanced the disease is. This is called

staging. In cancer of the pancreas, three stages of the disease are recognised:

Localised disease - where the disease is limited to the pancreas alone. This can

usually be treated with surgery.

Locally advanced disease - where the cancer has spread from the pancreas itself,

to involve the organs adjacent to it.

Metastatic disease - where the cancer has spread in the blood to involve other

organs far from the pancreas. For example, the lungs.

The final diagnosis is made after a biopsy is done. This is usually under

ultrasound guidance, where a needle is inserted into the tumour and some cells

removed. A pathologist examines these under a microscope, and checks for cancer

cells. In cases where surgery is the treatment of choice, biopsy might be done

at the same time.

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Preparation for visit to the doctor

Many people with cancer want to learn all they can about their disease and their

treatment choices, so they can take an active part in decisions about their

medical care. When a person is diagnosed with cancer, shock and stress are

natural reactions. These feelings may make it difficult for people to think of

all the questions that they want to ask the doctor. It often helps to make a

list. Some patients also want to have a family member or friend with them when

they talk to the doctor - to take part in the discussion, to take notes, or just

to listen.

Patients do not need to ask all their questions or remember all of the answers

at one time. They will have other chances to ask the doctor to explain things

and to get more information. These are some questions a patient may want to ask

the doctor before treatment begins:

What is my diagnosis?

What is the stage of the disease?

What are my treatment choices? What does each treatment involve? Which do you

recommend? Why?

What are the risks and possible side effects of each treatment?

What are the chances that the treatment will be successful?

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TreatmentCancer of the pancreas is very hard to control. This disease can be

cured only when it is found at an early stage, before it has spread. However,

even when the disease is advanced, treatment can improve the quality of a

person's life by controlling the symptoms and complications of the cancer.

People with pancreatic cancer are often treated by a team of specialists - which

may include surgeons, medical oncologists, radiation oncologists, and

endocrinologists. The choice of treatment depends on the type of cancer, the

stage of the cancer, and the general health of the patient. Of course, the

patient has the final say in the treatment proposed.

Cancer confined to the pancreas -- or with minimal local spread, may be treated

with surgery. This is often used in combination with chemotherapy and radiation

therapy. Some oncologists prefer to give combined chemo- and radiation therapy

for two to three months prior to surgery, while others prefer to give it

afterwards. In some centres, radiation may also be given during the operation.

Curative surgery is major surgery, and is only done by a specialist surgeon. The

Whipple procedure involves removal of the head of the pancreas, as well as the

duodenum, part of the stomach, bile duct and nearby lymph nodes. Cancer in the

body or tail of the pancreas usually requires a total pancreatectomy, which is

removal of the entire pancreas, as well as duodenum, gallbladder, bile duct,

spleen and lymph nodes. Unfortunately during surgery doctors frequently discover

that the cancer is more advanced than it had appeared on the scans, so the

operation is stopped. Such major surgery is not advised unless the entire tumour

can be removed.

The length of time it takes to recover from an operation varies for each person.

During recovery from surgery, a patient's diet and weight are checked carefully.

At first, patients may be fed only liquids and may be given extra nourishment

via a drip. Foods are added gradually. When the entire pancreas is removed, and

even sometimes when only part of the pancreas is removed, people with pancreatic

cancer may not have enough pancreatic juices or hormones. In these cases,

problems with digestion may occur. The doctor can suggest an appropriate diet

and prescribe medicine to help relieve diarrhoea or other problems such as pain,

feelings of fullness, or cramping.

See below for more information about nutrition for people with cancer.

Patients who do not have enough pancreatic hormones may develop other problems

too. For example, those who do not have enough insulin may develop diabetes. The

doctor can treat this problem by giving patients hormones to replace those no

longer produced by the pancreas.

If complete removal of the cancer is not possible, less radical surgery can help

to relieve symptoms due to blockage of the bowel or bile duct. In these cases a

bypass procedure is performed, or a stent inserted.

Locally advanced disease -- In these cases surgery is not a curative option. It

may be used to relieve obstructive symptoms as mentioned above, but its only

place is palliative. The main treatment in these cases would be radiation and

chemotherapy - either separately or together. These have been shown in several

studies to greatly relieve symptoms and improve quality of life.

Metastatic disease -- Once pancreatic cancer has spread to distant sites in the

body it cannot be cured. Several studies have looked at ways of trying to

improve the quality of life for patients who have such advanced disease.

Radiation may help to relieve pain, and several types of chemotherapy have been

shown to improve appetite and relieve pain. Unfortunately, these treatments do

not improve life expectancy. Despite this, the patients who received these

treatments in trials reported a definite benefit when compared to patients who

did not receive treatment.

Radiation therapy - (also called radiotherapy) is the use of high-energy rays to

damage cancer cells and stop them from growing and dividing. Like surgery,

radiation therapy is local therapy; the radiation can affect cancer cells only

in the treated area. The patient lies on a bed and a machine, similar to an

X-ray machine, is used to aim the radiation at the area defined by the radiation

oncologist. Doctors may use radiation therapy before surgery to shrink a tumour

so that it is easier to remove, or after surgery to destroy cancer cells that

may remain in the area. Radiation may also be given alone or with chemotherapy

to relieve pain or digestive problems if the tumour cannot be removed. In most

cases, patients receive radiation treatment as an outpatient in a hospital or

clinic. The treatments are short - usually lasting only minutes - but must be

given daily, four or five times a week. The course may be as short as three

weeks or last for several weeks, depending on what is

being treated.

Side effects of radiation depend on the dose given and the area treated.

Patients receiving radiation tend to get very tired, especially towards the end

of the treatment.

The skin in the treatment area may become itchy and red. The patient will be

asked not to wash or rub this area during treatment or to use any creams or

lotions without discussing this with the doctor first, as they may exacerbate

the problem. The skin will heal after radiation, but there may be permanent

" bronzing " of this area. There will also be hair loss (in the treated area

only).

Radiation over the abdomen can also cause nausea and vomiting as well as

diarrhoea and pain on swallowing. Medication can be given to combat these

problems, and they usually disappear at the end of the treatment.

Chemotherapy -- is the use of drugs to kill cancer cells. It may be given alone

or together with radiation therapy - either before or following surgery in early

cases, or to relieve symptoms of the disease if the cancer cannot be removed.

The doctor may use one drug or a combination of drugs.

Chemotherapy is usually given in cycles: a treatment period followed by a

recovery period, then another treatment period, and so on. Most anticancer drugs

are given by injection into a vein (IV); some are given by mouth. Chemotherapy

is a systemic therapy - meaning that the drugs flow through the body in the

bloodstream. Usually a person receives chemotherapy as an outpatient (at the

hospital, or at the doctor's office). However, a short hospital stay may be

needed, depending on the person's general health and on which drugs are used.

The side effects of chemotherapy depend on the specific drugs and doses used.

They also vary greatly from person to person. Before starting chemotherapy your

doctor will explain to you fully, the side effects that you can expect. Most

chemotherapy drugs affect all rapidly dividing cells in the body. That means

that the normal cells most commonly affected are the bone marrow cells, the hair

root cells, and the cells lining the digestive tract. For this reason, the blood

count must be monitored before every cycle of chemotherapy. The number of red

blood cells, white blood cells and platelets is monitored, as drops in any of

these counts can lead to problems. Many, but not all, of the chemotherapy drugs

may cause the hair to fall out. Also, during the first week or so after the

chemotherapy, certain drugs may cause ulcers in the mouth, nausea and vomiting,

or diarrhoea. The patient will be warned if this is to be expected with the

proposed treatment.

Pain Control

Pain is a common problem for people with pancreatic cancer, especially when the

cancer grows outside the pancreas and presses against nerves and other organs.

However, this can usually be controlled. It is important for patients to report

their pain so the doctor can take steps to help relieve it.

There are several ways to control pain caused by pancreatic cancer. In most

cases the doctor prescribes medicine; sometimes a combination of pain medicines

is needed. Pain relief medication may make some people drowsy and constipated,

but resting and taking laxatives may relieve this. In some cases, pain medicine

is not enough and the doctor may need to use other types of treatment that

affect nerves in the abdomen. For example, the doctor may inject alcohol into

the area around certain nerves to block the feeling of pain. This injection can

be done during surgery or by using a long needle inserted through the skin into

the abdomen. This procedure rarely causes problems and usually works. Sometimes

the surgeon cuts nerves in the abdomen to block the feeling of pain. In

addition, radiation therapy can help relieve pain by shrinking the tumour.

Occasionally, it may be necessary to insert an epidural catheter, through which

pain medication can be delivered daily. This involves an

injection rather like a lumbar puncture, where a small plastic tube is placed

into the space around the spinal cord, and medication is slowly injected

throughout the day by means of a syringe driver, which is carried in the pocket.

Second opinionA diagnosis of cancer has major implications. Many patients find

the diagnosis difficult to believe, especially if their symptoms have not been

sudden and obvious. In this case, the patient may like to obtain a second

opinion. The family doctor may be able to suggest a second oncologist to

consult. If a second pathology opinion is needed, the oncologist can arrange

this. Alternatively, cancer societies or the local hospital can help the patient

find a second opinion.

Clinical Trials Doctors conduct clinical trials to learn about the effectiveness

and side effects of new treatments, and many people with cancer take part in

these trials. In some clinical trials, all patients receive the new treatment.

In others, doctors compare different therapies by giving the new treatment to

one group of patients and the standard therapy to another group.

People who take part in these studies have the first chance to benefit from

treatments that have shown promise in earlier research. They also make an

important contribution to medical science. In clinical trials for pancreatic

cancer, doctors are studying different ways of giving radiation therapy, aiming

the rays at the cancer during surgery or implanting radioactive material in the

abdomen. They are also exploring new ways of giving chemotherapy, new drugs and

drug combinations, biological therapy, and new ways of combining various types

of treatment. Some trials are designed to study ways to reduce the side effects

of treatment and to improve quality of life. People interested in taking part in

a trial should discuss it with their doctor.

Nutrition for Cancer Patients

Eating well during cancer treatment means getting enough calories and protein to

help prevent weight loss and maintain strength. Proper nutrition often helps

people feel better and have more energy. However, some people with cancer find

it hard to eat well, and may lose their appetite. Common side effects of

treatment such as nausea, vomiting, or mouth sores can make eating difficult.

Often, foods taste different. Also, people being treated for cancer may not feel

like eating when they are uncomfortable or tired.

Cancer of the pancreas and its treatment may interfere with the production of

pancreatic enzymes and insulin. As a result, patients may have problems

digesting food and maintaining the proper blood sugar level. They may need to

take medicines to replace the enzymes and hormones normally produced by the

pancreas. These medicines must be given in just the right amount for each

patient. The doctor will watch the patient closely and adjust the doses or

suggest diet changes when needed. Careful planning and check-ups are important

to help avoid nutrition problems leading to weight loss, weakness and lack of

energy.

Doctors, nurses and dieticians can offer advice on how to eat well during cancer

treatment.

Follow-upRegular follow-up exams are very important after treatment for

pancreatic cancer. The doctor will continue to check the person closely, so that

if the cancer returns or progresses, it can be treated. Check-ups may include a

physical exam; blood, urine, and stool tests; chest X-rays; and CT scans.

People taking medicine to replace pancreatic hormones or digestive juices need

to see their doctor regularly, so the dose can be adjusted if necessary. Also,

it is important for the patient to let the doctor know about pain or any changes

or problems that occur.

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Support for Cancer Patients Living with a serious disease is not easy. People

with cancer and those who care about them face many problems and challenges.

Coping with these problems is often easier when people have helpful information

and support services. Worries about tests, treatments, hospital stays, and

medical bills are common. Doctors, nurses, and other members of the health care

team involved in support organisations can talk with patients and their families

about these concerns. Meeting with a social worker, counsellor, or a religious

leader also can be helpful to those who want to talk about their feelings or

discuss their concerns.

Cancer patients and their families may want to know what the future holds.

Sometimes they use statistics to try to predict what may happen. It is important

to remember that statistics are averages based on large numbers of patients.

They cannot be used to predict what will happen to a particular patient because

no two patients are alike, and treatments and responses vary greatly. The doctor

who takes care of the patient is in the best position to talk about the person's

outlook (prognosis).

Friends and relatives can be very supportive. Also, many people find it helpful

to discuss their concerns with others who have cancer. People with cancer often

get together in support groups, where they can share what they have learned

about coping with cancer and the effects of treatment. It is important to keep

in mind, however, that each patient is different. Treatment and ways of dealing

with cancer that work for one person may not be right for another - even if they

both have the same kind of cancer. It is always a good idea to discuss the

advice of friends and family members with the doctor.

Often, a social worker at the hospital or clinic can suggest groups that provide

emotional support or that help with rehabilitation, financial aid,

transportation, or home care.

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Prevention

The best preventative measure is not to smoke, and to follow a healthy lifestyle

and diet. People who think they may be at risk for pancreatic cancer should

discuss this concern with their doctor. The doctor may be able to suggest ways

to reduce the risk and can suggest an appropriate schedule of check-ups.

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Rupesh Parajuli

Nepal Chapter

Pancreatitis Association International (PAI)

Post Box No: 13946, Kathmandu, Nepal

Tel: 977-1-4479627, Fax: 977-1-4476878/4460560

Mobile: 977-9851078750

rupesh_parajuli@...

www.pancassociation.org

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