Malignancy of the pancreas, Cancer that starts in the pancreas is called pancreatic cancer. Pancreatic cancer has been called a "silent" disease because early pancreatic cancer usually does not cause symptoms. If the tumor blocks the common bile duct and bile cannot pass into the digestive system, the skin and whites of the eyes may become yellow (jaundiced), and the urine darker as a result of accumulated bile pigment called bilirubin.

The pancreas is a spongy, tube-shaped organ about 6 inches long. It is located in the back of the abdomen, behind the stomach. The head of the pancreas is on the right side of the abdomen. It is connected to the duodenum, the upper end of the small intestine. The narrow end of the pancreas, called the tail, extends to the left side of the body. Patients with any stage of pancreatic cancer are candidates for clinical trials because of the poor response to chemotherapy, radiation therapy, and surgery as conventionally used. The pancreas is divided functionally into the endocrine pancreas (that makes insulin and other hormones) and the exocrine pancreas (that makes pancreatic enzymes to aid the digestion). This information is limited to cancer of the exocrine pancreas, which is far and away the most common type of pancreatic cancer.

The pancreas makes pancreatic juices and hormones, including insulin. Pancreatic juices, also called enzymes, help digest food in the small intestine. Insulin controls the amount of sugar in the blood. As pancreatic juices are made, they flow into the main pancreatic duct. This duct joins the common bile duct, which connects the pancreas to the liver and the gallbladder. The common bile duct which carries bile (a fluid that helps digest fat), connects to the small intestine near the stomach. Despite the high mortality rate associated with pancreatic cancer, its causation is poorly understood. Smoking is known to be a major risk factor. Cigarette smokers develop cancer of the pancreas two to three times more often than do nonsmokers. Quitting smoking reduces the risk of pancreatic cancer.

Cancer of the pancreas is rarely curable. The overall survival rate is less than 4%. The cure rates are highest (although still usually under 25%) if the tumor is small (less than 2 cm in diameter) and is truly localized to the pancreas but, unfortunately, such cases account for fewer than 20% of all cases of pancreatic cancer. For patients with advanced cancers, the overall survival rate of all stages is less than 1% at 5 years with most patients dying within 1 year. Staging of the tumor is important to the diagnosis and to the identification of patients with disease that cannot be resected (removed by surgery). Staging has been aided by advances in imaging technology, including the spiral computed tomographic (CT) scan, magnetic resonance imaging (MRI) scan, positron emission tomographic (PET) scan, endoscopic ultrasound, and laparoscopic staging.

However, palliation to ease or relieve symptoms may be achieved with conventional treatment. Palliative measures may include surgical or radiologic biliary decompression, relief of gastric outlet obstruction, and pain control. These and other measures may significantly improve the quality of life.

It is essential to address the potentially disabling psychological events associated with the diagnosis and treatment of pancreatic cancer. The impact of this disease can weigh heavily upon the patient and all those close to him or her.

What is cancer?

Cancer is a group of diseases. More than 100 different types of cancer are known, and several types of cancer can develop in the pancreas. They all have one thing in common: abnormal cells grow and destroy body tissue. Healthy cells that make up the body's tissues grow, divide, and replace themselves in an orderly way. This process keeps the body in good repair. Sometimes, however, some cells lose the ability to control their growth. They grow too rapidly and without any order. Too much tissue is made, and tumors are formed. Tumors can be benign or malignant. Benign tumors are not cancer. They do not spread to other parts of the body and are hardly ever a threat to life. Often, benign tumors can be removed by surgery, and they are not likely to return. Malignant tumors are cancer. They can invade and destroy nearby healthy tissues and organs. Cancer cells also can break away from the tumor and spread to other parts of the body. The spread of cancer is called metastasis.

Cancer that starts in the pancreas is called pancreatic cancer. When pancreatic cancer spreads, it usually travels through the lymphatic system. The lymphatic system includes a network of thin tubes that branch, like blood vessels, into tissues all over the body. Cancer cells are carried through these vessels by lymph, a colorless, watery fluid that carries cells that fight infection. Along the network of lymphatic vessels are groups of small, bean-shaped organs called lymph nodes. Surgeons often remove lymph nodes near the pancreas to learn whether they contain cancer cells. Cancer cells can also be carried through the bloodstream to the liver, lungs, bone, or other organs. Pancreatic cancer that spreads to other organs is called metastatic pancreatic cancer.

What is the pancreas?

The pancreas is about 6 inches long, a spongy, tube-shaped organ. It is located in the back of the abdomen, behind the stomach. The head of the pancreas is on the right side of the abdomen. It is connected to the duodenum, the upper end of the small intestine. The narrow end of the pancreas, called the tail, extends to the left side of the body.

The pancreas makes pancreatic juices and hormones, including insulin. Pancreatic juices, also called enzymes, help digest food in the small intestine. Insulin controls the amount of sugar in the blood. Both enzymes and hormones are needed to keep the body working right.

As pancreatic juices are made, they flow into the main pancreatic duct. This duct joins the common bile duct, which connects the pancreas to the liver and the gallbladder. The common bile duct, which carries bile (a fluid that helps digest fat), connects to the small intestine near the stomach

What are pancreatic cancer symptoms and signs?

Pancreatic cancer has been called a "silent" disease because early pancreatic cancer usually does not cause symptoms. If the tumor blocks the common bile duct and bile cannot pass into the digestive system, the skin and whites of the eyes may become yellow, and the urine may become darker. This condition is called jaundice.

As the cancer grows and spreads, pain often develops in the upper abdomen and sometimes spreads to the back. The pain may become worse after the person eats or lies down. Cancer of the pancreas can also cause nausea, loss of appetite, weight loss, and weakness.

A rare type of pancreatic cancer, called islet cell cancer, begins in the cells of the pancreas that produce insulin and other hormones. Islet cells are also called the islets of Langerhans. Islet cell cancer can cause the pancreas to produce too much insulin or hormones. When this happens, the patient may feel weak or dizzy and may have chills, muscle spasms, or diarrhea. 2/2

What causes cancer of the pancreas?

The disease is not communicable or transmittable. No one can "catch" cancer from another person. Smoking is a major risk factor. Cigarette smokers develop cancer of the pancreas two to three times more often than nonsmokers. Quitting smoking reduces the risk of pancreatic cancer, lung cancer, and a number of other diseases.

How is cancer of the pancreas diagnosed?

To diagnose pancreatic cancer, the doctor does a complete physical exam and asks about the patient's personal and family medical history. In addition, to check general signs of health (temperature, pulse, blood pressure, and so on), the doctor usually orders blood, urine and stool tests. The doctor may also ask for a "barium swallow," or "upper GI series." For this test, the patient drinks a barium solution before x-rays of the upper digestive system are taken. The barium shows an outline of the pancreas on the x-rays.

Other tests may be ordered, such as:

• An angiogram, a special x-ray of blood vessels.
• CT scans, x-rays that give detailed pictures of a cross- section of the pancreas. These pictures are created by a computer.
• ERCP (endoscopic retrograde cholangiopancreatogram), is a special x-ray of the common bile duct. For this test, a long, flexible tube (endoscope) is passed down the patient's throat through the stomach and into the small intestine. A dye is injected into the common bile duct, and x-rays are taken. The doctor can also look through the endoscope and take tissue samples.
• Transabdominal ultrasound to view the pancreas. In this procedure, an instrument that sends out high-frequency sound waves, which cannot be heard, is passed over the abdomen. The sound waves echo off the pancreas. The echoes form a picture on a screen that looks like a television.
• Endoscopic ultrasound is a relatively new procedure that can be used to diagnose pancreatic cancer. For the procedure, an endoscope is passed in the same way as for ERCP; however, on the end of the endoscope is an ultrasound probe which scans the pancreas for cancers. Because the ultrasound probe is closer to the pancreas than with transabdominal ultrasound, it is possible to identify small cancers within the pancreas. The cancers also can be biopsied through the endoscope.

A biopsy is the only sure way for the doctor to know whether cancer is present. In a biopsy, the doctor removes some tissue from the pancreas. It is examined under a microscope by a pathologist, who checks for cancer cells.

One way to remove tissue is with a long needle that is passed through the skin into the pancreas. This is called a needle biopsy. Doctors use x-rays or ultrasound to guide the placement of the needle. Another type of biopsy is a brush biopsy. This is done during the ERCP. The doctor inserts a very small brush through the endoscope into the bile duct to rub off cells to examine under a microscope.

Tissue samples that are obtained with one kind of biopsy may not give a clear diagnosis, and the biopsy may need to be repeated using a different method.

How is cancer of the pancreas treated?

Treatment for pancreatic cancer depends on a number of factors. Among these are the type, size, and extent of the tumor as well as the patient's age and general health. A treatment plan is tailored to fit each patient's needs.

Treatment Methods

Cancer of the pancreas is curable only when it is found in its earliest stage, before it has spread. Otherwise, it is very difficult to cure. However, it can be treated, symptoms can be relieved, and the quality of the patient's life can be improved.

Pancreatic cancer is treated with surgery, radiation therapy, or chemotherapy. Sometimes several methods are used, and the patient is referred to doctors who specialize in different kinds of cancer treatment.

Surgery may be done to remove all or part of the pancreas. Sometimes it is also necessary to remove a portion of the stomach, the duodenum, and other nearby tissues. This operation is called a Whipple procedure. In cases where the cancer in the pancreas cannot be removed, the surgeon may be able to create a bypass around the common bile duct or the duodenum if either is blocked.

Radiation therapy (also called radiotherapy) uses high-powered rays to damage cancer cells and stop them from growing. Radiation is usually given 5 days a week for 5 to 6 weeks. This schedule helps to protect normal tissue by spreading out the total dose of radiation. The patient doesn't need to stay in the hospital for radiation therapy.

As a way to kill cancer cells Radiation is also being studied that remain in the area after surgery. In addition, radiation therapy can help relieve pain or digestive problems when the common bile duct or duodenum is blocked.

Chemotherapy uses drugs to kill cancer cells. The doctor may use just one drug or a combination. Chemotherapy may be given by mouth or by injection into a muscle or vein. The drugs enter the bloodstream and travel through the body. Chemotherapy is usually given in cycles; a treatment period followed by a recovery period, then another treatment period, and so on.

What are the side effects of treatment for cancer of the pancreas?

The methods used to treat pancreatic cancer are very powerful. It is hard to limit the effects of treatment so that only cancer cells are destroyed. Healthy tissue may also be damaged. That is why treatment often causes unpleasant side effects. Side effects depend on the type of treatment used and on the part of the body being treated.

Surgery for cancer of the pancreas is a major operation. While in the hospital, the patient will need special medications and may be fed only liquids. During recovery from surgery, the patient's diet and weight will be checked carefully.

During radiation therapy, the patient may become very tired as the treatment continues. Resting as much as possible is important. Skin reactions (redness or dryness) in the treated area are also common. Good skin care is important at this time, but the patient should not use any lotions or creams on the skin without checking with the doctor. Radiation therapy to the upper abdomen can cause nausea and vomiting. Usually, dietary changes or medications can ease these problems.

The side effects of chemotherapy depend on the drugs that are given. In addition, each person reacts differently. Chemotherapy affects rapidly growing cells, such as blood-forming cells, those that line the digestive tract, and those in the skin and hair. As a result, patients can have side effects such as a lowered resistance to infection, less energy, loss of appetite, nausea, vomiting, or mouth sores. Patients may also lose their hair.

Weight loss can be a serious problem for patients being treated for cancer of the pancreas. Well- nourished patients usually feel better and may be better able to withstand the side effects of their treatment. Therefore, nutrition is an important part of the treatment plan, and doctors may have a number of suggestions to help their patients get enough calories and protein. In many cases, patients feel better if they take food and beverages in very small amounts. Many patients find that eating several small meals and snacks throughout the day is easier than having three large meals.

In addition, treatment for cancer of the pancreas may interfere with production of insulin and pancreatic juices. The patient must take medicines to replace these; otherwise the level of blood sugar may be wrong and digestion may be affected. Even so, taking these medicines can often upset digestion. Careful planning and checkups are important to help the patient avoid weight loss and the weakness and lack of energy caused by poor nutrition.

Patients and family members are often afraid that cancer will cause pain. Cancer patients do not always have pain, but if it does occur, there are many ways to relieve or reduce it. It is important for the patient to let the doctor know about pain, because uncontrolled pain can cause loss of sleep and poor appetite. These problems can make it difficult for the patient to respond to treatment.

The side effects that patients have during cancer therapy vary for each person. They may even be different from one treatment to the next. Fortunately, most side effects are temporary. Doctors, nurses, and dietitians can explain the side effects of cancer treatment and can suggest ways to deal with them.

What does the future hold for patients with cancer of the pancreas?

There are constant effort from medical professional trying to learn what causes this disease and how to prevent it. They are also looking for better ways to diagnose and treat it.

For example, they are studying giving radiation therapy two or more times a day, or during surgery (intra-operative radiation), or with drugs that help protect normal tissue so that higher doses can be given.

Biological therapy is a new type of cancer treatment that uses natural and laboratory-produced substances to stimulate or restore the body's immune system so it can fight disease more effectively

How do patients and families adjust to cancer of the pancreas?

The diagnosis of pancreatic cancer can change the lives of cancer patients and the people who care about them. These changes in daily life can be difficult to handle. It is natural for patients and their families and friends to have many different and sometimes confusion emotions.

At times, patients and their loved ones may feel frightened, angry, or depressed. These are normal reactions that people have when dealing with a serious health problem. Others in the same situation have found that they cope with their emotions better if they can talk openly about their illness and their feelings with those who care about them. Sharing feelings with loved ones can help everyone feel more at ease, opening the way for others to show their concern and offer their support. Many patients find that it helps to talk with others who are facing problems like theirs.

Worries about tests, treatments, hospital stays, and medical bills are common. Talking with doctors, nurses, or other members of the health care team may help to calm fears and ease confusion.

Patients can take an active part in decisions about their medical care by asking questions about pancreatic cancer and their treatment choices. Patients, family, or friends often find it helpful to write down questions to ask the doctor as they think of them. Taking notes during visits to the doctor helps them remember what was said. Patients should ask the doctor to explain anything that is not clear.

Patients have many important questions, and the doctor is the best person to answer them. Most people ask about the extent of their cancer, how it can be treated, and how successful the treatment is likely to be.

The doctor can give advice about treatment, working, or limiting activities. Patients also may wish to discuss their concerns about the future, family relationships, and finances. If it is hard to talk to the doctor about feelings and other very personal matters, it may be helpful to speak with a nurse, social worker, counselor, or a member of the clergy.