Pancreatic cancer

Most people don’t experience early signs of pancreatic cancer. The doctor may suspect pancreatic cancer if the patient has recently developed diabetes or pancreatitis (a painful condition due to the inflammation of the pancreas). As the disease progresses, people may notice symptoms like:

• Pain in the upper abdomen, radiating to the back
• Jaundice (yellowing of the skin and the whites of the eyes)
• Tiredness and fatigue
• Loss of appetite
• Light-colored stools
• Dark-colored urine
• Loss of weight
• Formation of blood clots in the body
• Dry and itchy skin
• Worsening diabetes or a new diagnosis
• Nausea and vomiting

PNETs (Pancreatic Neuroendocrine Tumors) are rare pancreatic cancers that develop in hormone-producing cells. They may cause unique symptoms due to excess hormone production, such as:

• Zollinger-Ellison syndrome (in which the stomach makes too much acid), causing stomach ulcers
• Irritations on the tongue and corners of the mouth
• Malnutrition
• Shortness of breath
• Rashes or blisters on the skin
• Excessive thirst

Excessive thirst can be alarming. Frequent or excessive thirst could be a symptom of a serious health condition. Read about 5 common causes of excessive thirst or polydipsia.

The exact cause of pancreatic cancer is unknown.

Pancreatic cancer occurs when abnormal cells begin to grow within the pancreas. These abnormal cells develop due to changes (mutations) in their DNA. This mutated DNA causes the cells to grow uncontrollably and survive beyond the normal lifespan of cells. These masses of cells can form a tumor. When left untreated, these cells continue to proliferate.

Despite other gastrointestinal tumors, evidence of risk factors for the development of pancreatic cancer is poor and can be classified into environmental factors and genetic factors:

Environmental factors

These can be further classified into modifiable and non-modifiable factors that increase the risk of an individual developing pancreatic cancer. They include:

1. Modifiable factors

• Smoking: Say no to smoking with our widest range of smoking cessation products. Quit this habit today.
• Alcohol consumption: Pancreatic cancer is associated with heavy alcohol consumption of > 30 g per day.
• Chronic pancreatitis.
• Obesity.
• Diet.
• Infection: People with Helicobacter pylori (H-pylori) or hepatitis C infections.
• Exposure at the workplace: Metalworking and pesticides have been recognized as potential risk factors.

2. Non-modifiable factors

• Age: Pancreatic cancer generally occurs in patients over 55 years old, mostly between 70-80 years.
• Sex: The incidence of pancreatic cancer is lower in women than in men globally. This difference is even more evident in developed nations.
• Geographic location: The incidence rate in Africa is the lowest, while higher cases of cancer development are seen in China.
• Blood group: Studies have shown that people with type A, AB, or B blood groups have a higher risk of developing pancreatic cancer than those with type O.
• Diabetes: Can raise the risk of pancreatic cancer and might also be an early sign of it, with HbA1c being studied as a possible tool for early detection.
• Gut Microflora: Lower levels of Neisseria elongata and Streptococcus mitis, and higher levels of Porphyromonas gingivalis and Granulicatella adiacens are associated with an increased risk of pancreatic cancer.

Genetic factors

Certain genetic mutations and syndromes significantly increase the risk of pancreatic cancer. These include:

• Hereditary Breast and Ovarian Cancer Syndrome (HBOC).
• Lynch Syndrome (HNPCC).
• Familial Atypical Multiple Mole Melanoma Syndrome (FAMMM).
• Hereditary Pancreatitis (HP).
• Familial Adenomatous Polyposis (FAP).
• Peutz-Jeghers Syndrome (PJS).
• Cystic Fibrosis (CF).

Pancreatic cancer is challenging to diagnose, often presenting late with advanced or metastatic disease, depending on tumor size, location, and spread. The cancer is divided into five stages:

• Stage 0: Also known as carcinoma in situ, characterized by abnormal cells in the lining of the pancreas. These cells could become cancerous and spread to nearby tissue.
• Stage 1: Presence of tumor (cancerous cells) in the pancreas.
• Stage 2: The presence of a tumor in the pancreas, which has spread to nearby tissues, organs, or lymph nodes.
• Stage 3: Spread of cancer to major blood vessels near the pancreas, which may also have spread to nearby lymph nodes.
• Stage 4: Cancer has spread to distant organs in the body, such as the liver, lungs, or abdominal cavity, along with tissues or lymph nodes near the pancreas.

Cancer is one of the most dreaded diseases and can be difficult to treat if it has progressed to an advanced stage at the time of diagnosis. Read more about 8 common signs of cancer that you should know.

The diagnosis consists of the following:

• Physical examination:
  • The doctor will examine the patient's skin, tongue, and eyes to check for jaundice, indicated by yellowing.
  • An abnormal buildup of fluid in the abdomen, called ascites, may also be a sign of cancer.
• Blood tests:
  • The doctor may take samples of blood to check for abnormal levels of bilirubin and other substances.
  • Bilirubin levels may be elevated in people with pancreatic cancer due to blockage of the common bile duct by a tumor.
• Imaging tests: These tests help doctors determine the location of the cancer and whether it has spread from the pancreas to other parts of the body.
  • Computed tomography (CT or CAT) scan: Pancreatic protocol CT scans use contrast to precisely locate tumors and assess their relation to nearby organs and blood vessels.
  • Positron emission tomography (PET) scan or PET-CT scan: Combines PET and CT/MRI to create detailed images for a comprehensive evaluation of the affected area.
  • Endoscopic retrograde cholangiopancreatography (ERCP): A gastroenterologist uses an endoscope to examine bile ducts and place stents; however, it is not commonly used for diagnosis.
  • Ultrasound: Uses sound waves to visualize internal organs, with options like transabdominal ultrasound for the abdomen or endoscopic ultrasound (EUS) for detailed imaging via an endoscope.
  • Percutaneous transhepatic cholangiography (PTC): An X-ray procedure to detect bile duct blockages caused by tumors, using a needle to inject dye for imaging.
  • Magnetic resonance imaging (MRI): Produces detailed images of the body and tumor size, with MRCP (Magnetic Resonance Cholangiopancreatography) specialized for assessing pancreatic ducts and related issues.
• Biopsy: A biopsy removes a small amount of tissue for examination under a microscope, providing a definitive diagnosis for most cancers. There are a couple of different ways to collect a tissue sample:
  • Fine needle aspiration cytology (FNAC): Tissue sample removal by aspiration from the needle.
  • Core needle biopsy: The doctor uses a hollow needle to remove pieces of pancreatic tissue from a suspicious area.
• Testing for potential biomarkers:
  • CA 19-9 is a key marker for monitoring pancreatic cancer.
  • Researchers are exploring breath tests and DNA changes in pancreatic fluids to detect cancer early.

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Preventing pancreatic cancer is challenging due to its complex risk factors, including genetics, lifestyle, and environmental factors.

While complete prevention isn’t guaranteed, steps to help reduce the risk include:

• Avoiding smoking and alcohol
• Adopting a healthy lifestyle
• Managing chronic conditions
• Considering genetic counseling or screening for high-risk individuals

Note: Genetic testing for BRCA2 mutations or p16INK4A inactivity, along with secondary screening, may be recommended for individuals at high risk of pancreatic cancer.

Pancreatic cancer requires multidisciplinary treatment that includes:

1. Surgical management

• Pancreatectomy: The Whipple procedure (pancreaticoduodenectomy) or pancreatectomy (partial or total removal of the pancreas) is used to treat pancreatic cancer based on the tumor's location.
• Laparoscopic surgery: A minimally invasive procedure to access the abdomen or pelvis, often used for distal pancreatectomy.
• Vascular resection: Pancreatic cancer resection includes total pancreatectomy, distal pancreatectomy plus splenectomy (removal of the spleen).

2. Chemotherapy

• Modified leucovorin, 5-fluorouracil, irinotecan, and oxaliplatin (MFOLFIRINOX) for 6 months.
• Gemcitabine and capecitabine combined for 6 months.
• Folfirinox regimen, gemcitabine, and Pac-Nab in combination with chemotherapy in patients with metastasis.
• Gemcitabine (with or without erlotinib) combined with 54 Gy (radiation dose) is used for patients with locally advanced pancreatic cancer.

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3. Radiotherapy

• Radiation therapy uses X-rays to destroy or damage cancer cells, making them unable to proliferate. Radiotherapy is mainly used in patients with locally advanced pancreatic cancer.
• External beam radiation therapy: This uses external radiation therapy sources that emit X-rays, gamma rays, electrons, or heavy particles.
• Brachytherapy: A type of internal radiation therapy in which seeds, ribbons, or capsules that contain a radiation source are placed inside the body or near the tumors.

4. Targeted therapy

• This is very successful in many types of cancer; however, all other targeted drugs have failed in pancreatic cancer patients to date.
• Recently, the Food and Drug Administration (FDA) has approved pembrolizumab as a targeted treatment for pancreatic cancer.

5. Latest treatment protocols

• Gene therapy: Delivers specific genes to cancer cells, often carried by specially designed viruses.
• Cancer stem cells: Research currently focuses on identifying treatments that may specifically target pancreatic cancer stem cells.
• Genetic/molecular studies: Many new research developments are based on identifying damaged genes and proteins and repairing or changing how they work.
• Circulating tumor (ct)DNA: Studied to monitor treatment response, detect early disease recurrence, and identify resistance to treatment.

6. Other treatment modalities

• Percutaneous bile duct drainage: A procedure to drain bile to relieve pressure in the bile ducts caused by a blockage.
• Surgical gastrojejunostomy: A surgical procedure in which an anastomosis is created between the stomach and the proximal loop of the jejunum.
• Endoscopic duodenal stents: A stent is a small metal mesh tube placed in the narrowed or blocked area of your duodenum (the first part of the small intestine).

Certain herbal or home remedies have shown beneficial results in managing the symptoms of pancreatic cancer. However, it is important to always consult your doctor before starting anything new.

• Eucalyptus: Contains compounds with potential anti-inflammatory and antioxidant properties that may aid in managing cancer symptoms.
  How to use it? Brew leaves into tea or use eucalyptus oil in aromatherapy.
• Coix seed (Jau Ke Daane): Known for its anti-tumor and immune-boosting effects, it may aid in inhibiting cancer cell growth and improving immunity.
  How to use it? Boil seeds for porridge or grind into powder for smoothies.
• Moringa (Sahjan): Rich in antioxidants and anti-inflammatory agents, it may help reduce oxidative stress and support overall health.
  How to use it? Add fresh leaves to dishes or mix moringa powder in water or tea.

Want to know other benefits of moringa? Read This

Pancreatic cancer progresses unchecked for a long time before symptoms are recognized. Complications of pancreatic cancer include:

1. Common complications
   • Jaundice
   • Weight loss
   • Muscle wasting (cancer cachexia)
   • Abdominal pain
   • Diabetes
2. General complications after resection of the pancreas
   • Cardiac problems such as angina (chest pain), infarction (heart attack), and arrhythmias
   • Stroke
   • Cardiorespiratory distress (increase in the number of breaths)
   • Kidney dysfunction
   • Pneumonia
   • Thrombosis (blood clots)
   • Pulmonary embolism (blood clot lodged in an artery in the lung)
   • Psychological disturbances
   • Hepatic (liver) and metabolic dysfunction
3. Surgical complications
   • Intra-abdominal abscess (collection of pus in the inner lining of the stomach)
   • Hemorrhage (bleeding)
   • Fistulae of the pancreatointestinal anastomosis (abnormal connection between pancreas and intestinal sutures)

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The limitations of current treatment for pancreatic cancer have led to the need for new therapeutic approaches that show promising results. These include:

• Microbial Therapy

  There is strong evidence that the human microbiota plays a key role in regulating cancer development and response to cancer treatment. The results of intestinal microflora forming systemic immunity and tumor-specific immunity in pancreatic cancer have been confirmed, but the mechanism remains to be studied.

• Immunotherapy

  Immune checkpoint blockade (ICB) therapy is approved for several cancers, including melanoma, lung cancer, and kidney cancer. However, pancreatic cancer is less responsive to immunotherapy due to its tumor environment, which suppresses the immune system. Immunotherapy is currently under study and has yet to be approved for pancreatic cancer.

Whether you're a patient or a caregiver, living with pancreatic cancer significantly impacts daily life and requires careful consideration of various factors. Tips that can help include:

1. Managing the emotions
   • Gathering all necessary information regarding treatment
   • Communicating with loved ones
   • Joining support groups
   • Understanding physical limitations
   • Starting palliative care to alleviate other symptoms
   • Coping with practical issues such as:
     • Financial expenses
     • Childcare
     • Work issues
2. Surviving the physical side effects
   • Regularly discussing feelings with doctors and the healthcare team
   • Tracking new side effects or changes in existing side effects and informing your doctor immediately
   • Seeking treatment for long-term side effects and late effects
3. Supervising the costs of cancer care
   • Understanding the cost of treatment
   • Encouraging patients and their families to discuss financial concerns with a member of their healthcare team
   • Seeking support from organizations that assist with treatment, housing, travel, and other cancer-related costs
4. Focusing on diet
   • Consuming smaller and lighter meals throughout the day
   • Avoiding very high-fiber foods such as cereal and dried fruit in case of diarrhea
   • Sipping a nutritional supplement between meals to boost calorie intake
   • Maintaining blood sugar levels
   • Taking enzyme supplements
5. Preparing for treatment
   • Understanding prehabilitation (preparing for cancer treatment during the time available before it starts)
   • Preparing mentally and physically for treatment
   • Eating a wide range of foods in the right proportions
6. Getting follow-up care
   • Regular follow-up visits with exams and tests are crucial after treatment
   • Some side effects may persist or appear years later
   • Reporting new symptoms promptly, as they could indicate recurrence or a new issue

Cancer can drain a person physically and mentally. Gaining knowledge and awareness about cancer and the myths that surround it is necessary to enable timely diagnosis and treatment.