What is Cancer?Cancer is a disease that starts in our cells. Our bodies are made up of millions of cells, grouped together to form tissues or organs such as muscles and bones, the lungs, or the liver. Genes inside each cell order it to grow, work, reproduce and die. Normally, our cells obey these orders and we remain healthy. Sometimes a cell’s instructions get mixed up and it behaves abnormally. After a while, groups of abnormal cells can form lumps or tumours, or can spread to through the bloodstream and lymphatic system to other parts of the body. Tumours can be either benign (non-cancerous) or malignant (cancerous). Benign tumour cells stay in one place in the body and are not usually life-threatening. Malignant tumour cells are able to invade the tissues around them and spread to other parts of the body. Cancerous cells that spread to other parts of the body are called metastases. The first sign that a malignant tumour has spread is often swelling of nearby lymph nodes, but cancer can metastasize to almost any part of the body. It is important to find malignant tumours early and treat them. Cancers are named after the part of the body where they start. For example, cancer that starts in the colon but spreads to the liver is called colon cancer with liver metastases.” (The Canadian Cancer Society) |
Pancreatic CancerWhat Function Does the Pancreas Have? When Dad was diagnosed with Pancreatic Cancer, we (our family) decided that we first had to become knowledgeable about the pancreas function before we could begin to understand what cancer of the pancreas meant for Dad. Throughout our ordeal we quickly learned that education was not only the key to understanding what the disease meant for Dad but it was the key to understanding what questions to ask, ensuring that he received the best treatment available. To do this you must be knowledgeable and educated on the organ and on the disease. The Pancreas is an important organ of the digestive system located deep in the upper part of the abdomen, behind the stomach and in front of the spine and because of it's location it is often referred to as the "hidden organ." The pancreas is about six to eight inches long in an adult and contains thin tubes that come together like the veins of a leaf. These tubes join to form a single opening into the intestine that is located just beyond the stomach. The pancreas is a part of our digestive system which assists in the digestion of food. It produces proteins (enzymes) to help digest food and it produces insulin, which regulates sugar levels in our blood. Food enters our oesophagus, flows into our stomach, into the top of the small intestine called the duodenum, then into the large intestine, then the rectum and finally out the anal canal. When food enters the duodenum, bile and pancreatic fluids also enter here, through a common bile duct. The bile from the liver is in charge of digesting the fats, and the pancreatic fluids are in charge of producing insulin and digesting our food (as already stated). So, although the pancreas is a small organ is has a huge impact on our digestive system. The following is a diagram taken from the John Hopkins Web Site, which has been an excellent resource for us on Pancreatic Cancer. It illustrates the position of the pancreas (represented in yellow), and of the organs surrounding the pancreas.
Below is a chart which outlines the various parts and functions of the pancreas.
The head is the large, rounded end that is located on the right side of the abdomen and near the beginning of the small intestine, which is called the duodenum. In the head there are the majority of the cells that produce insulin. The body is the middle section, which is tucked behind the stomach. The tail is the thin end of the pancreas that is located on the left side of the abdomen next to the spleen. |
What is Pancreatic Cancer?Pancreatic cancer starts in the cells of the pancreas and will eventually affect the pancreas ability to assist in the digestion and the breakdown of food. More often then not, other organs linked to the pancreas will become damaged as well, such as the stomach, duodenum, liver, or gallbladder, leading to such symptoms as jaundice and digestion difficulties. For the majority of pancreatic cancer patients, it is only at this time (when other organs are involved), that the diagnosis of Pancreatic Cancer is made. The very location of the pancreas often makes it difficult for early diagnosis, meaning before the cancer has metastasized. Most often, pancreatic cancer start in the ducts that carry the enzymes to the duodenum, but pancreatic cancer may also start in the cells that produce insulin (islet cells). My Dad’s tumour started at the head of the pancreas. The tumour put pressure on the common bile duct, creating a blockage which caused his jaundice, alerting us to a problem. If the tumour was in the body or the tail of the pancreas he probably would not have had this early warning sign. Only about 30% of pancreatic cancer patients are fortunate enough to have the early warning signs and symptoms, making them eligible for surgery. Surgery is the only chance at a cure. It is important to understand what type of pancreatic cancer you have, for potential treatment options available to patients. The majority of pancreatic tumors are malignant (cancerous) and rarely present symptoms until the cancer is advanced. These cancerous tumors are adenocarcinomas. Rarely benign tumors are diagnosed, and although usually not an immediate health risk they can be referred to as premalignant and require surgical removal. Finally pancreatic cancer can also develop in the islet cells, as stated above. These tumors are named neuroendocrine and can result in the production of hormones, sometimes causing abnormal hormone levels. For information on various forms of pancreatic cancer you can click on the following link. Pancreatic Cancer.org |
Symptoms of Pancreatic CancerAs mentioned early, symptoms are often rare in the early stages of pancreatic cancer. My father (for example), a cyclist, completed a 40 km bike ride the day before his surgery, the Whipple Procedure (see below). I (his daughter and 29 years his junior) was trying my best to keep up with him! In other words, he felt wonderful!! This made the disease that much harder to accept not only for Dad but for his family. “How could he be this sick but feel this wonderful?”
In the rare cases of pancreatic cancer (cystadenocarcinoma) that affect the hormone-secreting portion of the pancreas, the pancreas will produce too much insulin or other hormones. Symptoms may include weakness or dizziness, chills, muscle spasms, or diarrhea. |
Diagnostic AssessmentsAlthough there is currently no screening test for pancreatic cancer, as a preventive measure, a variety of diagnostic assessments exist if pancreatic cancer is suspected. The most important tests used to detect pancreatic cancer are imaging tests such as ultrasound, CT scans and MRI scans. These tests use a variety of methods to see inside the body. Imaging tests can be simple x-rays or more complex scanning methods that use computers to reconstruct the structures in the body. The following list has been taken from the Mayo Clinic (www.mayoclinic.com) and details the test name, purpose and procedure. Becoming informed about the diagnostic tests available is important when ensuring an accurate assessment.
Ultrasound imagingIn this test, a device called a transducer is placed on your upper abdomen. High-frequency sound waves from the transducer reflect off your abdominal tissues and are translated by a computer into moving images of your internal organs, including your pancreas. Ultrasound tests are safe, noninvasive and relatively brief — a typical test takes less than an hour.
Computerized tomography (CT) scan.This imaging test allows your doctor to visualize your organs, including your pancreas, in two-dimensional slices. Split-second computer processing creates these images as a series of very thin X-ray beams pass through your body. Sometimes you may have a dye (contrast medium) injected into a vein before the test. The clearer images produced with the dye make it easier to distinguish a tumor from normal tissue. A CT scan exposes you to more radiation than do conventional X-rays, but in most cases, the benefits of the test outweigh the risks.
Magnetic resonance imaging (MRI).Instead of X-rays, this test uses a powerful magnetic field and radio waves to create images of your pancreas. During the test, you're placed in a cylindrical tube that can seem confining to some people. The machine also makes a loud thumping noise you might find disturbing. In most cases you'll be given headphones for the noise.
Positron Emission Tomography (PET scanner)- Positron emission tomography, or PET scan, is an imaging test that shows not radioactive glucose (sugar) is injected into a vein. Then a special camera detects the radioactivity that is preferentially taken up by malignant tissue. PET scans are increasingly read alongside CT or magnetic resonance imaging (MRI) scans, the combination ("co-registration") giving both anatomic and metabolic information (i.e., what the structure is, and what it is doing biochemically).Endoscopic retrograde cholangiopancreatiography (ERCP).In this procedure, a thin, flexible tube (endoscope) is gently passed down your throat, through your stomach and into the upper part of your small intestine. Air is used to inflate your intestinal tract so your doctor can more easily see the openings of your pancreatic and bile ducts. The bile ducts are thin tubes that carry bile, a fluid produced in your liver that helps digest fats. These ducts are often the site of pancreatic tumors. A dye is then injected into the ducts through a small hollow tube (catheter) that's passed through the endoscope. Finally, X-rays are taken of the ducts. Your throat may be sore for a time after the procedure, and you may feel bloated from the air introduced into your intestine.
Endoscopic ultrasound (EUS).In this test, an ultrasound device is passed through an endoscope into your stomach. The device directs sound waves to your pancreas. A computer then translates the sound waves into close-up images of your pancreas and your bile and pancreatic ducts. The images are superior to those produced by standard ultrasound and are particularly useful for detecting small pancreatic tumors.Percutaneous transhepatic cholangiography (PTC).In this test, your doctor carefully inserts a thin needle into your liver while you lie on a movable X-ray table. A dye is then injected into the bile ducts in your liver, and a special X-ray machine (fluoroscope) tracks the dye as it moves through the ducts. Any obstructions should show up on the X-ray. The table is rotated several times during the procedure so you can assume a variety of positions. During the test, you may have a feeling of pressure or fullness, or have slight discomfort in the right side of your back.Biopsy.In this procedure, a small sample of tissue is removed and examined for malignant cells under a microscope. It's the only way to make a definitive diagnosis of cancer. Biopsies of the pancreas and bile ducts can be performed in several ways. If you have a mass that can be reached with a needle, your doctor may choose to perform a fine-needle aspiration (FNA) — a procedure in which a very thin needle is inserted through your skin and into your pancreas. An ultrasound or CT scan is often used to guide the needle's placement. When the needle has reached the tumor, cells are withdrawn and sent to a lab for further study. Tissue samples can also be removed during ERCP or EUS. Sometimes, in a procedure similar to ERCP, your surgeon uses an endoscope to pass a catheter into your bile duct where it empties into your small intestine. But instead of injecting dye, your surgeon uses a small brush introduced through the catheter to scrape cells and bits of tissue from the lining of the duct.Laparoscopy.This procedure uses a small, lighted instrument (laparoscope) to view your pancreas and surrounding tissue. The instrument is attached to a television camera and inserted through a small incision in your abdomen. The camera allows your surgeon to clearly see what's happening inside you. During laparoscopy, your surgeon can take tissue samples to help confirm a diagnosis of cancer. Laparoscopy may also be used to determine how far cancer has spread. Risks include bleeding and infection and a slight chance of injury to your abdominal organs or blood vessels.CA19-9This is one of many assessments that may be used for the initial diagnosis of Pancreatic Cancer. This diagnostic assessment is also used during the treatment of Pancreatic Cancer, and for regular follow up assessments once treatment has been completed. This assessment is performed using a blood test.The CA19-9 is a blood test that measures the tumour markers for pancreatic cancer. Although, it is more accurate than any other blood test available, it is not used as the only diagnostic tool, as CA19-9 levels are elevated in only 50-75% of patients (John Hopkins Pathology). This is why this assessment is often more useful in measuring how effective chemotherapy and radiation treatments are, over extended periods of time. When evaluating treatment, a decrease or stability in the CA19-9 levels may indicate an improved prognosis. However when the tumour markers continue to increase, it may indicate a progression of the disease. During treatment these tumour markers are usually measured every 4-6 weeks. After the completion of treatment these tumour markers are generally measured every 3-4 months. These on-going assessments may be used with other diagnostic assessments to indicate either a progression or remission in the disease. Lab Tests on Line is a informational web site that was created to be a public resource on various clinical lab testing, created by the profession conducting these lab tests. You can find out information about a particular diagnostic test and write to these professionals if you have any further questions regarding specific lab tests. The link below will provide you with valuable information on CA 19-9 testing. http://www.labtestsonline.org/understanding/analytes/ca19_9/glance.html |
Staging of Pancreatic CancerThe diagnosis of pancreatic cancer is not complete unless staging is done. Subsequent decisions about treatment will be based upon the stage assigned. The results of various diagnostic tests will indicate how far the cancer has progressed and determine the stage. Generally speaking, different stages carry different prognoses (see table below). The charts reproduced below are commonly used to stage pancreatic tumors. This staging process is based on the modifications of the American joint Committee on Cancer (AJCC 2002). Table: 5 year survival of patients diagnosed with pancreatic cancer by each stage at the time of diagnosis.
Staging cancer is a standardized way to classify a tumour based on its size, whether is has spread, and where it has spread. It measures the extent of the disease. Knowing the stage of your cancer will help your doctor determine which treatment options are right for you. Metastasis Evaluation (M)Pancreatic cancer may spread locally to the lymph nodes and major blood vessels near the pancreas or to distant lymph nodes or organs such as the liver or lungs. In staging, this spread is documented as follows:
CLINICAL CLASSIFICATIONA simpler, more descriptive staging system for pancreatic cancer is often used by doctors. This system divides the cancers into groups based on whether or not the tumour can be removed surgically. Resectable cancer: this is the type of pancreatic cancer that can be surgically removed. These tumours may lie within the pancreas or extend beyond it, but there is no involvement of the critical arteries or veins in the area. Unresectable cancer: a) Metastatic cancer is when the tumour has spread beyond the area of the pancreas and involves other organs, such as the liver or lungs, or other areas of the abdomen. Unfortunately, almost half of all patients are diagnosed at this stage and b) Advanced local cancer: it is a tumour that has not metastasized yet but it has involved vital structures around the pancreas that cannot be safely removed by surgery. |
Effective TreatmentsTreatment of pancreatic cancer is often aimed at improving a patient’s quality of life, meaning that it has metastasized, before the diagnosis is made. The only proven course of treatment, most affective to date, is radiation and chemotherapy. RadiationRadiation Therapy uses high energy rays, aimed at the tumours being treated. The radiation is used in the attempt to damage cancerous cells and or prevent more cancerous cells from growing. It is often paired with chemotherapy. Patients who have had surgery (the Whipple Procedure) may also have follow up treatments of radiation, depending on the pathology report. ChemotherapyChemotherapy uses a drug(s) to kill cancer cells and may be used alone or with radiation therapy. This form of treatment may also be used after surgery, depending on the pathology report. Gemzar (Gemcitabine) is the most common and most effective chemotherapy drug available to patients and may be used in combination with a variety of other drugs. These combinations are often available in clinical trials, although no outstanding advancement in the treatment of pancreatic cancer has been made to date, which I am aware of. Click on the button to see the combo's that may be available to you as a patient. Chemotherapy CombinationsImmunotherapy and Vaccine Therapy are other forms of treatment available and will vary depending on where you live. Whipple ProcedureThe Whipple Procedure is the only treatment available which offers a possible cure for pancreatic cancer, although a very invasive procedure (one doctor speaking with us referred to it as the “atomic bomb of surgeries”). This is the procedure which my Dad had, and unfortunately later died from (however the complications he had were rare). Although The Whipple Procedure is one of the more invasive surgeries, it offers a small percentage of hope and at the very least, an extended life which would not be possible without the surgery. The surgery involves the removal of the head of the pancreas, the duodenum, part of the stomach, the gall bladder, lymph nodes and other nearby tissues. You may also require chemotherapy to destroy cancer cells and radiation therapy after you recover from the surgery, depending of the pathology report. Whipple Surgery Recovery TipsAnother type of surgery is a total pancreatectomy. This procedure removes the entire pancreas, the duodenum, common bile duct, gallbladder, spleen, and nearby lymph nodes. You may also require chemotherapy to destroy cancer cells and radiation therapy to shrink the tumor. Because pancreatic cancer affects the production of pancreatic enzymes and insulin, you may also need to take medication to replace these enzymes and hormones. Distal PancreatectomyThe Distal Pancreatectomy is a surgery used to treat pancreatic cancer when the cancer is in the tail of the pancreas and/or a small portion in the body of the pancreas. The spleen is also usually removed. The removal of the spleen is to prevent blood supply from the spleen to the pancreas which are intimately connected. At times a decision is made to not remove the spleen but the blood vessels to the spleen are separated from the pancreas and preserved. This is suggested for patients who have cystic tumors and inlet cell tumours. Double By-pass“The Double By-pass is a palliative surgical procedure to alleviate jaundice, nausea and vomiting for patients with advanced tumors in the head of the pancreas. The double bypass involves a bypass to the bile duct and a bypass to the stomach. Often a celiac nerve block is also performed.” (John Hopkins Pathology) Plastic and metal stentsPlastic and metal stents are another form of treatment which is used to relive the symptoms of jaundice , which comes with pancreatic cancer. These plastic or metal stents (tubes) are placed into the bile duct, when the duct has become obstructed by a tumour. The pancreatic tumour is usually pressing up against the bile duct and prevents the bile from traveling from the liver, through to the duodenum. These stents are usually placed during day surgery, using a technique called an endoscope. Plastic stents are used as temporary measures to relieve jaundice, when the patient is thought to be a candidate for surgery. A metal stent is used for the permanent treatment of jaundice, if surgery is not an option for the patient. Some centers many not routinely insert stents to relieve jaundice before surgery. This is to avoid delays and the slight risk of complications from the stent insertion procedure via endoscope such as infection and inflammation of the surrounding tissue. This decision will probably depend on whether the patient's symptoms are tolerable and not too severe. (Pancreatic Cancer-UK)
Many people seek new treatment methods through clinical trials in Canada and in other Countries. Understanding the different options of treatment available to you can be important, when deciding what is best for you and your family. Cancer Care Nova Scotia was developed by the provincial Department of Health, and offers information about clinical trials, available to patients in Nova Scotia. Their web sited is also a valuable resource for patients with cancer, living within the province. The following two links will take you to Canadian based clinical trials. Canadian Cancer Society - Clinical Trials National Cancer Institute of Canada - Clinical Trials |
Side Effects from Pancreatic CancerThere are some long-term consequences of the Whipple operation such as malabsorption, weight loss and need to change diet. Malabsorption: this is the poor digestion and absorption of food, resulting in loose stools that are greasy, pale and tend to float in the water. The pancreas produces enzymes required for digestion of food. Removal of part of the pancreas decreases the production of these enzymes. Therefore, in some patients there is need for long-term treatment with pancreatic enzyme capsules to be taken by mouth with each meal. Weight loss: it is common for patients to lose weight compared to their weight before their illness. After the operation, patients usually start regaining some of the lost weight by three months after surgery. Digestion / Diet and Weight LossMany patients with Pancreatic Cancer struggle against drastic weight loss which can occur before diagnosis, during treatment and/or after surgery. The following information will give you suggestions for nutritious supplements that will aid in the maintenance or increase in the patients weight. A patients goal is to maintain a healthy weight, so that a comfortable activity level can be maintained. Each patient, with caregiver support, will have to actively engage in a trial and error process to see what works best for them, however smaller and more frequent meals are recommended. Protein rich meals are also suggested. Dieticians can give advice about diet and supplements that can improve patients’ nutrition. In general, it takes several months for patients’ digestion and ability to eat to return to normal levels. Malabsorption means the poor digestion and absorption of food, resulting in loose stools that are greasy, pale and tend to float in the water. The pancreas produces enzymes required for digestion of food. Removal of part of the pancreas decreases the production of these enzymes. Therefore, in some patients there is need for long-term treatment with pancreatic enzyme capsules to be taken by mouth with each meal. The following is a link to PanCan which has an extensive write up regarding weight loss and digestion challenges for patients with Pancreatic Cancer. http://www.pancan.org/Patient/Pancreatic/Diet/more.html Recipe IdeasAscitesAscites can be a side effect of a patient who have been diagnosed with pancreatic cancer. Ascites is the result of fluid in the abdominal cavity. There can be many causes of ascites but pancreatic cancer is the cause we will discuss in this section. The cause of ascites is usually the result of poor liver function. Caregivers or patients may notice abdominal distension and rapid weight gain. Some people also develop swelling of ankles and shortness of breath. Ascites can cause pain in the patients abdomen and can cause difficulty in breathing. It also may hinder the ability to eat. Other complications can involve the fluid spreading into the patients chest and into the lung cavities. Ascites, associated with pancreatic cancer, usually is an indication that the end stage of the patient's life is nearing. Limited survival should be considered when determining the aggressiveness of further intervention. With that said there are various treatments that may be suggested by the physician some of which are; diuretics, paracentesis, and peritoneovenous shunting. Although many of these treatments will not prolong life, peritoneovenous shunts can be considered palliative care, as they possibly may keep a patient out of the hospital and improve the quality of life left. The following link discusses this phenomenon in more depth and was used as a reference when writing the above information on ascites. The article this link refers to is "Prognostic significance of new onset ascites in patients with pancreatic cance." rhttp://www.wjso.com/content/4/1/16 |
Risk FactorsThere is a long list of risk factors for pancreatic cancer. Some of the most important ones are as follows; Known risk factors for Pancreatic Cancer
Risk factors you Cannot InfluenceThere are two risk factors which a person has no control over. These would be your age and family history. Risk factors you Can Influence
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Final Stages of Pancreatic Cancerthough a difficult topic to discuss, many patients and families are often frightened and/or have many questions to ask about death. What will it look like? What will it feel like? What will they experience? What can they do to comfort loved ones? The following section will hopefully address some of these concerns or questions. The following button will give you a detailed look at what you can expect during the final stages of death. Final Stage of DeathThe following was written by Roger C. Bone, M.D., who was dying of cancer. He writes this "Guide to Dying," not from a physician's point of view, but from a cancer patients point of view, although acknowledges that perhaps his medical career assisted him in his ability to write the following. A Dying Person’s Guide to DyingHow does one prepare for death? This is often is a personal reflection of their own individual needs, however the following are some suggestions on how to continue living when you know you are dying. Living While Dying |
ReferencesThe National Cancer Institute of Canada - www.ncic.cancer.ca The Canadian Cancer Society - www.cancer.ca - 1-888-939-333 Cancer Care Nova Scotia ( a program of the provincial Department of Health that started in 1998) The Johns Hopkins Pathology - www.path.jhu.edu Penn State Hershey Medical Center Memorial Sloan-Kettering Cancer Center - (phone number 212-639-2000) M.D. Anderson - www.mdanderson.org Pancreatic Cancer UK - www.pancreaticcancer.org.uk The Mayo Clinic - http://www.mayoclinic.com Hospice - http://www.hospicenet.org |
