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Monday, March 10, 2008

Pancreatic Cancer

Pancreatic cancer is now the 4th leading cause of cancer death in the United States. It will cause more than 30,000 deaths this year in the United States alone. Pancreatic cancer is difficult to detect, hard to diagnose, early to metastasize (spread) and resistant to treatment.

Types Of Pancreatic Cancer

The most common type of pancreatic cancer is also known as pancreatic duct adenocarcinoma or simply pancreatic carcinoma. Other types of pancreatic cancer can occur as well including those arising from endocrine cells or exocrine cells. Endocrine cancers are also known as islet cell or neuroendocrine cancers. These tumors can produce hormones that produce a variety of symptoms such as changes in blood sugar or diarrhea. Exocrine pancreatic cancer is a disease in which cancerous cells originate within the tissues of the pancreas that produce digestive juices. The following information focuses mainly on pancreatic carcinoma, the most common cancer of the pancreas.

Symptoms of Pancreatic Cancer

Pancreatic cancer is sometimes called a "silent disease" because early pancreatic cancer often does not cause symptoms. But, as the cancer grows, symptoms may include:

· Weight loss

· Pain in the upper abdomen or upper back

· Yellow skin and eyes, dark urine, and light stool

· Weakness

· Loss of appetite

· Nausea and vomiting

These symptoms are not sure signs of pancreatic cancer. An infection or other problem could also cause these symptoms. Only a doctor can diagnose the cause of a person's symptoms. Anyone with these symptoms should see a doctor so that the doctor can treat any problem as early as possible.

Diagnosis of Pancreatic Cancer

If a patient has symptoms that suggest pancreatic cancer, the doctor asks about the patient's medical history. The doctor may perform a number of procedures, including one or more of the following:

· Physical exam -- The doctor examines the skin and eyes for signs of jaundice. The doctor then feels the abdomen to check for changes in the area near the pancreas, liver, and gallbladder. The doctor also checks for ascites, an abnormal buildup of fluid in the abdomen.

· Lab tests -- The doctor may take blood, urine, and stool samples to check for bilirubin and other substances. Bilirubin is a substance that passes from the liver to the gallbladder to the intestine. If the common bile duct is blocked by a tumor, the bilirubin cannot pass through normally. Blockage may cause the level of bilirubin in the blood, stool, or urine to become very high. High bilirubin levels can result from cancer or from noncancerous conditions.

· CT scan (Computed tomography) -- An x-ray machine linked to a computer takes a series of detailed pictures. The x-ray machine is shaped like a donut with a large hole. The patient lies on a bed that passes through the hole. As the bed moves slowly through the hole, the machine takes many x-rays. The computer puts the x-rays together to create pictures of the pancreas and other organs and blood vessels in the abdomen.

· Ultrasonography -- The ultrasound device uses sound waves that cannot be heard by humans. The sound waves produce a pattern of echoes as they bounce off internal organs. The echoes create a picture of the pancreas and other organs inside the abdomen. The echoes from tumors are different from echoes made by healthy tissues.

The ultrasound procedure may use an external or internal device, or both types:

o Transabdominal ultrasound: To make images of the pancreas, the doctor places the ultrasound device on the abdomen and slowly moves it around.

o EUS (Endoscopic ultrasound): The doctor passes a thin, lighted tube (endoscope) through the patient's mouth and stomach, down into the first part of the small intestine. At the tip of the endoscope is an ultrasound device. The doctor slowly withdraws the endoscope from the intestine toward the stomach to make images of the pancreas and surrounding organs and tissues.

· ERCP (endoscopic retrograde cholangiopancreatography) -- The doctor passes an endoscope through the patient's mouth and stomach, down into the first part of the small intestine. The doctor slips a smaller tube (catheter) through the endoscope into the bile ducts and pancreatic ducts. After injecting dye through the catheter into the ducts, the doctor takes x-ray pictures. The x-rays can show whether the ducts are narrowed or blocked by a tumor or other condition.

· PTC (percutaneous transhepatic cholangiography) -- A dye is injected through a thin needle inserted through the skin into the liver. Unless there is a blockage, the dye should move freely through the bile ducts. The dye makes the bile ducts show up on x-ray pictures. From the pictures, the doctor can tell whether there is a blockage from a tumor or other condition.

· Biopsy -- In some cases, the doctor may remove tissue. A pathologist then uses a microscope to look for cancer cells in the tissue. The doctor may obtain tissue in several ways. One way is by inserting a needle into the pancreas to remove cells. This is called fine-needle aspiration. The doctor uses x-ray or ultrasound to guide the needle. Sometimes the doctor obtains a sample of tissue during EUS or ERCP. Another way is to open the abdomen during an operation. Most of the time, biopsies are done without the need for surgery. Biopsies may not be required before proceeding with surgery if there is a high likelihood that a pancreatic cancer is present.

Many people diagnosed with pancreatic cancer want to take an active part in making decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, the shock and stress that people may feel after a diagnosis of cancer can make it hard for them to think of everything they want to ask the doctor. Often it helps to make a list of questions before an appointment. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. 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.

Before starting treatment, a patient may want a second opinion about the diagnosis and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient requests it. Gathering medical records and arranging to see another doctor may take a little time. In most cases, a brief delay to get another opinion will not make therapy less helpful. Always feel free to seek a second opinion.

Causes, incidence, and risk factors of Pancreatic Cancer

Despite advances in medical science, we still have a poor understanding of the causes of pancreatic cancer. Doctors can seldom explain why one person gets pancreatic cancer and another does not. However, it is clear that this disease is not contagious. No one can "catch" cancer from another person.

Research has shown that people with certain risk factors are more likely than others to develop pancreatic cancer. A risk factor is anything that increases a person's chance of developing a disease.

Studies have found the following risk factors:

· Age -- The likelihood of developing pancreatic cancer increases with age. Most pancreatic cancers occur in people over the age of 60.

· Smoking -- Cigarette smokers are two or three times more likely than nonsmokers to develop pancreatic cancer.

· Diabetes -- Pancreatic cancer occurs more often in people who have diabetes than in people who do not.

· Being male – Slightly more men than women are diagnosed with pancreatic cancer.

· Being African American -- African Americans are more likely than Asians, Hispanics, or Whites to get pancreatic cancer.

· Family history -- The risk for developing pancreatic cancer triples if a person's mother, father, sister, or brother had the disease. Also, a family history of colon or ovarian cancer increases the risk of pancreatic cancer.

· Chronic pancreatitis -- Chronic pancreatitis is a painful condition of the pancreas. Some evidence suggests that chronic pancreatitis may increase the risk of pancreatic cancer. The risk of pancreatic cancer is increased more than fifty fold in persons with certain forms of inherited pancreatitis.

Other studies suggest that exposure to certain chemicals in the workplace or a diet high in fat may increase the chance of getting pancreatic cancer.

Despite this, most people with known risk factors do not get pancreatic cancer. On the other hand, many who do get the disease have none of these factors. People who think they may be at risk for pancreatic cancer should discuss this concern with their doctor. The doctor may suggest ways to reduce the risk and can plan an appropriate schedule for checkups.

Treatment of Pancreatic Cancer

When pancreatic cancer is diagnosed or even suspected, the doctor needs to know the extent also known as the stage of disease to plan the best treatment. Staging is a careful attempt to find out the size of the tumor in the pancreas, whether the cancer has spread, and if so, to what parts of the body. At the time of diagnosis, only about 20% of pancreatic cancers can be removed by surgery.

Surgery for pancreatic cancer is a major operation. The surgeon may remove all or part of the pancreas. The extent of surgery depends on the location and size of the tumor, the stage of the disease, and the patient's general health.

· Whipple procedure: If the tumor is in the head (the widest part) of the pancreas, the surgeon removes the head of the pancreas and part of the small intestine, bile duct, and stomach. The surgeon may also remove other nearby tissues such as lymph nodes.

· Distal pancreatectomy: The surgeon removes the body and tail of the pancreas if the tumor is in either of these parts. The surgeon commonly also removes the spleen.

· Total pancreatectomy: The surgeon removes the entire pancreas, part of the small intestine, a portion of the stomach, the common bile duct, the gallbladder, the spleen, and nearby lymph nodes.

Sometimes the cancer cannot be completely removed. If the tumor is blocking the common bile duct or small intestine, the surgeon can create a bypass. A bypass allows fluids to flow through the digestive tract. It can help relieve jaundice, pain, nausea and vomiting that often result from a blockage.

The doctor often can relieve blockage without doing bypass surgery. The doctor (generally, a specialist known as a gastroenterologist) uses an endoscope to place a stent in the blocked area. A stent is a tiny plastic or metal mesh tube that helps keep the duct or duodenum open.

After surgery, some patients are fed liquids intravenously (by IV) and through feeding tubes placed into the abdomen. Patients slowly return to eating solid foods by mouth. A few weeks after surgery, the feeding tubes are removed.

Removal of part or all of the pancreas may make it hard for a patient to digest foods. The health care team can suggest a diet plan and medicines to help relieve diarrhea, pain, cramping, or feelings of fullness. During the recovery from surgery, the doctor will carefully monitor the patient's diet and weight. At first, a patient may have only liquids and may receive extra nourishment intravenously or by feeding tube into the intestine. Solid foods are added to the diet gradually.

Also, patients may not have enough pancreatic enzymes or hormones after surgery. Those who do not have enough insulin may develop diabetes. The doctor can give the patient insulin, other hormones, and enzymes to help maintain good nutrition and proper control of the blood sugar.

When a pancreatic cancer is removed surgically, often additional treatments such as radiation therapy and chemotherapy are recommended.

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. A large machine directs radiation at the abdomen. Radiation therapy may be given alone, or with surgery, chemotherapy, or both.

Radiation therapy affects cancer cells only in the treated area. For radiation therapy, patients go to the hospital or clinic, often 5 days a week for several weeks. Radiation therapy may cause patients to become very tired as treatment continues. Resting is important, but doctors usually advise patients to try to stay as active as they can. In addition, when patients receive radiation therapy, the skin in the treated area may sometimes become red, dry, and tender.

Radiation therapy to the abdomen may cause nausea, vomiting, diarrhea, or other problems with digestion. The health care team can offer medicine or suggest diet changes to control these problems. For most patients, the side effects of radiation therapy go away when treatment is over.

Chemotherapy is the use of drugs to kill cancer cells. Doctors also give chemotherapy to help reduce pain and other problems caused by pancreatic cancer. The side effects of chemotherapy depend mainly on the drugs and the doses the patient receives as well as how the drugs are given. In addition, as with other types of treatment, side effects vary from patient to patient. It may be given alone, with radiation, or with surgery and radiation.

Chemotherapy is an outpatient treatment given at the hospital, clinic, or doctor's office. Chemotherapy, mainly given by injection, affects rapidly dividing cells throughout the body, including blood cells. Blood cells fight infection, help the blood to clot, and carry oxygen to all parts of the body. When anticancer drugs damage healthy blood cells, patients are more likely to get infections, may bruise or bleed easily, and may have less energy. Cells in hair roots and cells that line the stomach and intestines also divide rapidly. As a result, patients may lose their hair and may have other side effects such as poor appetite, nausea and vomiting, diarrhea, or mouth sores. Usually, these side effects go away gradually during the recovery periods between treatments or after treatment is over. The health care team can suggest ways to relieve side effects.

Prognosis of Pancreatic Cancer

At this time, pancreatic cancer can be cured only when it is found at an early stage, before it has spread. However, other treatments may be able to control the disease and help patients live longer and feel better. People living with pancreatic cancer may worry about the future. They may worry about caring for themselves or their families, keeping their jobs, or continuing daily activities. Concerns about treatments and managing side effects, hospital stays, and medical bills are also common.

Palliative therapy may be chosen for treatment with patients that have incurable or uncontrollable pancreatic cancer. Palliative therapy is treatment given to relieve the symptoms and reduce the suffering caused by cancer. Palliative therapy aims to improve quality of life by controlling pain and other problems caused by this disease.

Doctors, nurses, and other members of the health care team can answer questions about treatment, diet, working, or other matters. Meeting with a social worker, counselor, or member of the clergy can be helpful to those who want to talk about their feelings or discuss their concerns. Often, a social worker can suggest resources for financial aid, transportation, home care, emotional support, or other services.

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