Pancreatic cancer

Symptoms Of 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 like:

• 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 thirst or excessive thirst could be a symptom of a serious health condition. Read about 5 common causes of excessive thirst or polydipsia.
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Types Of Pancreatic Cancer

Types of pancreatic cancer based on their cell of origin include:

Exocrine pancreatic cancer

Most of the pancreatic tumors are exocrine tumors. They start in the exocrine cells (that produce enzymes for digestion) of the pancreas and include:

Adenocarcinoma: The most common type of pancreatic cancer is adenocarcinoma. It is an exocrine tumor that starts in the cells lining the pancreatic duct, which make enzymes for digestion.

• Mucinous cystic neoplasm: This is an invasive adenocarcinoma and is a cyst filled with thick fluid. Mucinous cystic neoplasms can be non-cancerous (benign) if they are not invasive.

 Other rare exocrine tumors include:

• Squamous cell carcinoma: This is extremely rare and forms in the pancreatic ducts, and is made purely of squamous cells, which are not typically seen in the pancreas.

• Adenosquamous carcinoma: This is the rarest type of pancreatic cancer. It is a more aggressive tumor with a poorer prognosis.

• Colloid carcinoma: These develop from a benign cyst called an intraductal papillary mucinous neoplasm (IPMN).

Neuroendocrine pancreatic cancer

Neuroendocrine tumors (pancreatic NETs or PNETs) come from the abnormal growth of endocrine cells in the pancreas called islet cells, which are responsible for controlling blood sugar levels (hence called islet cell tumors).

PNETs are classified by the hormones they make and common types include:

• Gastrinoma: A gastrin-producing tumor usually located in the pancreas or the duodenal wall. Gastrin is a peptide hormone that stimulates the secretion of gastric acid.

• Glucagonoma: Glucagonoma is a very rare tumor of the islet cells of the pancreas, which leads to an excess of the hormone glucagon in the blood.

• Insulinoma: Pancreatic tumor that leads to extra insulin production causing hypoglycemia (low blood sugar).

• Somatostatinoma: They start in neuroendocrine cells that make the hormone somatostatin.

• VIPoma:  A non-beta pancreatic islet cell tumor secreting vasoactive intestinal peptide (VIP).

• Nonfunctional islet cell tumor: A tumor arising from the rare pancreatic islet cell and no hormone is involved.

Causes Of Pancreatic Cancer

The exact cause of pancreatic cancer is unknown.

• Pancreatic cancer occurs when abnormal cells begin to grow within the pancreas. These abnormal cells develop because of changes (mutations) in their DNA. 
• This mutated DNA dictates the cells grow uncontrollably and continue living after normal cells die. 
• These masses of cells can form a tumor. When left untreated, these cells continue to 
  
  

Risk Factors For Pancreatic Cancer

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
  
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• 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 has been recognized as a potential risk factor.

2. Non-modifiable factors

• Age: Pancreatic cancer generally occurs in patients over 55 years old, mostly between 70-80 years.

• Sex: The incidence of PC 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, and higher cases of development of cancer 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 PC 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)

Diagnosis Of Pancreatic Cancer

Pancreatic cancer is challenging to diagnose, often presenting late with advanced or metastatic disease, depending on tumor size, location, and spread. Depending on this the cancer is divided into 5 stages. These are:

1. Stage 0: Also known as carcinoma in situ and is characterized by abnormal cells in the lining of the pancreas. The cells could become cancerous and spread to nearby tissue.

2. Stage 1: Presence of tumor (cancerous cells) in the pancreas.

3. Stage 2:  The presence of a tumor in the pancreas, which has spread to nearby tissues, organs, or lymph nodes.

4. Stage 3: Spread of cancer to major blood vessels near the pancreas. It may have also spread to nearby lymph nodes.

5. Stage 4: In this stage, cancer has spread to distant organs in the body like the liver, lungs, or abdominal cavity along with tissues or lymph nodes near the pancreas.

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The diagnosis consists of the following:

Physical examination 

• The doctor will examine the patient's skin, tongue, and eyes to see if they are yellow, a sign of jaundice. 

• An abnormal buildup of fluid in the abdomen, called ascites, may be another sign of cancer.

Blood tests

• The doctor may take samples of blood to check for abnormal levels of bilirubin and other substances. 

• Bilirubin is a chemical that may reach high levels in people with pancreatic cancer due to blockage of the common bile duct by a tumor. 
  
  

Imaging tests

These tests help doctors find out where the cancer is located 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, though it's 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): 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.
  
  

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Biopsy

A biopsy removes a small amount of tissue for examination under a microscope. It can make a definite diagnosis for most cancers. There are a couple of different ways to collect a tissue sample:

• Fine needle aspiration cytology (FNAC): It is the 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.

Prevention Of Pancreatic Cancer

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

• While complete prevention isn’t guaranteed, steps like avoiding smoking and alcohol, adopting a healthy lifestyle, managing chronic conditions, and considering genetic counseling or screening for high-risk individuals can help reduce the risk. 

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

Specialist To Visit

Cancer is not a single disease but a group of related diseases. Hence, it requires comprehensive care. Doctors who take care of patients with pancreatic cancer and help in diagnosing and formulating a treatment plan are:

• Gastroenterologist

• Oncologist

A gastroenterologist is a doctor who treats diseases of the esophagus, stomach, small intestine, colon and rectum, pancreas, and gallbladder.

An oncologist is a doctor who treats cancer and provides medical care for a person diagnosed with cancer.

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Treatment 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: It is 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. It uses:

• External beam radiation therapy: This uses external radiation therapy sources that emit X-rays, gamma rays, electrons or heavy particles.
   

• Brachytherapy: It is 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, though, to date, all other targeted drugs have failed in pancreatic cancer patients.

• Recently the Food and Drug Administration (FDA) has approved pembrolizumab as a targeted treatment for pancreatic cancer.

5. Latest treatment protocols

• Gene therapy: Gene therapy delivers specific genes to cancer cells, which are 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: ctDNA is 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).

Home-care For Pancreatic Cancer

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?
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Complications Of Pancreatic Cancer

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 like 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 gets 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 (an abnormal connection between pancreas and intestinal sutures).

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Alternative Therapies For Pancreatic Cancer

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

1. Microbial therapy

• There is now 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. 

2. Immunotherapy

• Immune checkpoint blockade (ICB) therapy is approved for several cancers like melanoma, lung cancer, and kidney cancer. 

• However, pancreatic cancer is less responsive to immunotherapy because its tumor environment suppresses the immune system, and immunotherapy is currently under study and yet to be approved.

Living With 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

• Getting all the information needed to go about with the treatment

• Talking to loved ones

• Joining support groups

• Understanding the physical limitations

• Starting palliative care to get relief from other symptoms

• Coping with practical issues like:

• Financial expenses

• Childcare

• Work issues
  
  

2. Surviving the physical side effects

• Talk to the doctors and healthcare team regularly about the feelings

• Keep a track about any new side effects or changes in existing side effects and inform your doctor immediately

• Get treatment for long-term side effects and late effects.
  
  

3. Supervising the costs of cancer care

• Understanding the cost of the treatment

• Encouraging the patients and their families to talk about financial concerns with a member of their healthcare team

• Getting support from organizations that help with treatment, housing, travel, and other cancer-related costs.
  
  

4. Focusing on diet

• Sticking to 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 the calorie intake

• Maintaining blood sugar levels

• Taking enzyme supplements
  
  

5. Preparing for the treatment

• Understanding prehabilitation ( getting ready for cancer treatment in whatever time you have before it starts)

• Preparing mentally and physically for the treatment

• Eating a wide range of foods in the right proportion
  
  

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.

• Report 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. 
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