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Pancreatic cancer

Pancreatic cancer is a disease resulting from uncontrollable growth of pancreatic cells. Uncontrollable growth of cells will lead to development of a mass called tumor. Tumor can either be benign (enclosed in one area and cannot spread) or malignant (can spread to other parts). As pancreatic tumor grows it will start affecting functions of the pancreas and finally it will grow to other parts of the body including nearby blood vessels and organs. Pancreatic cancer can start at any part of the pancreas, so in order to understand well about pancreatic cancer, it is important to first know the structure and functions of pancreas.

About pancreas
Pancreas is a soft lobulated organ located behind the stomach (between the stomach and spine). Pancreas is 13-15cm long made up of three parts (head, body and tail). There are two types of cells with different functions in the pancreas.

• Exocrine cells. These cells makeup exocrine part of the pancreas. Exocrine cells are responsible for production of special proteins called enzymes which act as catalyst in digestion of food in small intestine. After production, enzymes are released into tiny ducts that will combine to form large ducts which will further combine to form pancreatic duct. Pancreatic duct will join with common bile duct (carries bile from the liver) and empty the contents into the duodenum.
• Endocrine cells. These makeup endocrine part of the pancreas. These cells are scattered among exocrine cells in clusters called pancreatic islets (islets of Langerhans). These cells produce hormones that regulate blood sugar.

Types of pancreatic cancer
Exocrine pancreatic cancers.
Exocrine cancers start develop from exocrine cells. It is the most common type of pancreatic cancer. This type is further subdivided into;
• Adenocarcinomas. This is the most common exocrine tumor that begins from the lining of pancreatic duct.
• Adenosquamous carcinomas.
• Undifferentiated carcinomas.

Endocrine pancreatic tumors. These are less common pancreatic cancers. Endocrine pancreatic cancers start from endocrine cells. These are also called pancreatic neuroendocrine tumors (PNETs). Pancreatic neuroendocrine tumors are further subdivided into the following;
• Functioning PNETs. These are pancreatic endocrine tumors that produce hormones (excess hormones). This group includes;
• Insulinoma. Begin from insulin producing cells. Produce too much insulin.
• Gastrinoma. Begin from gastrin producing cells. Produce too much gastrin.
• Glucagonoma. Begin from glucagon producing cells. Produce too much glucagon.
• Somatostatinoma. Begin from somatostatin producing cells. Produce too much somatostatin.
• VIPoma. Begin from vasoactive intestine peptide. Produce vasoactive intestinal polypeptide.
• Non-functioning PNETs. These are pancreatic endocrine tumors that do not produce hormones. These are likely to be detected at late stage when tumor has grown large and spread to other organs.

Risk factors
When it comes to cancer, anything that increases your probability of developing cancer is called a risk factor. Risk factors only influence development of cancer but it does not directly cause cancer. Sometimes people with risk factors do not develop the disease while those with no risk factors do develop the disease. Knowing risk factors will help you live your life making some better healthy choices to reduce the risk. The following factors may increase your risk of developing pancreatic cancer.

• Smoking. Cigarrate smokers are more likely to develop pancreatic cancer than those who do not smoke. Cigarrate smoke contain chemicals that have potential of causing cancer (carcinogen).
• Age. Statistics indicate that, pancreatic cancer is more common to those with 45 years and above.
• Gender. Statistics shows that, number of men who develop pancreatic cancer is high compared to that of female. This is highly linked to general life style of men that include smoking.
• Family history. Although most people with pancreatic cancer do not have family history of the disease, but some develop pancreatic cancer because of the inherited gene with faulty that runs in the family.
• Inherited syndromes. Some genetic syndromes are highly linked to development of pancreatic cancer. These syndromes include Peutz-Jeghers syndrome, the familial breast cancer gene (BRCA1 and BRCA2), familial atypical multiple mole melanoma syndrome, Lynch syndrome and hereditary pancreatitis.
• Chronic pancreatitis. Chronic inflammation of pancreas may increase your chance of developing pancreatic cancer.
• Type 2 diabetes. The specific reason is still unknown but people with type 2 diabetes are said to be at increased risk of developing pancreatic cancer. This type of diabetes most often develop in adults and is related to overweight and obesity.
• Liver cirrhosis. Cirrhosis is scaring of liver. People with liver cirrhosis are said to be at slightly higher risk of developing pancreatic cancer than those with no cirrhosis.

To prevent a disease you first need to know what causes it. Unfortunately for pancreatic cancer there is no known specific cause of pancreatic cancer. So there is no sure way of preventing pancreatic cancer but there are some factors that can help in reducing your chance of developing pancreatic cancer. These factors include the following;
• Avoid cigarrate smoking. Since smoking increase the risk of developing pancreatic cancer, so avoiding smoking will reduce the risk of developing pancreatic cancer.
• Physical exercises. Physical exercises will help to burn some excess fats in the body hence prevent you from obesity which will result to reduced chance of developing type 2 diabetes which is one of the risk factors of pancreatic cancer.
• Seeking medical treatment for pancreatic inflammation. This will reduce the chance of suffering from chronic inflammation which would increase the chance of developing pancreatic cancer.

Early detection
When it comes to cancer, early detection normally provide better treatment outcome. When pancreatic cancer is found early at stage, chance for better treatment outcome is very high. However detecting pancreatic cancer early is difficult because pancreas is deep inside the body, so early tumors can’t be seen or felt by health care providers during routine physical exams.

Screening is the process of running some tests to someone with no signs and symptoms of the disease with the intention of testing for presence or absence of the disease.

Screening is the process of running some tests to someone with no symptoms of a certain disease with the intention of determining presence or absence of that disease. For several other types of cancers, screening has helped in their early detection. However currently there is no screening test recommended for pancreatic cancers. This is because, no screening tests has helped to lower the risk of dying from pancreatic cancer.

But for those at very high risk of developing pancreatic cancer due to family history, tests like endoscopic ultrasound may help in screening.

Signs and symptoms
Most cases of pancreatic cancer, do not show any symptoms while at early stage. When pancreatic cancer start causing symptoms it is likely that it is in advanced stage. Most of the symptoms are similar to those of other medical conditions so the only way to find out if it is pancreatic cancer or not is through having some medical tests, hence seeing the doctor as soon as someone start experiencing any of the symptoms is very important. Signs and symptoms of pancreatic cancer include the following;

• Unexplained weight loss
• Loss of appetite
• Nausea and/or vomiting
• Jaundice; Yellowish of skin and eyes
• Belly or back pain (pain in the upper abdomen or upper back)
• Enlarged gallbladder or liver
• Hyperglycaemia. Too much sugar in the blood.
• Hypoglycaemia. Too low sugar in the blood.
• Increased urination
• Increased thirst.
• Blood clots. Clotting of blood in large vein normally in the leg. It is called deep vein thrombosis.

Diagnosis Medical diagnosis simply means identification of nature of an illness by elimination of the symptoms. Normally people don`t go to hospital knowing they have cancer but during diagnostic procedures is when doctors detect the disease.

Following suspicion of the disease, doctors normally run combination of tests to determine whether there are cancerous cells in the body or not and if there are cancer cells, how far have they spread. Along with thorough medical history and physical examination, doctors normally use combination of the following tests to diagnose cancer.

Laboratory tests. Laboratory tests are important in ruling out other conditions and confirming diagnosis. For cancer diagnosis laboratory tests normally include blood tests, urine tests, tumor markers and other body fluids tests.

• Blood tests. Blood tests help to reveal level of different substances in the blood which will help doctors to know if there is anything wrong in the body. From blood tests doctors can see complete blood count which indicates number, size and maturity of blood cells. Also from the blood tests doctors can analyze if kidney and liver are working properly.
• Urine tests. Urine tests (urinalysis) involve laboratory examination of urine to check presence of blood, proteins, and other substances such as drugs. For instance blood in the urine may be an indication of benign condition, infection or other health problem.
• Tumor markers. These are biomarkers (proteins) that can be produced by both cancer cells and normal body cells in response to cancer. Tumor markers are released into the blood or urine. Although studies are still conducted to determine role of these markers in diagnosing cancer because sometimes people with benign condition will have elevated level of these proteins. Also not all tumors have their markers and some markers are not specific to one type of tumor.
• Other body fluids. Despite being rarely used, sometimes body fluids can be tested in the lab during diagnosis of cancer. For instance the use of cerebral spinal fluid (CSF) and pleural fluid. CSF is used in diagnosis of brain tumors while pleural fluid for lung cancer.

Diagnostic imaging
Diagnostic imagings involve tests that create pictures of inside the body that help the doctor to see if there is tumor or not. There are several imaging tests used in cancer diagnosis depending on the type and location of cancer suspected. These imaging tests include;

• Computed tomography (CT) scan. CT scan machine is a donut-shaped scanner that uses x-rays to create series of pictures of body organs from different angles. This machine is linked to a computer where those series of pictures taken will be combined to create a 3D- image of inside the body. During the scanning process patient will lie still on the table which will slide into the scanner. In order to get a clear image, sometimes the doctor will inject the patient with a contrast material before scanning. From the images the doctor will be able to differentiate between healthy and unhealthy tissues.
• Magnetic resonance imaging (MRI). MRI is an imaging technique that uses powerful magnet and radio waves to take series of pictures of body organs and create a 3D image in a computer linked to a machine. Just like in CT, during MRI procedure the patient will lie on a table that will slide into a long round chamber. Also during this procedure the doctor may inject the patient with a contrast material for clear image view.
• X-ray. This is an imaging technique that is uses low dose of radiation to create pictures of inside your body. Technician will position the patient and direct the x-ray beam to the intended part of the body.
• Ultrasound. Ultrasound is a diagnostic imaging procedure that uses high energy sound waves to produce images of organs inside the body. During the examination, a patient will lie on the table while the technician will slowly move a device called transducer on the skin over the part of the body that is being examined.
• PET scan. Positron emission tomography (PET) scan is an imaging test that uses radioactive glucose to create 3-D images of areas inside the body. Radioactive glucose is used for this test because cancer cells tend to absorb more glucose than normal body cells, so the scan will show which areas of the body has more glucose than others. Before the scan, doctor will inject the patient with tracer called radioactive glucose then during imaging the patient will be asked to lie on the table that will be moving back and forth through the scanner.
• Bone scan. Bone scan is used to examine bones. When it comes to cancer, bone scan is used for diagnosis of bone cancer or cancer that has metastasized into the bones. Before the test, patient will be injected with small amount of radioactive material that tends to collect more on abnormal parts of the bones. Then pictures that will be taken by a scan will indicate the distribution of those radioactive materials in the bones throughout the body.

Biopsy is a diagnostic procedure that involves removing a tissue sample from the body and examines it under microscope in the laboratory. Examination in the laboratory is normally done by a pathologist who will check if the cells in the tissue are cancerous or not. In most cancer cases, biopsy is considered to be the confirmatory test. Depending on the location and type of cancer, biopsy can be obtained in different ways. Some of them include;
• Using needle. By using a thin needle, doctors can draw same tissue or fluid for examination under microscope. This method can be used to draw some fluid (spinal tap), bone marrow (bone marrow aspiration), blood or small amount of tumor from the suspected organ such as liver and breast (fine needle aspiration).
• Surgery. Abnormal tissue samples are obtained while the doctor is performing the surgery. Tissues are then sent to the lab for examination during the surgery. If the surgeon removes just a portion of abnormal area, it is called incisional biopsy while when the entire tumor (abnormal site) is removed it is called excisional biopsy.
• Using endoscope. Endoscope is a thin, lighted tube with a camera (focusing telescope) at the end. It is used for viewing inside the body through natural openings like mouth and anus. During an examination if the doctor sees any abnormal tissue, then endoscope can also be used to take sample for that tissue. There are different kinds of endoscopy exams depending on the site of the body being examined. Some of the exams include colonoscopy (for rectum and colon), bronchoscopy (for trachea, bronchi and lungs) and esophagogastroduodenoscopy EGD (for esophagus, stomach and duodenum)

In addition to physical examination and medical history, diagnosis of pancreatic cancer normally involves the use of Ultrasound, CT-Scan, PET Scan, biopsy, MRI Scan, Endoscopic Ultrasound (EUS) and blood tests through which the doctor will also be able to assess level of certain tumor makers like CA 19-9 and Chromogranin –A in case of PNETs. Also if the disease is PNET, the level of certain hormones normally tends to rise. Also diagnosis may involve the use of MRCP Scan (Magnetic resonance cholangiopancreatography) which is a type of MRI scan that produces more detailed images and can be used to check the common bile duct for blockage (obstruction).

Staging is a standard way used by cancer care team to explain how far the cancer has grown or spread. Once an imaging modality has helped to establish a probable diagnosis of pancreatic cancer, the next issue is deciding suitable treatment option for the disease. Staging has enabled oncology team to decide on the suitable treatment option. In this process of staging doctors normally use systems in order to describe the stage of cancer.
For pancreatic cancer, can be staged in two ways;

• By TNM staging system (tumor, node and metastasis).
• By characterizing pancreatic masses as resectable, borderline resectable or unresectable (locally advanced or metastasized).

In Tanzania, TNM system is the most used staging system so even in this page, the discussion will be on TNM staging system. As explained before TNM is the combination of three worlds, tumor, node and metastasis.
>>> Tumor. Tumor explains size (how large is the tumor?) and its location.
>>> Node. This explain lymph nodes involved.
>>> Metastasis. Metastasis explains how far has disease spread.

There are four stages under this system (I –IV) (one through four). More description on this TNM system is as follows;

Tumor (T)
TX. Primary tumor cannot be evaluated
T0. There is no evidence of primary tumor.
Tis. Carcinoma in situ. This is very early cancer and is confined in the pancreas.
T1. Tumor is 2cm or smaller in size and is only in the pancreas.
T2. Tumor is larger than 2cm but still is in the pancreas only.
T3. Tumor extend beyond pancreas into surrounding organs but not into major blood
Vessels and nerves.
T4. Tumor has spread beyond pancreas to distant sites and has involved major blood vessel And nerves

NX. Reginal lymph node involvement cannot be evaluated
N0. No evidence of reginal lymph node involvement.
N1. Reginal lymph nodes are involved.

• MX. Distant metastasis cannot be evaluated.
• M0. No evidence of distant metastasis.
• M1. The disease has spread to other parts of the body.
In order to provide the specific stage of PANCREATIC cancer stage, doctors will combine all those there in terms tumor, node and metastasis to complete TNM system. The stages are as follows;

Stage 0 (Tis, N0, M0): Tumor is in situ (carcinoma in situ) with no evidence of lymph node Involvement or distant metastasis.
Stage IA (T1, N0, M0): The tumor is 2 cm or smaller in the pancreas with no evidence of Lymph node involvement or distant metastasis.
Stage IB (T2, N0, M0): A tumor larger than 2 cm is in the pancreas but there is no evidence of Lymph node involvement or distant metastasis.
Stage IIA (T3, N0, M0): A tumor has spread beyond the pancreas, but the tumor has not spread Major blood vessels and nerves. No evidence of lymph node involvement Or distant metastasis.
Stage IIB (T1-T3, N1, M0): A tumor is of any size and may have spread beyond pancreas But has not spread to major blood vessels and nerves. Reginal Lymph nodes are involved but there is no distant metastasis
Stage III (T4, N1, M0): A tumor has spread to nearby major blood vessels or nerves. There is Reginal lymph nodes involvement but tumor has not spread to other Distant parts of the body.
Stage IV (any T, any N, M1): Tumor is of any size that may have invaded major blood vessels And reginal lymph node. Tumor has also metastasized to other Distant parts of the body.

Classifying pancreatic cancer
depending on whether tumor is;- Resectable or not Resectable. This choice of classifying (staging) pancreatic cancer is preferred for treatment reasons as it is considered to be simple.

Resectable. Tumor is only in the pancreas or has spread just beyond it but has not invaded Major blood vessels. Tumor can be completely be removed by surgery.

Borderline resectable. Tumor may have just extended to nearby major blood vessels but Surgeon believes it can be completely removed surgically after Shrinking tumor with either chemotherapy or radiotherapy.

Locally advanced. Tumor is still located only in the area around the pancreas, but it cannot be surgically removed because it has grown into major blood vessels or to nearby organs. However, there are no signs that it has spread to any distant parts of the body.

Metastatic. Tumor cannot be surgically removed. Tumor has spread beyond pancreas and to other distant organs, such as the liver or distant areas of the abdomen.

Treatment Following cancer diagnosis, the doctor will break the news and it is normally not very easy to accept that it is cancer. The doctor will be there to help the patient process the news and to help the patient in taking the next steps. After the patient receives and processes the news that he/she has cancer, one of the most important steps that will follow is decision making. The doctor will present to the patient (relatives/parents/guardians) with all the possible treatment options and explain what they mean. Then with the help of the doctor, the patient (relatives/parents/guardian) will have to choose which treatment option is good depending on benefits of such option. Despite all the information given by the doctor, sometimes the patient may still be unsatisfied with what he/she has been told. In such situation, the patient is free and advised to seek a second opinion. Second opinion is the opinion that the patient may seek from another specialist (doctor) regarding his/her health problem and in this case it is cancer. Second opinion may include confirmation of the diagnosis, more clarification on your primary doctor recommendations or even reassurances that all the options have been explored. In addition to standard care treatment options, sometimes there are those new treatments or drugs or combination of treatments that have not been approved yet to be used as standard care treatments for a particular cancer (disease) but have shown some promising results that they may help. These type of treatments are called clinical trials. If there are some clinical trials for your case, the doctor may present to the patient or the patient may ask if there are any clinical trials for the particular cancer case. Over the years, have improved treatments and led to better outcomes to people diagnosed with various diseases including cancer. If you have decided to take part in clinical trial, you can also withdraw at any time

Treatment options

Surgery is the treatment option of pancreatic cancer that involve removing tumor by operation. For pancreatic cancer, this type of treatment option is performed by a specialized doctor known as pancreatic surgeon. For pancreatic cancer, surgery involve removing part or all of the pancreas. Surgical removal (resection) of the tumor is usually the most suitable treatment for people with early-stage disease who are in good health. The surgeon will aim to remove all the tumor from the pancreas as well as the surrounding tissue. The type of surgery will depend on the size of the tumor and where it is located. Types of surgery for pancreatic cancer include the following;

• The Whipple procedure. This is the procedure for treating tumors located in the head of the pancreas. In this procedure, a surgeon will remove the head of the pancreas and part of the small intestine, bile duct, and stomach. Surgeon will then reconnect the digestive tract and biliary system. This is the most common resection surgery for exocrine pancreatic tumors.
• Distal pancreatectomy. This type of surgery is for tumors located in the tail of the pancreas. During surgery, the surgeon will remove the tail and body of the pancreas, as well as the spleen. This surgery is more likely an option to treat early-stage pancreatic NETs.
• Total pancreatectomy. This is an option used if cancer is large or spread throughout the pancreas or it is located in multiple areas in the pancreas. In this surgery, surgeon will remove the entire pancreas, part of the small intestine, a portion of the stomach, the common bile duct, the gallbladder, and the spleen.
It is possible to live without a pancreas. However, the body will no longer produce insulin, so you will need to have regular insulin injections. It will also be necessary to take pancreatic enzyme pills to help digest certain foods.

Side effects

• Feeling pain
• Feeling weak
• Feeling tired
• Difficulty in digesting certain foods. You will be given enzyme pills.
• Risk of diabetes. This is controlled through using artificial insulin. (insulin injections)
• Reactions from anesthesia

Radiation therapy
Radiation therapy is the use of high energy x-rays or other radiation particles to destroy cancer cells. This type of treatment option is given by a specialized doctor known as radiation oncologist. For pancreatic cancer, external beam radiation therapy is the most used type of radiation therapy. In this type of radiation therapy, beam of radiation is directed to the tumor from the machine which is position outside the body.

Radiation therapy is usually used in combination with chemotherapy (chemoradiation) to treat locally advanced cancers, i.e. cancer that has spread beyond the pancreas and cannot be removed with surgery. Combination of chemotherapy and radiation therapy may occasionally be used before surgery (neo adjuvant therapy) so as to shrink the tumor enough so it can be removed by surgery. Also the combination may be given after surgery for early stage cancer to reduce the risk of cancer recurring.

side effects
• Fatigue
• Nausea and/or vomiting
• Diarrhea
• Skin reaction at the site where radiation pass through
• Poor appetite

Chemotherapy is the use of drugs to kill or slow growth of cancer cells. This type of treatment is given by a specialized doctor known as medical oncologist. Chemotherapy drugs can be given through injections (intravenously) or orally as pills or capsule

Chemotherapy is sometimes used in combination with radiotherapy (chemoradiation) to treat locally advanced cancers, i.e. cancer that has spread beyond the pancreas and cannot be removed with surgery. If you have advanced pancreatic cancer, chemotherapy may be given as palliative treatment to relieve symptoms and improve survival. Chemotherapy is not commonly used to treat pancreatic NETs.

side effects
• Nausea and/or vomiting
• Loss of appetite
• Mouth sores
• Diarrhea
• Risk of infection due to lower white blood cells
• Low red blood cells count that will cause weakness or breathlessness
• Skin rashes

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