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Why Advances in Pancreatic Cancer Detection, Treatment Remain Elusive

April 08, 2021

Dr. Bret Schipper
Chief of Surgical Oncology Hartford and Central Region
Director of Oncologic Surgery Hartford Healthcare Cancer Institute
Director of Heated Intraperitoneal Chemotherapy Program

Pancreatic cancer remains one of the cancers with less-than-optimal survival statistics. Unfortunately, even as there have been significant advances in treatment paradigms in many other cancers, we have struggled to move the bar significantly in pancreatic cancer treatment.

In the last few decades, we have managed to get the combined stage five-year survival statistics only to about 10 percent. Part of this struggle is the lack of early detection and screening methods. Unlike breast and colon cancer that have mammograms and colonoscopies, we have not yet identified a cost-effective and reliable screening tool for pancreatic cancer.

We have had some advances in chemotherapy and radiation treatments that have helped. We also now are focusing a lot of attention on identifying those that are at higher risk to develop pancreatic cancer and how do we identify these patients so they can be screened closely.

To understand the biology and clinical findings associated with pancreatic cancer, you must first understand the gland’s location and purpose. The pancreas is a gland about 6 inches long, shaped like a thin pear lying on its side. The broader end of the pancreas is called the head, the middle section the body and the narrow end the tail.

The pancreas lies between the stomach and the spine. The head of the pancreas is along the curve of your duodenum, the first part of the small intestine just beyond the stomach. The pancreas plays a dual role in your bodily functions:

• Endocrine system: The pancreas secretes hormones, including the blood sugar-regulating hormones: insulin and glucagon.
• Exocrine system: The pancreas also secretes enzymes into your digestive tract through a duct into your duodenum.

Pancreatic cancer is hard to detect at an early stage. It does not usually cause symptoms until it is more advanced. When patients do get symptoms, they are often vague. They include yellowing of the skin and eyes, pain in the abdomen and back, weight loss and fatigue. Also, because the pancreas is hidden behind other organs, healthcare providers cannot see or feel the tumors during routine exams.

Doctors use a physical exam, blood tests, imaging tests and a biopsy to diagnose it. Because we don’t have any ideal methods for screening the general population, it is often found at an advanced stage and can spread quickly. Pancreatic cancer can be treated in different ways. Possible treatments include surgery, radiation, chemotherapy and targeted therapy. Targeted therapy uses drugs or other substances that attack specific cancer cells with less harm to normal cells.

There are also certain risk factors that can place patients at higher risk for pancreatic cancer. As mentioned earlier, this is where a lot of research is being done to understand who is at higher risk and screen them closely to catch something early so they can be a surgery candidate.

Some risk factors are modifiable by lifestyle changes, and some, unfortunately, are genetic and not able to be modified. Modifiable factors, including smoking and obesity, may increase the risk of pancreas cancer. Other factors include a personal history of diabetes or chronic pancreatitis and a family history of pancreatic cancer or pancreatitis.

Unfortunately, many of the higher risk factors are genetic. We are now able to also identify certain genetic abnormalities that have an increased risk of developing pancreatic cancer that ranges from a few percent all the way up to about 20 percent higher risk.

These include:

• Multiple endocrine neoplasia type 1 (MEN1) syndrome.
• Hereditary nonpolyposis colon cancer (HNPCC; Lynch syndrome).
• von Hippel-Lindau syndrome.
• Peutz-Jeghers syndrome.
• Hereditary breast and ovarian cancer syndrome.
• Familial atypical multiple mole melanoma (FAMMM) syndrome.

During the workup of a pancreatic mass or cancer, a few tests patients can fully evaluate the extent of the tumor.

These tests allow doctors to look closely at the function of the gland as well as look at the tumor itself and take a biopsy:

• Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances, such as bilirubin, released into the blood by organs and tissues in the body.  If this is elevated, it could be a sign of a lesion in the pancreas.
• Tumor marker test: A blood sample is checked to measure the amounts of certain substances, such as CA 19-9, which is a tumor marker that can be elevated in pancreatic cancers.
• MRI/CAT Scan: These tests allow us to get a picture of the pancreas and look for any abnormalities, as well as determine if the cancer is locally advanced or metastatic to other locations.
• PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
• Endoscopic ultrasound (EUS): A procedure in which an endoscope is inserted into the mouth down into the stomach to look at the pancreas closely.  A probe at the end of the endoscope is used to bounce high-energy sound waves (ultrasound) off the gland and allow us to visualize the tumor and get a biopsy.

Once the workup is complete, a multidisciplinary team meets to decide the treatment plan. The treatment plan varies for each patient by the extent of disease and other factors.

Patients typically fall into one of the following categories:

• Resectable pancreatic cancer: These tumors do not appear to involve any surrounding structures such as blood vessels or lymph nodes.  These patients tend to go to surgery first for tumor removal and then follow up with chemotherapy and possibly radiation, depending on the pathology
• Borderline or locally advanced pancreatic cancer: This cancer has grown into lymph nodes or a major blood vessel or nearby tissue or organs.  These patients typically get upfront chemotherapy and sometimes radiation to try and downstage(shrink) them and get them to surgery.
• Metastatic pancreatic cancer: Spreads to other distant organs, so surgery is no longer an option, and chemotherapy and radiation are used to try and slow down the progression.

Here at Hartford HealthCare, we have put together a world-class multidisciplinary team to take patients through the continuum of workup and treatment of pancreatic cancer. The team meets weekly to discuss all of our patients and develop a consensus on each patient’s management.

Our team includes oncologists, surgeons, radiation oncologists, pathologists, radiologists, research staff and navigators who make sure patients are treated with respect and worked up and treated in a timely and efficient manner.

It can be a scary and stressful time in a patient’s life when first diagnosed with pancreatic cancer, but here at Hartford Healthcare we have the latest treatment protocols as well as clinical trials that are helping to advance the survival statistics and help patients beat this terrible disease.

Dr. Bret Schipper is Director of Oncologic Surgery at the Hartford Healthcare Cancer Institute.