Pancreatic Cancer

General Information

About

Pancreatic cancer develops in the pancreas, an organ that sits deep in your abdomen and produces enzymes to help break down food and as it passes through the GI tract, as well as the hormones insulin and glucagon that control blood sugar levels.

Pancreatic cancer is fairly rare but has one of the highest fatality rates for cancer: The disease does not usually cause noticeable signs in its earliest stages and often goes undetected, despite the tumor wrapping itself around arteries, veins, nerves, and the bile duct.  Diagnosis is also challenging given the location of the pancreas and it's intricate role regulating the body.

However, we are not backing down, and neither should you. We’re continuing to develop new ways to manage and cure the disease, including targeted therapies and new methods for performing surgeries and delivering chemotherapy and radiation. While we can’t remove all tumors, our experienced surgeons have success with even the most complex cases—even those considered inoperable by other doctors.

Risk Factors

We don’t know what causes most pancreatic cancers, but several risk factors can increase your chance of developing the disease:

  • Most cases of pancreatic occur after age 60.
  • Cigarette smokers are two to three times more likely than nonsmokers to develop pancreatic cancer.
  • The disease is more common in men than women.
  • African-Americans tend to get this cancer more often than individuals from other ethnic groups.
  • People with diabetes have a greater risk, as do those with a history of chronic pancreatitis, a chronic inflammation of the pancreas.
  • If you have immediate family members with a history of pancreatic, colorectal, or ovarian cancer, you have an increased risk.

Take these steps to lower your risk:

  • If you smoke, quit.
  • Maintain a healthy weight.
  • Limit your consumption of pork, red meat, and processed meat-such as lunch meat, sausage, and bacon.
  • Avoid cooking meats at high temperatures. Doing so can help reduce your exposure to harmful chemicals that are formed in high temperature cooking.
  • Include at least five servings of fruits and vegetables in your diet, daily diet

Signs & Symptoms

Noticeable signs or symptoms are not present in the early stages of pancreatic cancer. As the cancer grows, symptoms may include:

  • Pain in the middle or upper abdomen
  • Yellowed skin and eyes
  • Weakness or fatigue
  • Appetite loss
  • Nausea and Vomiting
  • Weight loss

Detection 

To determine if you are suffering from a GIST tumor, as well as whether it is surgically removable, your surgical oncologist will perform a number of diagnostic tests, including:

  • Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the chest, abdomen, and pelvis, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
  • Endoscopic ultrasound (EUS): Sound waves create images of body tissues where high-energy sound waves are bounced off internal tissues and organs; the echoes are then changed into pictures called sonograms. EUS can also guide the removal of tissue for biopsies.
  • Laparoscopy: A laparoscope (a thin, lighted tube) is inserted through an incision in the abdominal wall to determine if the cancer is within the pancreas only or has spread to nearby tissues and if it can be removed by surgery later.
  • Endoscopic retrograde cholangiopancreatography (ERCP): An x-ray of the ducts that carry bile from the liver to the gallbladder and from the gallbladder to the small intestine. Because pancreatic cancer can cause these ducts to narrow and block or slow the flow of bile, causing jaundice, the ERCP can detect this blockage. ERCP can also remove tissue for biopsies.
  • Chest X-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
  • Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. The biopsy may be done after surgery to remove the tumor. If the tumor clearly cannot be removed by surgery, the biopsy may be done using a fine needle to remove cells from the tumor.
  • MRI: MRI scans use radio waves and strong magnets instead of X-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases.  These scans can help oncologists find the extent of the cancer in the abdomen
  • Liver function test: Evaluates how well your liver is working, as pancreatic cancer may affect your liver function.
  • Serum bilirubin test: Measures the amount of bilirubin (a fluid produced by the liver) in your blood.

 

Stages

Doctors use a staging system to describe the extent of spread of most types of cancer, including gastrointestinal stromal tumors (GISTs). The most common system used is the TNM system of the American Joint Committee on Cancer (AJCC). This system is based on 4 key pieces of information:

  • T describes the size of the primary tumor, measured in centimeters (cm).
  • N describes whether the cancer has spread to nearby (regional) lymph nodes (this is very rare for GISTs).
  • M indicates whether the cancer has metastasized (spread) to other organs of the body. If a GIST does spread, most often it is within the abdomen, such as to the liver. Less often, it may spread to the lungs and bones.
  • The mitotic rate is a measure of how fast the cancer cells are growing and dividing. It is described as either low or high. A low mitotic rate predicts a better outcome.

Numbers or letters appear after T, N, and M to provide more details about each of these factors:

  • The numbers 0 through 4 indicate increasing severity.
  • The letter X means “cannot be assessed” because the information is not available.

Stage 0 (Carcinoma in Situ)abnormal cells are found in the lining of the pancreas. These abnormal cells may becomecancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

Stage I: cancer has formed and is found in the pancreas only. Stage I is divided into stage IA and stage IB, based on the size of the tumor.

  • Stage IA: The tumor is 2 centimeters or smaller.
  • Stage IB: The tumor is larger than 2 centimeters.

Stage II: cancer may have spread to nearby tissue and organs, and may have spread to lymph nodes near the pancreas. Stage II is divided into stage IIA and stage IIB, based on where the cancer has spread.

  • Stage IIA: Cancer has spread to nearby tissue and organs but has not spread to nearby lymph nodes.
  • Stage IIB: Cancer has spread to nearby lymph nodes and may have spread to nearby tissue and organs.

Stage III: cancer has spread to the major blood vessels near the pancreas. These include the superior mesenteric artery, celiac axis, common hepatic artery, and portal vein. Cancer may have spread to nearby lymph nodes.

Stage IV: cancer may be any size and has spread to distant organs, such as the lung, liver, and peritoneal cavity (the space in the abdomen that contains the intestines, stomach, and liver). Cancer may also have spread to tissue and organs near the pancreas or to lymph nodes.

 

Treatments

Surgery is the only way to cure pancreatic cancer that has not spread (metastasized), and is the best way to contain tumors. Unfortunately, doctors often see later-stage disease, with tumors wrapped around arteries and veins, nerves and the bile duct—making operations more challenging or even impossible.

  • We provide a full range of pancreatic cancer treatment, with our recommendations based on:
  • The cancer’s stage (the size of the tumor, how far it has grown into the wall of the pancreas and whether the cancer has spread to nearby tissues, lymph nodes or other parts of the body)
  • Whether the tumor is operable
  • Whether the cancer is newly diagnosed or has returned
  • Your overall health

At MedStar Health, we’re pioneering new ways to make these tumors operable, including chemotherapy followed by precise radiation (CyberKnife). We’re also looking at a new way to give heated chemotherapy (HIPEC) immediately after surgery, to reduce the chance the cancer will return (recur), while continuing the design of innovative clinical trials to implement highly promising drug treatment strategies.

While pancreatic surgeries are the most complex abdominal operations, we have the most experienced team in the area, performing more procedures than any other group.

Surgery

Your pancreas has three portions: a wider end (the head), a middle section (the body) and a narrow end (the tail).

Our goal in surgery is to leave enough of the pancreas to produce digestive juices and insulin, reattaching the remaining organ so that it functions like it did before. But sometimes that’s not possible. We often have to remove all or other parts of nearby organs as well, to ensure we get as much of the cancer as possible. Your team will thoroughly explain its recommendation:

  • Distal Pancreatectomy: The tail and body of the pancreas are removed, and usually your spleen (splenectomy) as well, since it shares blood vessels.
  • Laparoscopic Distal Pancreatectomy: This procedure targets the same area as a distal pancreatectomy but is done with a minimally invasive approach.
  • Pancreaticoduodenectomy (Whipple Procedure): The head of the pancreas, the gallbladder, part of the small intestine and the bile duct are removed. We may also need to remove part of the stomach, though that’s often avoidable. The Whipple is the most common pancreatic surgery, with the best chance for a cure or long-term disease control. Research shows that the this complex operation is best performed by experienced surgeons who stay sharp by regularly treating patients—our highly skilled specialists’ volume is higher than the national average.
  • Laparoscopic Pancreaticoduodenectomy (Whipple Procedure): This procedure targets the same area as a pancreaticoduodenectomy but is done with a minimally invasive approach. That makes it even more complex—meaning it should only be done by experienced surgeons like ours.
  • Total Pancreatectomy: The entire pancreas is removed, as well as part of the stomach, part of the small intestine, the common bile duct, the gallbladder, the spleen and nearby lymph nodes. The operation is unusual and only done when the cancer has invaded the whole organ and there are no other options.

 

Biliary Obstructions

Sometimes, a pancreatic tumor blocks the tubes that transport bile. This causes a biliary obstruction, which requires treatment. Your doctor may recommend one of two approaches:

  1. Surgery
  2. Placement of a biliary stent (tiny metal tube) during an endoscopic retrograde cholangiopancreatography (ERCP).
  3. Follow-up Care

Patients who have their spleen or pancreas removed (or who otherwise lose pancreatic function) receive additional follow-up care:

  • Insulin: You will need to follow a diabetic diet and take insulin if your pancreas is removed.
  • Pancreatic Enzyme Insufficiency: Pancreatic enzyme replacement therapy will help aid your digestion if you lose your pancreas, or its function.
  • Vaccines: Certain vaccines are recommended for all patients whose spleen is removed, since the organ plays an important role in the immune system and your risk of infection rises.

Minimally Invasive Surgery

Whenever possible, we take a minimally invasive approach with our surgeries, making a smaller incision(s) and using special instruments and a laparoscope—a thin tube with a tiny video camera that allows our surgeons to view the targeted area in real time. While conventional, open surgery is still recommended for some patients, a minimally invasive procedure means:

  • Less post-operative pain
  • Shorter hospitalization
  • Faster recovery (typically 2-3 weeks, vs. 6 weeks)
  • Much smaller scar

Minimally invasive pancreatic procedures are demanding, requiring surgeons who already have expertise with conventional approaches. But our experienced team is finding success with these newer techniques, and we’re among the few places in the country to offer them. We’ve also performed more of them than other center in the D.C. metro area.

Chemotherapy

The standard approach for pancreatic chemotherapy is to give the drugs after surgery to kill off any remaining cancer cells, or as a treatment for inoperable tumors (with or without radiation, in either case). But drug therapy for this disease is challenging: Only 25 percent of surgical patients benefit, and digestive tumors can quickly develop a resistance to today’s chemotherapies.

We believe the answers lie in more tailored, personalized therapies. We are studying new chemotherapy combinations, as well as using existing drugs with newer, targeted therapies. Our clinical trials also include:

  • Testing tumors for chemotherapy susceptibility
  • Shrinking tumors before surgery with chemotherapy and special radiation
  • Giving chemotherapy (HIPEC) immediately after some surgeries

Our team includes internationally renowned research physicians and one of the area’s largest and most experienced groups of medical oncologists specializing in gastrointestinal cancers.

Testing Tumors

Chemotherapy given after surgery (a typical approach) only benefits 25 percent of those undergoing successful pancreatic operations, but there is currently no way to predict the effectiveness beforehand. That’s why a specialized team of our surgeons, radiation oncologists and medical oncologists are collaborating on a clinical trial to test the vulnerability of individual tumors before treatment starts.

The goal is to maximize the effectiveness of chemotherapy in appropriate patients, while avoiding unnecessary treatment in the rest.

Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Pancreatic cancer is a particularly challenging condition, and approximately 90 percent of patients eventually see the disease return (recur) after surgery. But one of our clinical trials is studying a promising approach called Hyperthermic Intraperitoneal Chemotherapy (HIPEC), delivered by Dr. Paul Sugarbaker—a co-developer of the technique and one of the world’s leading experts.

Here’s how it works:

  1. The primary tumor is removed using a Whipple procedure, but any cancer that has spread to the lining of the abdominal cavity (the peritoneum) is left in place.
  2. Patients usually take chemotherapy at home and then recuperate.
  3. Doctors surgically remove all visible, remaining cancer with a special electroevaporative technique (cytoreductive surgery, or debulking).
  4. Before the operation ends, chemotherapy is heated to make it more effective, then applied directly to the surgical site while doctors manipulate the organs to control distribution. This allows a higher dose of chemotherapy while minimizing side effects.
  5. A catheter is placed for any further chemotherapy and the surgical site is repaired.

Dr. Sugarbaker expects the procedure can extend survival, and that it is most effect when patients are:

  • Young
  • Otherwise healthy
  • Faced with a limited number of metastases (tumors that have spread)

Radiation

Radiation therapy uses high-energy X-rays or other radiation to attack tumors. Doctors often try to shrink pancreatic tumors before surgery with radiation and chemotherapy, combine chemotherapy and radiation (chemoradiation) after surgery to kill any remaining cancer cells or apply radiation if cancer returns.

Armed with the cutting-edge CyberKnife system, our experienced radiation oncologists are studying a way to shrink even more tumors so additional patients can receive surgery. Other clinical trials include a look at using a targeted therapy to make cancerous cells more vulnerable to radiation, increasing treatment effectiveness.

Types

We offer several types of radiation therapy for pancreatic cancer:

External-Beam Radiation Therapy: Given by a machine outside the body and includes:

  • Intensity-Modulated Radiation Therapy (IMRT): Our radiation oncologists can change treatment intensity as they go based on tissue type, delivering specific doses to different parts of a tumor and sparing healthy tissue.
  • Image-Guided Radiation Therapy (IGRT): Your radiation oncology team uses high-quality imaging to carefully adjust radiation beams and doses to best fit the size, shape and location of the tumor, sparing healthy tissue.

CyberKnife

CyberKnife is an advanced external radiation technology that delivers precisely targeted, laser-like radiation through image-guidance systems and a robot arm rotating around your body. We were one of the first teams in the country to use CyberKnife for both newly diagnosed and returning (recurring) pancreatic cancer, and remain among the most experienced.

CyberKnife provides several advantages over other external radiation:

  • Precision and Tolerance
    • External: The broad sweep of typical external radiation not only hits the tumor, but also the small bowel and nearby organs—causing cramping, pain, nausea and diarrhea. External radiation also can’t adjust for tumor movement while you breathe, so a larger area gets irradiated to ensure no cancer cells are missed.
    • CyberKnife: CyberKnife delivers hundreds of tiny beams at various angles, with sub-millimeter precision. It can also track and adjust for tumor motion, minimizing the harm to surrounding areas while delivering a higher dose of radiation to the cancer.
  • Convenience
  • External: Radiation is given over six weeks.
  • CyberKnife: Since higher radiation doses can safely be given during each session, treatment takes just one or two weeks.

Preparation for CyberKnife

Before CyberKnife treatment begins, tiny gold markers (fiducials) get placed around the tumor to mark the target. In the past, this required minimally invasive surgery. But one of our gastroenterologists developed a way to avoid surgery, threading a special tube (endoscope) through the mouth and to the pancreas.

CyberKnife Clinical Trials

While doctors attempt to make many pancreatic tumors operable by first shrinking them with traditional external radiation and chemotherapy, they are often not successful.

That’s why our team is running a clinical trial to use CyberKnife for the radiation portion, driven by two motivations:

  • CyberKnife can safely deliver a higher dose of radiation to the tumor with fewer side effects during treatment.
  • Patients won’t need as much time to recover between chemotherapy and radiation, maximizing the effectiveness of each therapy and giving the tumor less time to advance.

Our goal is to provide a surgical option to more patients, helping them live longer. As part of the trial, we are also giving some patients a targeted therapy, to see if we can make cancerous cells more susceptible to radiation.

Targeted Therapy

Targeted therapy—drugs and other substances aimed at specific molecules that help tumors grow, progress, and spread— represents a new front in attacking cancer. The idea is to target a tumor’s unique characteristics, including genes, proteins, supporting blood vessels, or host tissue, while limiting damage to healthy cells.

Targeted therapies may replace current treatments, or complement them, and we are studying a number of new targets and approaches.

Types

We offer several types of targeted therapies, many of them in clinical trials:

  • Growth Factor Inhibitors: These therapies target certain surface molecules—growth factor receptors—on cancer cells that help them grow.
  • Anti-Angiogenesis Factors: They block the growth of blood vessels needed by tumors.
  • Drugs for Tumor Stroma (Supporting Tissue): They attack dense supporting tissue around pancreatic tumors, to potentially make them more susceptible to chemotherapy.
  • Monoclonal Antibodies: They mimic immune system proteins to deliver toxins or radioactive substances directly to cancerous cells.
  • Checkpoint Inhibitors: They release the normal brakes on the body’s immune system.
  • Cancer Vaccines: They are designed to treat, not prevent, pancreatic cancer by boosting the immune system’s response

Metastatic Pancreatic Cancer

Pancreatic cancer cells spread quickly, and the disease is hard to diagnose in its early stages. That means by the time the cancer is found, it has often spread (metastasized) to other areas of the body. If that happens, our experienced and compassionate team can still provide top care. Our treatment recommendations may include:

  • Chemotherapy: If surgery is not an option, these drugs might slow the cancer’s growth, even if they may not be able to destroy the entire tumor.
  • Targeted Therapy: A type of targeted therapy called immunotherapy might be able to direct your immune system to identify and target the cancer.
  • Pain Management: Our specialized palliative care team can help manage your pain and other symptoms. They do everything they can to make you as comfortable as possible.

 

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