Pancreatic cancer: symptoms, treatment
Pancreatic cancer is treacherous: the disease remains asymptomatic for a long time. Later, the symptoms resemble those of a chronically inflamed pancreas (upper abdominal pain, digestive disorders, etc.). This is why pancreatic cancer is often only discovered when it is already more advanced. The chances of recovery are then usually poor. Read about the symptoms that can occur in pancreatic cancer, how the tumor develops and is treated and what the prognosis is!
- What is pancreatic cancer? Malignant tumor of the pancreas. It is relatively rare in Germany (about 16 out of 100,000 people fall ill each year). The mean age of onset of the disease is 70 years (men) and 76 years (women). Despite its rarity, pancreatic carcinoma is the third most common tumor of the gastrointestinal tract (after colon and stomach cancer).
- Risk factors: smoking, alcohol consumption, obesity, diabetes mellitus, hereditary breast cancer or ovarian cancer, etc.
- Symptoms: no complaints for a long time; later upper abdominal pain, back pain, weight loss, loss of appetite, jaundice, diabetes mellitus, nausea and vomiting, indigestion, fatty stools etc.
- Investigations: Blood tests (with determination of tumour markers), abdominal ultrasound, endoscopic ultrasound (endosonography), computer tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreaticography (MRCP; special MRI examination), taking and analysis of a tissue sample, possibly laparoscopy (laparoscopy), chest X-ray (X-ray thorax) and other examinations
- Treatment: Operation, possibly chemotherapy, radiotherapy (only in certain cases), pain therapy
- Prognosis: Healing is only possible if the tumour is still localised. However, because pancreatic cancer is often discovered late and usually grows rapidly and aggressively, the prognosis is generally unfavourable.
Pancreatic cancer: symptoms
The symptoms of pancreatic cancer are influenced by the type and location of the tumour:
The pancreas, consisting of head, body and tail, is located in the upper abdomen behind the stomach and directly in front of the spine. It consists of two different types of glandular tissue:
- The exocrine tissue forms the largest part. It produces a digestive juice containing enzymes, which is passed into the small intestine.
- Scattered in the exocrine gland tissue are cell groups of endocrine tissue, the so-called islets of Langerhans. These gland cells produce hormones such as insulin, which lowers blood sugar, and its antagonist glucagon. They are released into the blood.
About 95 percent of all pancreatic tumors develop from exocrine gland tissue. In the remaining cases, the tumour develops from hormone-forming (endocrine) gland cells. Depending on the type of cell, this is referred to as an insulinoma or a glucagonoma, for example.
Most commonly, pancreatic cancer develops in the head part of the pancreas. In exocrine pancreatic cancer, the tumor is usually located in the pancreatic head, which produces digestive juices.
Common symptoms of pancreatic cancer
With any form of pancreatic cancer, those affected usually do not notice the disease for a long time. As soon as symptoms appear, the cancer often presses on neighbouring structures (bile duct, stomach, small intestine etc.) or grows into them. It is not uncommon for metastases to be present. Often in this advanced stage of pancreatic cancer symptoms of the following nature occur:
- persistent pain in the upper abdomen and back: The back pain can increase in the supine position.
- Loss of appetite
- Weight loss: When pancreatic cancer causes the exocrine tissue to produce too little or no digestive enzymes, the nutrients in the intestine can only be broken down to a limited extent or not at all. The impaired nutrient supply leads to weight loss.
- Digestive disorders and fatty stools: The lack of digestive enzymes from the diseased pancreas means, among other things, that the fat from food can no longer be properly absorbed in the intestines. It is then excreted undigested with the stool – the resulting fatty stool is bright, shiny and has a pungent odor.
- Nausea and vomiting
- Jaundice (icterus): Pancreatic cancer in the head of the pancreas can press on or block the bile duct (which runs through the head of the pancreas to a certain extent). The bile then accumulates, causing jaundice: the skin, mucous membranes and the white corium in the eye turn yellowish. The urine is dark, the stool is light.
- Diabetes mellitus: Sometimes the tumour produces too little or no insulin at all. This is then usually an endocrine tumour. The lack of insulin leads to diabetes.
The symptoms of pancreatic cancer are similar to those of pancreatitis (inflammation of the pancreas). Sometimes both diseases occur together. Both can make the diagnosis more difficult.
An endocrine pancreatic tumour sometimes produces increased amounts of the gastric acid stimulating hormone gastrin. This can lead to the formation of a stomach ulcer because too much stomach acid irritates the stomach lining. However, since stomach ulcers can have other causes, they are as little a part of the specific symptoms of pancreatic cancer as back pain.
Less frequently, small blood clots form in pancreatic cancer due to pressure on surrounding vessels. These can block the affected vessel (thrombosis). This often happens, for example, in the splenic vein that runs near the pancreas.
The pancreas also contains a high concentration of the blood clotting factor thrombokinase. The cancer-related organ changes can disrupt the blood clotting system so that small clots form everywhere in the vessels (disseminated intravascular coagulopathy, DIC). The coagulation factors are thus depleted, which increases the risk of bleeding. In addition, clots can become detached and block a vessel elsewhere (embolism).
If the pancreatic cancer spreads to the peritoneum (peritoneal carcinomatosis), the cancer cells secrete fluid into the abdominal cavity – “ascites” (ascites) develops. Possible signs are a bulging or enlarged stomach, unwanted weight gain and digestive problems.
Pancreatic cancer: treatment
If pancreatic carcinoma is discovered at an early stage, we try to cure it as completely as possible. Unfortunately, pancreatic cancer is often discovered very late. A cure is then usually no longer possible. The treatment then serves to alleviate the patient’s symptoms and to slow down or stop further spread of the tumour (palliative therapy).
In principle, the doctor has various options for pancreatic cancer treatment at his disposal. When which therapy is appropriate depends on the individual case.
Surgery is only considered in 10 to 20 percent of patients with pancreatic cancer. This is because the procedure is only really effective if the surrounding tissue is still cancer-free. If the tumour can be completely removed during the operation, healing is possible under certain circumstances.
The most common site of pancreatic cancer is the pancreatic head. Then a Kausch-Whipple operation is generally performed: The surgeon removes the head of the pancreas as well as the gallbladder, bile duct, small intestine, lower stomach and regional lymph nodes. An alternative is the pylorus-preserving pancreatic head resection. The lower part of the stomach (pylorus = stomach outlet) remains intact.
In the case of pancreatic carcinoma of the tail of the pancreas, the spleen must often also be removed.
In some cases of pancreatic cancer it is not enough to cut out the diseased tissue from the pancreas – the entire pancreas must be removed.
After the operation, many patients have to take the now missing pancreatic digestive enzymes in capsule form. This is the only way for the digestion to continue to function.
As a rule, pancreatic cancer surgery is followed by chemotherapy (adjuvant chemotherapy). Special drugs (cytostatics) are administered which can prevent the rapid division of cells. This is intended to eliminate cancer cells that may still be present in the body after the operation. If possible, chemotherapy should be started within six weeks after the operation and last for half a year.
Sometimes chemotherapy is performed before the operation. This neoadjuvant chemotherapy is designed to reduce the size of the tumour so that it can then be more easily excised.
Radiotherapy (radiotherapy) for pancreatic cancer is not generally recommended. However, it can be applied in the context of controlled studies. For example, in such a study one can try to support pancreatic cancer treatment with a combined radiation and chemotherapy (radiochemotherapy). This may be considered in the case of locally advanced pancreatic carcinoma that cannot be operated on successfully.
If pancreatic cancer is no longer curable, radiation can also be used specifically to alleviate symptoms (such as tumor pain).
Many people with pancreatic cancer suffer from severe pain in the abdomen. These are treated by means of pain therapy according to the step-by-step scheme of the World Health Organization (WHO):
First, one tries to relieve the pain with non-opioid drugs such as paracetamol or ASS. If this is not enough, the doctor will also prescribe weakly effective opioids such as tramadol. If the pain cannot be controlled even by this, the non-opioid painkillers of level 1 are combined with highly effective opioids (such as morphine). These have the strongest analgesic effect.
In some patients with incurable pancreatic cancer, this drug-based pain therapy does not help sufficiently. Then, one can try to block a nerve plexus in the abdomen, the so-called plexus coeliacus. This prevents the transmission of pain stimuli to the brain.
Especially in palliative pancreatic cancer treatment (i.e. when the cancer is no longer curable), additional measures are often taken for the patient’s well-being. The aim is to ensure that the patient can spend the rest of his or her life without (severe) complaints.
This can often be achieved with an individually adapted pain therapy (as described above). If necessary, further palliative measures are added. If, for example, the tumour constricts or blocks the bile duct, sufferers suffer from jaundice. Then endoscopic surgery can help: Using a thin, tubular instrument (endoscope), the doctor inserts a small plastic tube (stent) into the bile duct to keep it open.
A stomach opening through the tumour can also be widened using an endoscope. In the case of severe constriction, it may make sense to supply the patient with the required nutrients via a feeding tube in the future (enteral nutrition). Also possible is parenteral nutrition – the administration of nutrient solutions directly into the blood.
In addition to physicians, physiotherapists, masseurs, social workers, psychologists and pastors can also effectively support the palliative treatment of pancreatic cancer patients.
In all palliative treatment measures for pancreatic cancer, physician and patient must jointly consider that the average life expectancy for non-operable tumors is only three to five months after diagnosis. Therefore, measures that cause severe side effects should be avoided here.
Nutrition in pancreatic cancer
There are no specific dietary requirements for pancreatic cancer. Patients should eat what they tolerate best. In general, however, easily digestible food is recommended. It should be divided into several small meals instead of the usual three main meals per day. The grease supply should be limited. Even hard-to-digest dietary fibres such as raw vegetables or whole grains should land on the plate too frequently. Alcohol should be taboo for pancreatic cancer.
To compensate for the deficient digestive function in pancreatic cancer, the corresponding enzymes can be supplied in the form of a substitution preparation (pancreatin). The patient takes the pancreatin capsules together with a meal.
Pancreatic cancer: causes and risk factors
It is not yet fully understood why pancreatic cancer develops. Probably a hereditary disposition plays a certain role. Smoking and alcohol consumption are considered to be proven risk factors: according to experts, heavy smokers have an increased so-called cotinine level. This substance is produced when nicotine is broken down in the body and is considered carcinogenic. Regular alcohol consumption often causes inflammation of the pancreas – and chronic inflammation makes the glandular tissue more susceptible to pancreatic cancer.
Metabolic changes in severe overweight and abdominal fat can also lead to a kind of chronic inflammation. This is why obese people are more likely to get pancreatic cancer. Since pancreatic tissue is also pre-damaged in diabetes mellitus patients, they are also more susceptible to pancreatic cancer.
Certain illnesses are further secured risk factors. For example, women with hereditary breast cancer or ovarian cancer and their relatives have an increased risk of pancreatic cancer. Some rare hereditary diseases also make people more susceptible to a malignant pancreatic tumour (e.g. Peutz-Jeghers syndrome).
In addition, there are several factors that are believed to increase the risk of pancreatic cancer. These include frequent consumption of sugar and smoked or grilled foods and frequent contact with certain chemicals and toxins (chromium and chromium compounds, chlorinated hydrocarbons, herbicides, pesticides, etc.).
Tip: To reduce the risk of pancreatic cancer, you should not smoke, avoid alcohol if possible and make sure you have a healthy body weight. It is also possible that a diet rich in fruit and vegetables can reduce the risk of disease.
Pancreatic cancer: examinations and diagnosis
If pancreatic cancer is suspected, the doctor will first have a detailed conversation with the patient to establish his or her medical history (anamnesis). Among other things, he can have all complaints described in detail, asks about any previous illnesses and about known pancreatic carcinoma illnesses in the family.
The anamnesis interview is followed by various examinations. They are used to clarify suspected pancreatic cancer and to rule out diseases with similar symptoms (such as pancreatitis). If the suspicion of pancreatic carcinoma is confirmed, the examinations also help to determine the spread of the tumour in the body.
- Physical examination: The doctor palpates the abdomen, for example, to detect swelling or hardening in the abdomen.
- Blood analysis: A blood analysis gives the doctor information about the general health of the patient as well as the function of various organs (such as the liver). In addition, so-called tumour markers are determined. These are certain substances that can be elevated in a tumor disease (CA 19-9, CA 50, CEA). The tumor markers can be used to determine the tumor stage and to assess the course of the disease.
- Abdominal ultrasound: Using ultrasound, the doctor can assess the size and condition of the pancreas and other abdominal organs (liver, gallbladder, stomach, small intestine, etc.) and the surrounding lymph nodes.
- Endosonography: This is an endoscopic ultrasound examination (ultrasound “from inside”). To do this, a tubular instrument (endoscope) with a small ultrasound probe is pushed over the mouth and stomach and into the duodenum. Since the pancreas is located close to it, even the smallest tissue changes can be detected in ultrasound. If necessary, the doctor can also use the endoscope to insert a fine hollow needle into the pancreas to take a tissue sample from the pancreas (biopsy).
- Tissue sample: As mentioned above, tissue samples from suspect sites are usually taken during endosonography. It is also possible to insert a hollow needle directly through the abdominal wall into the pancreas to remove tissue.
- Computer tomography (CT): This special X-ray examination is used to produce detailed sectional images of the pancreas and other structures. This enables the doctor to assess the exact location and size of the tumour and detect any metastases (for example in lymph nodes or liver).
- Magnetic resonance tomography (MRT): Here too, detailed sectional images of body structures are produced, but with the aid of strong electromagnetic fields. The location and spread (metastases) of the cancer can be easily identified. Magnetic resonance cholangiopancreaticography (MRCP) is particularly meaningful for the diagnosis of pancreatic cancer: In this MRT examination, the duct systems of the pancreas and bile are shown in detail. Most pancreatic carcinomas develop from the cells that line the exocrine gland tissue (so-called adenocarcinomas).
- Laparoscopy: Sometimes there is evidence that the pancreatic tumor has already spread to neighboring organs or to the peritoneum (for example, in the case of greatly elevated tumor marker CA 19-9 or abdominal dropsy), even though no metastases can be detected in imaging. Then a laparoscopy can bring clarity.
- Chest x-ray: On the x-rays, any metastases in the lungs can be detected.
Pancreatic carcinoma: Stages
Depending on the extent of the malignant tissue change, pancreatic cancer is divided into four stages:
- Stage 1: The tumour is limited to the pancreas.
- Stage 2: The adjacent tissue is also affected by the cancer.
- Stage 3: There are metastases in the lymphatic tissue.
- Stage 4: Metastases have also formed in other organs (such as lung or liver metastases).
Pancreatic cancer: course of disease and prognosis
The course of pancreatic cancer depends mainly on the type of tumour: most pancreatic carcinomas are adenocarcinomas (formed from the cells lining the excretory ducts of the exocrine gland tissue). These tumours grow rapidly and spread rapidly via blood and lymph to other parts of the body. If they are not detected early (which is rarely the case), the prognosis looks rather unfavourable. Rarer forms of pancreatic cancer, on the other hand, usually grow more slowly and less aggressively. Their prognosis is therefore usually more favourable.
In general, the earlier a pancreatic carcinoma is detected and treated, the better the chances of recovery. If the tumour is inoperable, life expectancy is short: on average, patients die three to four months after diagnosis.
Overall, pancreatic cancer has the lowest survival rates of all cancers: Five years after diagnosis, only nine to ten percent of patients have not yet died from the pancreatic tumour (relative five-year survival rate in the United States).