Long Odds Why Pancreatic Cancer Is Still Too Often a Death Sentence

In the world of healthcare, few words are as frightening as cancer. Yet, the medical community has found ways, over the years, to significantly reduce the mortality rates for certain types of cancer.

Pancreatic cancer is not one of them.

In fact, 45,000 new cases are diagnosed each year, and some 38,000 people die from the disease annually, said Dr. Richard Wait, chairman of the Department of Surgery at Baystate Medical Center. “The mortality is horrifically high. In fact, 80{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of these cancers that develop, by the time they are found, are too large or too diffuse for treatment with any type of surgery — and surgery is, in fact, the only cure for pancreatic cancer.”

Pancreatic cancer forms in the tissues of the pancreas, a digestive and endocrine organ that lies behind the stomach. The pancreas secretes enzymes that aid in digestion as well as hormones that help regulate the metabolism of sugars.

The reason pancreatic cancer has such a poor prognosis, Wait said, is that no effective screening test has ever been developed to catch it early. Cancerous cells may develop in the ‘head’ or ‘body’ of the small, fish-shaped organ, and it typically spreads rapidly and is seldom detected in its early stages, before symptoms emerge.

“When the cancer is developing in the body, the tail becomes very large before the patient presents with pain, nausea, vomiting, and weight loss,” Wait said. On the other hand, pancreatic head lesions almost always manifest as jaundice because it affects the bile ducts. “That’s usually one of the first signs; the tumors are really small when the patient gets jaundice,” he explained, making this kind of pancreatic cancer more operable than one that affects the body and tail.

In any case, “the cure rates haven’t changed a lot over the past 30 years,” he told HCN, “although the mortality associated with surgical treatment has decreased markedly.”

The challenge, of course, is detecting the cancer while it’s still operable. On that front, modern healthcare has a long way to go.

The pancreas plays a key role in multiple body functions, Wait said. “It’s basically a dual-purpose organ. It functions as an exocrine organ; it makes enzymes through a system of tubes and ducts on the intestine. If you don’t have pancreatic secretions, food would travel through the whole GI system and not get absorbed.”

Meanwhile, “the pancreas also serves an endocrine function because of the number of hormones it secretes, the most prominent and well-known being insulin.”

Pancreatic cancer occurs when cells in the pancreas develop mutations in their DNA, causing the cells to grow uncontrollably and continue living after normal cells would die, eventually forming a tumor. About 95{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of all pancreatic cancer is exocrine, meaning it begins in the cells that line the ducts of the pancreas. Rarely, cancer can form in the hormone-producing cells of the pancreas, a condition known as endocrine cancer.

“They’re very different in how they present and how they grow, and their overall mortality,” Wait said. “What most people think of as pancreatic cancer is the exocrine.”

The incidence of pancreatic cancer is on the rise, Wait said, although it’s not clear why. “In terms of trying to lower the risk and find these tumors, the only things we know that increases the risk of pancreatic cancer is smoking,” he noted.

While smoking is now on the decline, it had increased over many years, and because of the lag time involved in developing disease, today’s increasing pancreatic cancer may reflect the higher smoking incidence of the recent past. Smoking might also explain why men are 30{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} more likely to contract the disease than women, simply because more men than women use tobacco products.

As for other risk factors, “diet may well play a role — in populations of patients who eat a high-fat diet, eat a lot of meat, the risk may be increased — but that’s not clear-cut at all,” Wait said. In addition, “about 10{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of patients may have some kind of genetic disorder, and cancer can run in families, but, again, there’s not a very good way to screen patients, even those with multiple family members with cancer.”

Pancreatic cancer is the fourth-most-common cause of cancer-related deaths in the U.S. and the eighth worldwide. For all stages combined, the one- and five-year relative survival rates are 25{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} and 6{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}, respectively. For locally advanced and metastatic disease — encompassing about 80{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of all cases — the mean survival is about 10 and 6 months, respectively.

Once a tumor is found, the only possible cure is still surgery, Wait said. “The surgery is aimed at taking out that portion of the pancreas that contains cancer.”

For tumors in the pancreatic tail and body, a surgeon will remove the tail and a small portion of the body — and possibly the spleen — in a procedure called distal pancreatectomy. For cancer located in the head of the pancreas, the surgeon will remove the head as well as a portion of the small intestine, the gallbladder, and part of the bile duct. Part of the stomach may be removed as well.

This surgery is known as the ‘Whipple procedure,’ named after Dr. Allen Whipple, who first developed it in 1935. “It’s still basically the same procedure, although the results are better,” Wait said. “It has been shown that the results for the Whipple procedure and other pancreatic-surgery procedures are better in those institutions that do large numbers, so we always encourage patients to go to high-volume centers, of which Baystate is one.”

Surgical treatment is usually reinforced by both chemotherapy and radiation therapy after the procedure, he added. “On occasion, we’ll use chemotherapy first, before the surgery, if the tumor is large.”

Because removing part of the pancreas decreases its endocrine function, blood sugar is typically higher after surgery, he explained. “If you were diabetic before, you’ll be more diabetic after and maybe need stronger medicine. If you were not diabetic before surgery, oftentimes you are after surgery, but you may not require insulin — just diet modifications or oral medications.”

When pancreatic cancer is diagnosed and the doctor determines it’s operable, Wait said, “the average survival time is 11 months if we don’t do surgery, and the average time if patients receive full treatment is 22 to 24 months — about double the life expectancy.” Most people who make it to five years can consider themselves cancer-free, he added.

To demonstrate the disease’s harsh mortality rate, Wait noted that 1 in 78 people contract pancreatic cancer, as opposed to 1 in 6 women who are diagnosed with breast cancer at some point — yet, because breast cancer is far more manageable, the total annual deaths from the two are very similar.

“There are no screening tests for pancreatic cancer,” he reiterated. “Some things are being developed in an attempt to screen for it, but nothing yet has been proven useful. In fact, a high-school student in Maryland did some work at Johns Hopkins and came up with a urine test, which they’re testing right now.”

Historically, however, answers have been frustratingly elusive.

“Our hope is that we find some way to screen patients and develop some new DNA testing that may show which people are most vulnerable to developing pancreatic cancer,” Wait  said, “and also develop therapies that will really improve survival, because it’s clear that surgery alone almost always only extends survival, but doesn’t cure the patient.”

Because, even if pancreatic cancer remains a death sentence, every month of life counts.