50 ENDOCRINOLOGY: PANCREATIC CANCER
Pancreatic Cancer: A Public Health Burden An interview with Theresa Lowry Lehnen (PhD), Clinical Nurse Practitioner and Associate Lecturer South East Technological University
• Gender-more common in males than females • Ethnicity-more common in African Americans than Caucasians • Family history • Blood group A patients have a 40% higher risk than those with other blood types • Pancreatic microbiota Presentation and Diagnosis
The global incidence and mortality of pancreatic cancer are increasing annually. Worldwide, the incidence is projected to rise to 18.6 per 100,000 by 2050, with the average annual growth of 1.1%, indicating that pancreatic cancer will pose a significant public health burden.
rates for both genders increases with age. Surgical resection is the only current option for a cure, however, only 20% of pancreatic cancer is surgically resectable at the time of diagnosis.”
Theresa Lowry Lehnen, Clinical Nurse Practitioner and Associate Lecturer South East Technological University told us more about the 12th most common cancer worldwide.
The aetiology of pancreatic cancer is poorly understood, Theresa says. 95% of tumours carry mutations in the K-RAS2 proto-oncogene, the activation of which leads to increased cell proliferation, loss of the normal response to apoptotic signals, dysplasia and ultimately cancer.
Pancreatic cancer is the 11th most common cancer in women, and the 12th most common in men. Theresa notes, “Globally there were more than 495,000 new cases of pancreatic cancer in 2020, and it affects over 600 people in Ireland annually. Despite rapid advances in modern medicine and significant improvements in survival rates of many cancers, pancreatic cancer is still a highly fatal gastrointestinal cancer with difficulty in early detection, and a low 5-year survival rate. “Pancreatic cancer 5-year survival rates range from 2% to 9%, with little difference between high and low-income, and middle-income countries. The 5-year survival rate varies globally in different regions and countries, but does not exceed 10%. It is predicted that patients with non-operative pancreatic cancer have a lower 5-year survival rate. “The estimated global, 5-year survival rate for pancreatic cancer is about 5%. Approximately 90% of all cases are among people over 55 years of age, and the incidence
Aetiology and Risk Factors
In the pancreas, K-RAS mutations tend to cause the development of precancerous lesions called pancreatic intraepithelial neoplasia (PIN), which are present in up to a third of older people, but will only lead to cancer in about 1% of cases. It is estimated that it takes up to 20 years from the time of the first mutation to develop the fullblown disease. Many non-modifiable and modifiable risk factors are associated with pancreatic cancer. • Age older than 55 years • Smoking • Diabetes • Obesity • Chronic pancreatitis • Cirrhosis of the liver • Helicobacter pylori infection • Work exposure to chemicals in the dry cleaning and metalworking industry
MARCH 2023 • HPN | HOSPITALPROFESSIONALNEWS.IE
Theresa explains, “Symptoms of pancreatic cancer include; pain or discomfort in the abdomen, which may spread to the back; unexplained weight loss; indigestion; jaundice; loss of appetite; nausea; feeling full very quickly; a lasting change in bowel habits-steatorrhea; a new diagnosis of diabetes without weight gain; and tiredness. “Sometimes there may be no signs or symptoms in the early stages of pancreatic cancer. Diagnostic tests include, history, examination, laboratory tests, transabdominal ultrasound, abdominal CT scan, PTC (percutaneous transhepatic cholangiography), MRCP scan (magnetic resonance cholangiopancreatography), Endoscopic Ultrasound (EUS), Laparoscopy and Biospy. “General examination may reveal jaundice, pallor, skin excoriations or weight loss/cachexia. Abdominal examination may reveal epigastric tenderness; an upper abdominal mass; nodular hepatomegaly; ascites; and a palpable gallbladder. Courvoisier’s law states that the presence of a non-tender enlarged gallbladder means that jaundice is unlikely to be due to gallstones, as chronic cholecystitis causes the gallbladder to become shrunken and fibrotic. A palpable gallbladder is, therefore, a worrying sign. There may also be cervical lymphadenopathy. “Patients with adenocarcinoma of pancreas typically present with painless jaundice (70%) usually due to obstruction of the common bile duct from the pancreatic head tumour. Weight loss occurs in about 90% of patients and abdominal pain in about 75%. Weakness, pruritus from bile salts in the skin, anorexia, palpable, non-tender, distended gallbladder, acholic stools, and dark urine may be present. Patients may present
with recent-onset diabetes, and sometimes may present with recurrent deep vein thrombosis (DVT) due to hypercoagulability that prompts clinicians to suspect cancer and a full workup. “Blood tests include, FBC, U+E, LFTs, coagulation-studies, glucose, and lipid-profile.” Staging investigations for patients with confirmed pancreatic cancer include: • Triple-phase “pancreas protocol” CT scan is the gold standard for assessment of pancreatic cancer. By taking images at different times after IV contrast administration, it provides detailed imaging of the tumour itself, its invasion into surrounding tissues, the degree of vascular infiltration and biliary tree dilatation, and presence of lymphatic or liver metastasis. It can be used to accurately predict surgical resectability in up to 90% of cases. • Bone scan or PET scan can accurately detect distant metastases. • Diagnostic laparoscopy is used to rule out intraperitoneal spread in high-risk patients. • Biopsies for histopathology can be obtained percutaneously, endoscopically via EUS/ERCP, or laparoscopically and in some cases through an open procedure. Endoscopic biopsy is considered to be the safest and most appropriate approach. 8 Differential diagnosis includes acute pancreatitis, chronic pancreatitis, cholangitis, cholecystitis, choledochal cyst, peptic ulcer disease, cholangiocarcinoma, and gastric cancer. Treatment and Management Treatment for pancreatic cancer includes surgery, chemotherapy and radiotherapy. Theresa continues, “The treatment and management of pancreatic cancer is determined by whether the tumour is resectable or not, but other important factors include the patient’s overall health and fitness for major surgery and postoperative chemotherapy. “There are surgical treatments available for both resectable cancers and palliate unresectable disease, and these are