Pancreatic cancer - Awareness of symptoms helps in early treatment

Dr Suresh Singhvi

New Delhi: Pancreatic cancer occurs when a malignant tumor forms in the pancreas. 

There are two main types of pancreatic cancer:

Exocrine tumours -These make up the vast majority of all pancreatic cancers (around 90%) and come from the cells that line the ducts in the pancreas which carry digestive juices into the intestine. These are called pancreatic ductal adenocarcinomas.

Endocrine tumours - These are known as neuroendocrine tumours, and are much less common. These tumours  sometimes make hormones such as insulin, and glucagon, to control blood sugar.  These constitute 2-5% tumors of the pancreas.

Benign tumors of the pancreas- These occur in young patients and can reach big size. They need to be treated by expert Surgeons who specialize in Pancreas.

What causes pancreatic cancer?

The causes of pancreatic cancer are not known. However, there are some risk factors that make developing pancreatic cancer more likely:

Cigarette smoking – There is a direct relationship between the amount you smoke and the risk of pancreatic cancer.

Age – The risk of developing pancreatic cancer increases with age.

Chronic pancreatitis – Long-term inflammation of the pancreas (pancreatitis) has been linked to pancreatic cancer.

Diabetes – There have been a number of reports which suggest that diabetics have an increased risk of developing pancreatic cancer.

Obesity – Recent studies have shown that risk is higher in people who are obese (have a Body Mass Index more than 30). Some studies show that obese women who carry their weight on their stomach area are at an increased risk of developing pancreatic cancer.

Other, rare tumours in the pancreas

Tumours that arise from tissues close to the pancreas, such as the bile duct (cholangiocarcinoma), Ampulla of Vater, (Ampullary adenocarcinoma), or duodenum (duodenal adenocarcinoma), may cause similar symptoms to pancreatic cancer but have similar surgical treatment and, importantly, a very different prognosis.

Pancreatic cancer symptoms & signs

Pancreatic cancer is often referred to as a “silent cancer” because it is thought that the early symptoms can be vague and unrecognised.  Symptoms however can present themselves early in many cases. Here are some of the most common symptoms to look out for:

Classic pancreatic cancer symptoms can include:

• Painless jaundice (yellow skin/eyes, dark urine, itching).  This is related to bile duct obstruction
• Weight loss which is significant and unexplained
• Abdominal pain which is new-onset and significant

Other possible symptoms of pancreatic cancer:

• Pain in the upper abdomen that radiates to the back which is new, significant and persistent that is relieved by leaning forward
• Back pain
• Diabetes which is new-onset and not associated with weight gain
• Vague indigestion (dyspepsia) or abdominal discomfort (not responding to prescribed medication)
• Loss of appetite
• Nausea and vomiting
• Pain when eating
• Steatorrhea (fatty stools that are often pale and smell foul)

Not everyone will have all of these symptoms.  For example, those who have a tumour in the body or tail of the pancreas are unlikely to have painless jaundice.  All of these symptoms can have other causes, and there is not yet a reliable and easy test for pancreatic cancer.

Explanation of the symptoms:

Pain in the abdomen and upper back

Approximately 70 per cent of patients with pancreatic cancer go to the doctor initially due to pain.  This pain is often described as beginning in the stomach area and radiating around to the upper back (just above where a woman’s bra strap would be).

This pain is worse when lying down than sitting up.

Generally the reason for the pain is because of the tumour pressing against your abdomen and spine.

Jaundice

Half of patients will have yellowing of the skin and whites of the eyes, jaundice, when they first go to the doctors.  This is related to the tumour blocking the bile duct which leads to a build-up of bile in the liver.

Jaundice may be more obvious in the whites of the eyes and bad jaundice can cause itching of the skin.

Depression

Many of our patients or relatives have said that they have experienced mood changes before being diagnosed.

Mild to severe depression can often present itself in the early stages of pancreatic cancer.  This is why if someone who has never suffered from a severe bout of depression before should express their concerns to their GP.  It can often highlight a medical problem in the very early stages.

Bowel changes

A tumour in the pancreas can cause bowel disturbances which means you do not absorb your food properly.  This will result in regular, large bowel movements of pale and smelly stool.   This can also cause weight loss.

Diabetes

Diabetes is due to a deficiency in insulin, which is produced by the pancreas.  A tumor can stop the pancreas producing insulin leading to an onset of diabetes in the early stages of pancreatic cancer.

You may have diabetes if you have low energy, pass more urine than normal and feel extremely thirsty.

Diagnosis

Patients with symptoms that suggest they have pancreatic cancer need quick investigation, usually by a CT scan and early referral to a specialist unit for other investigations.

These investigations and tests will help your specialist team diagnose, treat and monitor your condition. These tests are referred to as “staging investigations”. The results of these tests will provide information about the abnormal area in your pancreas and your general health.

There are two aspects to “staging” investigations.  Some are designed to find out as much as possible about the tumor itself, and some are designed to assess your general fitness. There are many treatment options and your doctors will be trying to work out which is best for you, taking into account all of the information.  These decisions are usually taken at a multidisciplinary team (MDT) meeting.

Surgical treatment- After all the investigations to look at staging and fitness for operation, the patient when fit, is advised to undergo a major operation of the pancreas - whipples operation (when the tumor is situated in the head of pancreas).

If the tumor is situated in the tail of the pancreas, then patient undergoes a surgery to remove the tail of the pancreas, which is less complex than the surgery of the head of pancreas tumor. The operation of whipples procedure is a complex major surgery and should be done in a tertiary hospital with all support specialties available.

(The author is a Liver transplant Surgeon and Liver/Pancreatic Surgeon with Sir Ganga Ram Hospital, New Delhi. Website: www.livercareindia.com)