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Pancreatic Cancer

  • What is pancreatic cancer?

    Pancreas cancer

    The pancreas is an organ in the abdomen that releases digestive enzymes and hormones. One of the hormone’s insulin helps to manage blood sugar levels. Abnormal growths or tumours can develop in the pancreas. These tumours may either be cancerous (malignant) or non-cancerous (benign).

    Cancerous tumours if left untreated can spread to nearby organs and blood vessels. Advanced disease tends to spread to the liver or lungs. The most common form of pancreatic cancer is pancreatic ductal adenocarcinoma.

    In Singapore, the incidence of pancreatic cancer has increased over the last 40 years. Between 2003 and 2007, approximately 1,000 cases were diagnosed, making it the 6th and 7th most common cause of cancer death among men and women, respectively.

  • Pancreatic cancer forms when cells in the pancreas mutate and grow abnormally, forming a tumour. The exact causes of pancreatic cancer are unclear but there are several factors that are associated with pancreatic cancer.

    Risk factors for pancreatic cancer

    • Age

      The risk for pancreatic cancer increases with age. In most cases, around 80% of cases are found in those 60 – 80 years of age.
    • Chemical exposure

      Those with occupations that involve the heavy use of chemicals, especially those in metal-working and dry cleaning, may be at increased risk.
    • Diabetes

      The risk for pancreatic cancer is higher in those with new onset of diabetes.
    • Diet

      A diet high in fat and smoked or processed meat has been linked to increased risk of pancreatic cancer.
    • Family history

      Having a close family member with pancreatic cancer may increase your risk.
    • Gender

      Men are more likely to develop pancreatic cancer.
    • Genetics

      Genetic syndromes such as the BRCA2 gene mutation, Lynch syndrome, and familial atypical mole-malignant melanoma (FAMM) syndrome place individuals at increased risk.
    • Nutrient deficiencies

      Some studies have made a possible connection between pancreatic cancer and low levels of lycopene and selenium, which are found in lean meat and red or yellow vegetables.
    • Obesity

      Those with a Mass Body Index (BMI) above 30 are more likely to develop pancreatic cancer.
    • Pancreatitis

      Pancreatitis refers to chronic inflammation of the pancreas, which may be caused by heavy use of alcohol.
    • Smoking

      The more a person smokes, the higher their risk for developing pancreatic cancer.

    The combined effect of smoking, long-standing diabetes, and a poor diet increases a person’s risk of pancreatic cancer beyond the risk of any one of these factors alone.

    While there is no clear way to prevent pancreatic cancer, there are steps you can take to reduce your risk.

    Reducing the risk of pancreatic cancer

    • Avoid or quit smoking

      Smoking-related risk decreases after you quit. It is estimated that, after 10 years of not smoking, your risk is the same as a person who has never smoked.
    • Eat a healthy diet

      A diet with less fat, sugar and processed meat, and more fruits and vegetables of many colours, can help to reduce the risk of many diseases and cancers, including pancreatic cancer.
    • Exercise

      Getting more exercise can help to reduce your risk. Obese individuals who get more exercise are about half as likely to get pancreatic cancer compared to those who got no exercise at all.
    • Limit or avoid consumption of alcohol

      Heavy alcohol use is linked to pancreatitis, a risk factor for pancreatic cancer.
    • Limit or avoid exposure to chemicals

      Where possible, try to avoid your exposure to workplace chemicals with protective gear or speak to your supervisor about your work arrangements.
    • Maintain a healthy body weight

      A healthy diet and regular exercise can help you to keep to a healthy body weight and reduce your risk for many conditions, including pancreatic cancer.
  • The symptoms of pancreatic cancer are usually nonspecific. Patients can present with symptoms such as nausea, fatigue, or back pain. They may begin gradually and get worse over time.

    The usual symptoms of pancreatic cancer may include:

    • Jaundice

      Pancreatic cancer can cause blockage of the bile duct. This can lead to jaundice. Jaundice is caused by the build-up of bilirubin, a substance produced by the liver. High levels of bilirubin in the blood can lead to a yellowish tint on the skin or in the whites of the eyes, dark urine, light-coloured stools, or itchy skin.
    • Abdominal pain

      Sometimes called mid-epigastric pain, it is felt below the ribs, in the upper abdomen and may radiate to the lower back. This may be caused by the tumour pressing on nearby organs or the spread of cancer to the nerves.
    • Diabetes

      Pancreatic cancer can affect the cells responsible for creating insulin, leading to diabetes.
    • Fatigue

      Feeling easily or constantly tired may be a sign of several conditions, including pancreatic cancer.
    • Weight loss

      People with pancreatic cancer often experience loss of appetite, which can lead to weight loss.
  • Surgeons will take a medical history followed by a physical examination. Pancreatic cancer is usually diagnosed using a combination of blood test and radiological scans. The diagnostic tests will help doctors to determine the stage of the cancer. This will help them tailor a suitable treatment plan for the patient.

    Diagnostic tests for pancreatic cancer may include one or more of the following:

    • Blood tests

      Blood tests, sometimes known as blood chemistry studies, can check for substances in the blood such as higher bilirubin levels which may indicate signs of disease.
    • Tumour marker test

      Analysis of a sample of blood, urine or tissue can reveal substances produced by cancerous cells. High levels of these substances, known as tumour markers, can sometimes help to identify specific types of cancer.
    • Magnetic resonance imaging (MRI)

      An MRI uses magnetic rays and is a good imaging modality for organs such as the liver or pancreas. It takes a series of detailed pictures to create a clear image of the pancreas and surrounding tissues.
    • Computerised tomography (CT) scan

      In a CT scan, a computer linked to an X-ray machine captures images from different angles. Contrast is usually injected into the vein to better visualise the pancreas and surrounding organs.
    • Positron emission tomography (PET) scan

      In a PET scan, a small amount of radioactive glucose is injected into the vein. The scan will indicate where the glucose is being consumed, indicating the location of the tumour.
    • Ultrasound

      An ultrasound uses high-energy soundwaves that bounce off internal tissues and structures to create an image called a sonogram. An abdominal ultrasound is taken externally, on the surface of the skin. Endoscopic ultrasound (EUS) is a special ultrasound imaging where it is done from the inside of your abdomen via endoscopy. This technique is often used to do biopsy and assess invasion of the tumour.
    • Endoscopic retrograde cholangiopancreatography (ERCP)

      This procedure x-rays the bile ducts which can become narrowed or blocked due to pancreatic cancer. It is performed with the help of a dye and an endoscope. A thin tube is passed through the mouth into the oesophagus, stomach and the first part of the small intestine. In addition to detecting blockages, an ERCP also allows the doctor to treat the blockage by inserting a stent.
    • Percutaneous transhepatic cholangiography (PTC)

      In a PTC, a dye is inserted into the liver or bile ducts and then x-rayed to reveal any blockage. A stent may be used to allow drainage of bile. A PTC is usually performed if an ERCP is not possible.
    • Biopsy

      Biopsy is the removal of cells or tissues for analysis. It can be performed in different ways, using a needle or during laparoscopy.
  • Treatment for pancreatic cancer depends on the stage and location of the cancer. Your doctor may recommend a combination of surgery, radiotherapy or chemotherapy to remove the tumour. You should see a surgeon who specialises in pancreatic surgery before you start any form of treatment for pancreatic cancers. Surgery is the only form of cure for pancreatic cancers.

    • Surgery

      Surgery is performed to help remove the tumour. Complete surgical removal of the tumour is the only form of cure for pancreatic cancer. The position of the tumour will determine the part of the pancreas to be removed.
    • Radiotherapy

      Radiotherapy uses high-energy x-rays or other forms of radiation to destroy the cancer cells or to keep them from growing further. It may be used as an adjunct to surgery or as an option where surgery is not an option.
    • Chemotherapy

      Chemotherapy uses strong drugs to kill cancer cells or stop the cancer cells from dividing. Chemotherapy can be used after or before surgery. It can help prevent the cancer from returning after surgery or improve the chance of successful surgery.

    Early diagnosis and treatment of pancreatic cancer offer the best chances for effective treatment. Speak to a doctor to find out more about your treatment options. Surgery is the only form of cure for pancreatic cancers.

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  • Complications of pancreatic cancer may include:

    • Jaundice

      When the tumour is in the head of the pancreas, it often causes obstruction to the common bile duct. The patient will get jaundice. This will lead to infection of the biliary tree called cholangitis. This condition is life-threatening when not treated.
    • Pancreatic insufficiency

      Pancreatic cancer can interfere with the normal functions of the pancreas, which is to produce digestive enzymes that help to neutralise stomach acids and break down fat, protein and carbohydrates. Insufficient enzymes can lead to poor absorption of nutrients and malnutrition. Similarly, surgery to remove the pancreas may also have the same effect. You may need to take prescription medication to replace these enzymes.
    • Obstruction of stomach or small intestine

      A tumour can block the gastric outlet (where stomach contents pass into the small intestine) or the duodenum (the early part of the small intestine). This will lead to nausea and vomiting, and a patient will not tolerate much oral intake.
    • Cachexia

      Cachexia is a syndrome characterised by loss of appetite, weight loss, and muscle wasting. It is thought to be present in up to 80% of people with pancreatic cancer.
    • Distant metastases

      Pancreatic caners can spread locally and invade adjacent organs. It can also spread to other organs such as the lungs or liver. When it has spread to distant organs, treatment can only be palliative in nature.
    • Blood clots

      Blood clots that break off in the leg (deep vein thrombosis) or lung (pulmonary embolism) is both a complication and a potential symptom of pancreatic cancer.
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