Diagnosis and Treatment for Pancreatic Cancer
One reason for the often poor outcome of pancreatic cancer is the location of the pancreas deep inside the body. Pancreatic tumors can’t be seen or felt by doctors during routine physical exams, and patients usually have no symptoms until the cancer has spread to other organs.
Currently there are no blood tests to find early cancers of the pancreas. There is a possibility that an extra sensitive probe can be passed into the stomach to better visualize the pancreas (endoscopic ultrasound) and this might be useful in screening people with a high risk of pancreatic cancer.
A substance called CA 19-9 is released into the blood by exocrine pancreatic cancer cells and can be detected by blood tests. However, by the time CA 19-9 blood levels are high enough to be accurately detected by available methods, the cancer may no longer be in its early stages. This is why the test is not recommended for routine screening of people without symptoms or a known diagnosis of cancer. The CA 19-9 test is sometimes used during treatment to see if the therapy is working or after treatment to see if the cancer has recurred.
Another substance, carcinoembryonic antigen (CEA), can help detect advanced pancreatic cancer in some people. But it isn’t sensitive enough to find the cancer early and is not recommended as a screening test.
Endoscopic ultrasound (EUS) is a procedure used to image the digestive tract, including the pancreas. A thin, flexible, lighted tube with a small ultrasound probe attached to the end is passed through the patient’s mouth into the stomach and the top part of the small intestine called the duodenum. The ultrasound component of the endoscope uses sound waves to create visual images of the pancreas.
Inherited DNA changes are thought to cause as many as 10% of pancreatic cancers. Because these inherited cases are sometimes linked with other cancers, determining whether a patient’s relatives have an increased risk is not simple.
If you’re interesting in genetic testing, please talk with Dr. Bilchik and his team who can help interpret and explain the test results and what they may mean.
How is Pancreatic Cancer Diagnosed?
Dr. Bilchik and his team will take a complete medical history and do a physical exam prior to beginning any diagnostic procedures for pancreatic cancer. If pancreatic cancer is suspected, we may perform any of the following tests in order to make a definitive diagnosis.
Ultrasound (also called sonography)
This diagnostic imaging technique uses high-frequency sound waves to create an image of the internal organs, specifically the liver, pancreas, spleen, and kidneys and to assess blood flow through various vessels. The ultrasound may be done with either an external or internal device:
- Transabdominal ultrasound. The technician places an ultrasound device on the abdomen to create the image of the pancreas.
- Endoscopic ultrasound (EUS). The doctor inserts an endoscope, a small, flexible tube with an ultrasound device at the tip, through the mouth and stomach, and into the small intestine. As the doctor slowly withdraws the endoscope, images of the pancreas and other organs are made.
Your doctor can use these pictures to determine the size and location of a tumor in the pancreas and whether the tumor has spread to nearby blood vessels or other structures. Endoscopic ultrasound can also allow passage of a needle into a suspected tumor to obtain tissue samples. This is a type of biopsy called fine-needle aspiration. Cells obtained from the biopsy can then be analyzed to see if they are cancerous; this information can be used to guide treatment.
Computed Tomography Scan (CT or CAT scan)
This diagnostic imaging procedure uses a combination of X-rays and computer technology to produce horizontal, or axial, images of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general X-rays. This is the most important test to look for pancreas cancer and to evaluate whether it can be removed during surgery or whether it has spread to other organs such as the liver or lungs.
Magnetic Resonance Imaging (MRI)
An MRI is a diagnostic procedure that uses a combination of large magnets, radio-frequencies, and a computer to produce detailed images of organs and structures within the body. Specific MRI evaluation of the bile duct, pancreas and pancreatic duct is called magnetic resonance cholangiopancreatography (MRCP).
Endoscopic Retrograde Cholangiopancreatography (ERCP)
This procedure allows us to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. A long, flexible, lighted tube called an endoscope is guided through the patient’s mouth and throat, then through the esophagus, stomach, and duodenum (first part of the small intestine). Saint John’s physicians can examine the inside of these organs and detect any abnormalities. A tube is passed through the scope, and a dye is injected to allow the bile and pancreatic ducts to be seen on an X-ray.
Percutaneous Transhepatic Cholangiography (PTC)
During a PTC test, a needle is inserted through the skin and into the liver. Dye (contrast) injected through the needle allows the bile duct structures to be seen via X-ray. This test is generally only done if an ERCP cannot be done.
A sample of pancreatic tissue is removed with a needle or during surgery and then examined under a microscope.
Special Blood Tests
In addition to the CA 19-9 blood test other blood tests may be necessary to determine if the pancreas tumor is a neuroendocrine type tumor. These include chromogranin, serotonin, 5HIAA and pancreastatin.
Positron Emission Tomography (PET)
This is a type of nuclear medicine procedure. For this test, a radioactive substance, usually bound to a type of sugar, is injected through a vein before the body is scanned. Cancer cells take up sugar more than normal cells and this shows up on the x-ray image as a dark spot. This test is not as specific as CT scanning, and is not used alone to diagnose pancreatic cancer. A PET scan is often done in combination with a CT scan and may be useful in evaluating whether cancer has spread to other organs such as the liver or lung.
Treating Pancreatic Cancer
Before we set up a specific treatment protocol for your pancreatic cancer, we will take the following into account:
- Your age, overall health, and medical history
- Location and extent of the disease
- Type of cancer
- Your tolerance of specific medicines, procedures, or therapies
- Expectations for the course of the disease
- Your opinion or preference
Depending on the type and stage, pancreatic cancer may be treated with the following:
Surgery may be necessary to remove the entire tumor, a section, or the entire pancreas and often parts of other organs. The type of surgery performed depends on the stage of the pancreatic cancer, the location and size of the tumor, and your overall health. The surgeons at St John’s have extensive experience operating on the pancreas. These operations, because of their complexity should be done at centers of excellence, of which St John’s is one. Blood transfusion and admission to the intensive care unit are rarely required. Most patients can eat soon after surgery and generally leave the hospital in less than one week.
Types of surgery for pancreatic cancer include the following:
- Whipple procedure: This procedure involves removal of the head of the pancreas, part of the small intestine, the gall bladder and part of the common bile duct, part of the stomach, and lymph nodes near the head of the pancreas. Most pancreatic tumors occur in the head of the pancreas, so the Whipple procedure is the most commonly performed surgical procedure for pancreatic cancer.
- Distal pancreatectomy: If the tumor is located in the body and tail of the pancreas, both of these sections of the pancreas will be removed, along with the spleen. This is most often done by a laparoscopic procedure; recovery is rapid.
- Total pancreatectomy: The entire pancreas, part of the small intestine and stomach, the common bile duct, the spleen, the gallbladder, and some lymph nodes will be removed. This type of operation is not done often.
- Palliative surgery: For more advanced cancers that cannot be completely removed, surgery may be undertaken to relieve symptoms caused by problems such as a blocked bile duct or obstruction of the stomach.
External Radiation (external beam therapy)
Radiation treatment, administered by a radiation therapist, sends high levels of radiation precisely and directly to the cancer cells. Since radiation is used to kill cancer cells and to shrink tumors, special shields may be used to protect the tissue surrounding the treatment area. Radiation treatments are painless and usually last a few minutes. Radiation therapy may be given alone, or in combination with surgery and/or chemotherapy.
Chemotherapy involves the use of anticancer drugs to kill cancer cells. In most cases, chemotherapy works by interfering with the cancer cell’s ability to grow or reproduce. Different groups of drugs work in different ways to fight cancer cells. Chemotherapy may be given alone, or in combination with surgery and radiation therapy. Chemotherapy and radiation can sometimes be given before surgery to shrink the tumor, making the surgery easier to perform.
Medication to Relieve or Reduce Pain
Your GI cancer team will recommend a treatment plan appropriate for your pancreatic cancer.