Surgery Offers Best Hope for Patients
Stuart Wilson, MDMedical College of Wisconsin Surgical Oncologist
Pancreatic cancer — the fourth leading cause of cancer death in the United States — is often called a “silent disease” because there are often no symptoms in the early stage. Advanced imaging methods are helping physicians to better define the extent of the disease in patients. This is critical in determining which patients may benefit from surgery — the best option for long-term survival. Stuart Wilson, MD, discusses surgical options for treating pancreatic cancer.
Q. What is the function of the pancreas?The pancreas is best known for producing insulin and playing a key role in the disease of diabetes mellitus. The pancreas releases insulin and glucagon into the bloodstream to keep the blood sugar levels within a normal range. It also plays a key role in nutrition. As food enters the intestine, the pancreas produces enzymes to aid in the digestion of fats, proteins, and carbohydrates.
The pancreas is a gland about six inches in length located within the abdomen behind the stomach. It is composed of three parts: the head, body and tail.
Q. What causes this cancer, and whom does it affect?We do not know what causes most cases of pancreatic cancer, nor why one person gets it and another does not. We tend to see slightly more cases of pancreatic cancer in men than in women. Most cases occur in people in their 50s, 60s and 70s; it is unusual to see it in anyone younger. In general, pancreatic cancer has a poor prognosis for long-term survival. Less than 20 percent of people with pancreatic cancer will survive greater than five years. For example, in 2006 an estimated 33,000 new cases of pancreatic cancer will be diagnosed while 32,000 people will die from pancreatic cancer.
Q. What are the risk factors? Many of the risk factors associated with other forms of cancer — smoking, heavy alcohol use and obesity — seem to play a role in developing pancreatic cancer. Smokers are twice as likely as nonsmokers to develop this cancer. The incidence is also increased in countries with high-fat diets. People who suffer from chronic pancreatitis, a disease in which the pancreas becomes inflamed, also face a higher risk as do people who have cirrhosis of the liver or diabetes.
Q. What are the signs and symptoms? In the early stages of pancreatic cancer, many people have no symptoms. At times symptoms may be vague such as heartburn or epigastric distress. The most common presenting symptom for cancers that start within the head of the pancreas is painless jaundice. Jaundice is caused by a blockage of bile coming from the liver into the intestine. When the flow of bile is obstructed, jaundice is noted by yellowing of the skin, urine that becomes dark like tea, and clay colored stools. Other symptoms may include abdominal pain, back pain, loss of appetite, weight loss, weakness, and a new diagnosis of diabetes.
Q. How is it diagnosed? The diagnosis of pancreatic cancer is changing. Increased use of and improved technology for radiologic studies have led to finding smaller pancreatic tumors as well as finding pancreatic tumors incidentally when a patient is being evaluated for other diseases.
Pancreatic cancers have been identified with multiple radiologic tests used to image the abdomen. These studies include computed tomography (CT), MRI, and ultrasound. For example, if a pancreatic disease such as cancer is suspected a CT scan will provide cross sectional images of the pancreas often detecting a tumor.
A diagnostic procedure called endoscopic retrograde cholangiopancreatography (ERCP) combines the use of X-rays and an endoscope — a long, flexible, lighted tube. The endoscope is inserted through the mouth and stomach, into the duodenum, which is the first part of the small intestine. This allows a view of the common opening to the ducts from the liver and pancreas. A stent, or narrow tube, is passed through the endoscope and into the ducts. A contrast material (dye) is injected into the ducts so they can be seen on X-rays.
In some cases it may be beneficial to obtain a biopsy of a pancreatic tumor before or instead of doing a resection in surgery. Traditionally, CT and ultrasound have been used to guide the aspiration of a pancreatic mass. More recently, endoscopic ultrasound is being used because of its superior imaging capability.
Q. What are the treatment options? The best chance for cure is an early diagnosis and surgical removal of the cancer. About half of patients with pancreatic cancer are candidates for surgery. All or part of the pancreas may be removed, depending on the location and size of the tumor, the stage of the disease, and the patient’s overall health. The most common surgery performed, the Whipple procedure, involves removing the head of the pancreas, the gall bladder, the common bile duct, and the duodenum.
If the cancer has spread beyond the pancreas to other organs or into large blood vessels, surgical removal will not cure this type of cancer. In this instance, as the cancer grows, one may experience symptoms of an obstruction to the bile duct or stomach. To prevent these symptoms both surgical and endoscopic procedures may be used.
- Biliary bypass surgery is performed when the cancer blocks the bile duct. This involves cutting the bile duct above the obstruction and sewing it to the small intestine to create a new pathway around the blocked area.
- Another option when the tumor blocks the bile duct is to place a stent (a small tube) through an endoscope without surgery. The stent allows the bile to drain to the outside of the body or into the small intestine.
- If the tumor blocks the flow of food from the stomach, gastric bypass surgery may be done. An opening in the stomach is sewn directly to the small intestine so the person can continue to eat normally.
Following surgery for symptom relief, patients may also elect to receive chemotherapy or radiation to slow the progress of the disease.
Q. What are the outcomes? Pancreatic cancer can be cured surgically when it is found at an early stage. Even under the best conditions, however, this cancer may recur in at least half of the patients who have undergone a surgical removal of their tumor.
In medical facilities with a strong team approach to caring for people with pancreatic cancer, the five-year survival rate has increased significantly for those who have surgery. Today, the five-year survival rate is near 20 percent. While this may appear low, the rate was less than 5 percent about 20 to 30 years ago.
At Froedtert & the Medical College of Wisconsin, we have the advanced technology to detect the disease and the many disciplines needed to care for and evaluate patients to identify the good surgical candidates, perform the surgery, and provide post-operative care. These are the factors that contribute to good outcomes.
When a surgical cure is not possible, other therapies may slow the growth of the disease and help patients live longer, more comfortable lives.
Source: Every Day, Interview with Stuart Wilson, MD
Date: Aug - Dec 2006