Frequently Asked Questions
Use of Complementary and Alternative Methods
Healthcare consumers in the United States are turning to complementary and alternative medicine in record numbers, and this trend is predicted to continue to grow. The use of over-the-counter herbal remedies and vitamins is also growing. As more people are living longer, chronic illnesses, including cancer, have become more common. Sometimes conventional medicine cannot cure chronic illnesses. As a result, many patients may turn to complementary and alternative medicine in search of cures.1
Studies show that up to 60 percent of patients who have cancer use complementary or alternative methods.2 Traditional medicine may seem cold and impersonal to some patients. Part of the problem is that doctors sometimes spend little time with patients because of pressures to provide cost-effective care.3 The use of complementary or alternative methods may make patients feel that they are taking an active part in their own treatment and care, and that they have more control over their disease.
Definitions of Terms
Some of the terms used in complementary and alternative medicine need to be defined3:
- Complementary therapy: A method added to conventional or traditional treatments. Complementary therapy may ease the side effects of standard treatments or provide physical or mental benefits to patients with cancer; examples are meditation to relieve stress and acupuncture to relieve pain.
- Integrative therapy: Combined use of proven treatments and complementary therapies. Integrative therapy is becoming available in cancer centers and hospitals across the United States.
- Alternative therapy: A treatment that has not been tested scientifically and is used in place of traditional treatments.
- Unconventional therapy: All types of complementary and alternative treatments that fall outside of proven therapies.
- Proven therapies: Traditional or standard treatments that have been tested and are approved by the Food and Drug Administration (FDA).
- Questionable therapy: Unproven or untested treatments.
- Quackery: Promotion of treatments claiming to prevent, diagnose, or cure cancers that are unproven or known to be false. These methods are often based on the use of anecdotal stories or patient testimonials about their effectiveness. Unfortunately for patients with pancreatic cancer, there has been much of this form of treatment touted, particularly on the Internet.
Table 8-1. Some Reputable Sources of Information About Complementary and Alternative Medicine
|American Cancer Society||www.cancer.org|
|National Cancer Institute||www.cancer.gov|
|National Center for Complementary and Alternative Medicine, National Institutes of Health||nccam.nih.gov|
|National Council Against Health Fraud||www.ncahf.org|
Types of Complementary and Alternative Methods
Complementary and alternative methods can be divided into several groups2,3:
- Medical systems (eg, homeopathic and naturopathic medicine)
- Mind-body-spirit methods (e.g., support groups, meditation, aromatherapy, biofeedback, yoga, and prayer), which focus on the connections between the mind, body, and spirit, and their power to heal
- Dietary (eg, the macrobiotic diet) and special nutritional programs or herbal mixtures (eg, foods, herbs, vitamins, and dietary supplements)
- Manipulative and body-based methods (eg, chiropractic, osteopathic manipulation, acupuncture, and massage), which are based on the idea that problems in one part of the body often affect other parts of the body
- Energy therapies (eg, biofield therapy and bioelectromagnetic-based therapy)
- Pharmacological and biological treatments, in which substances produced from chemicals or concentrated from plants and other living things (eg, laetrile and shark cartilage) are used
Risks and Benefits
Some complementary methods may improve a patient’s well-being by relieving pain and reducing symptoms and side effects. These methods may help patients handle stress, anxiety, and depression. Some complementary methods that have been shown to be helpful to patients with cancer include2:
- Acupuncture for pain or for nausea and vomiting from chemotherapy
- Massage therapy for anxiety or pain
- Mind-body-spirit therapies such as hypnosis, relaxation training,imagery, and music therapy
|ST. JOHN’S WORT AND DRUG INTERACTIONS4||
One herbal remedy called St. John’s Wort has been shown to interact with some drugs. The herb affects the way the body processes or breaks down drugs; in some cases, it may speed or slow the breakdown. Drugs that can be affected include indinavir and possibly other drugs used to control HIV infection; irinotecan and possibly other drugs used to treat cancer; cyclosporine, which prevents the body from rejecting transplanted organs; digoxin, which strengthens heart muscle contractions; warfarin and related blood thinning drugs; birth control pills; and antidepressants..
However, complementary and alternative therapies have risks. Just because a product claims to be “natural” does not necessarily mean that it is safe.5 Most dietary supplements, vitamins, and herbs are not approved by the FDA because they have not been tested. These products may contain contaminants, or they may interact with prescription drugs.6 Some products can be very potent and may have unpredictable effects.2 They also may be harmful ( Box 8-1 ).5 In general, patients with pancreatic cancer who are considering the use of complementary therapy or alternative treatments should discuss these methods with their healthcare team.
ALERTS TO POTENTIALLY HARMFUL THERAPIES5
Acknowledging the growing public interest in complementary and alternative methods, especially among patients living with cancer, the American Cancer Society3:
- Supports the rights of individuals with cancer to decide which treatment is best for them
- Encourages people to discuss all treatments they may be considering with their doctors and other healthcare providers
- Encourages people with cancer to consider using proven, effective methods
- Encourages people with cancer to consider enrolling in clinical trials
- Encourages healthcare professionals to ask patients about their use of these treatments
- Encourages healthcare professionals to listen and communicate with patients regarding these treatments
If you are considering using complementary or alternative therapies, the ACS has some tips for frank discussions with your doctor and other healthcare providers ( Box 8-2 ).
TIPS FOR PATIENTS CONSIDERING COMPLEMENTARY OR ALTERNATIVE THERAPIES3
1. Eyre HJ, Lange DP, Morris LB. Informed Decisions: The Complete Book of Cancer Diagnosis, Treatment, and Recovery. 2nd ed. American Cancer Society–Health Content Products. Atlanta, GA; 2002.
2. Cassileth BR, Deng G. Complementary and alternative therapies for cancer. The Oncologist. 2004;9:80-9.
3. American Cancer Society’s Guide to Complementary and Alternative Cancer Methods. Atlanta, GA: American Cancer Society; 2000.
4. National Center for Complementary and Alternative Medicine. http://nccam. nih.gov/health/stjohnswort. Accessed April 22, 2007.
5. Weiger WA, Smith M, Boon H, et al. Advising patients who seek complementary and alternative medical therapies for cancer. Ann Intern Med. 202:137:889-903.
6. Cassileth BR. Evaluating complementary and alternative therapies for cancer patients. CA Cancer J Clin. 1999; 49:362-75.
Reprinted with permission from "Understanding Pancreatic Cancer", a publication of The Lustgarten Foundation for Pancreatic Cancer Research
Staging cancer is a standardized way to classify a tumor based on its size, whether it has spread, and where it has spread. In other words, staging measures the extent of the disease.1 Your doctor will order diagnostic tests to determine the stage of your disease. Knowing the stage of your cancer will help your doctor determine which treatment options are right for you. The stage of your cancer is the most important factor in making good treatment choices.
Most cancers are staged using the TNM system of classification, which was developed by the American Joint Committee on Cancer (AJCC).2
TNM Classification System
The TNM system uses three factors to evaluate cancer: tumor, node, and metastasis1,3:
- T stands for tumor and describes the size and location of the primary tumor, if and how far it has spread within the pancreas, and if it has spread to nearby structures.
- N stands for node and describes evidence of metastases in lymph nodes close to the pancreas, that is, whether or not the tumor has spread to the regional lymph nodes.
- M stands for metastasis and describes evidence of distant metastases, that is, whether or not the cancer has spread to distant parts of the body.
Tumor Evaluation (T)
Based on information from diagnostic tests, the “T” is given a number to describe the size and location of the tumor1,4:
- TX: The primary tumor cannot be evaluated
- T0: No evidence of cancer is found in the pancreas
- Tis: This classification is used when there is a condition called carcinoma (cancer) in situ, or Tis, meaning that the tumor remains in a pre-invasive state and is within the pancreas
- T1: The tumor is in the pancreas only, and it is 2 centimeters (cm) or smaller in size [2 cm = .80 inches]
- T2: The tumor is in the pancreas only, and it is larger than 2 cm
- T3: The tumor has spread to surrounding tissue near the pancreas but not to the major blood vessels
- T4: The tumor extends beyond the pancreas into the major blood vessels near the pancreas; T4 tumors cannot be removed completely by surgery
Node Evaluation (N)
Lymph nodes are small, bean-shaped structures found in the neck, underarm, groin, chest, abdomen, and pelvis – and throughout the body. They store white blood cells, called lymphocytes, which the body uses to fight infection and disease. Lymphatic fluid circulates through lymph vessels, just as blood circulates through blood vessels. Eventually, the lymphatic fluid empties into blood vessels in the upper chest.5 Lymph node enlargement detected either by CT or MRI scan may indicate that cancer has spread to that lymph node. A biopsy also can be performed on lymph nodes to check for cancerous cells. The node staging method is as follows1,4:
- NX: The regional lymph nodes cannot be evaluated
- N0: The cancer was not found in the regional lymph nodes
- N1: The cancer has spread to the regional lymph nodes
Metastasis Evaluation (M)
Pancreatic cancer may spread locally to the lymph nodes and major blood vessels near the pancreas or to distant lymph nodes or organs such as the liver or lungs.6 In staging, this spread is documented as follows1,4:
- MX: Distant spread of the disease (metastasis) cannot be evaluated
- M0: The disease has not spread to distant lymph nodes or to distant organs
- M1: The disease has spread to distant lymph nodes or to distant organs
Combining T, N, and M defines the stage of cancer. Each patient’s condition is evaluated for T, N, and M, and the descriptions are combined to form a stage ( Figures 5-1 to 5-4 ).1,4,7
|Stage 0:||Refers to cancer in situ, or the cancer has not invaded outside the ducts in which it originated (Tis, N0, M0)|
|Stage IA:||The tumor in the pancreas is 2 cm or smaller and has not spread to lymph nodes or other parts of the body (T1, N0, M0)|
|Stage IB:||The tumor in the pancreas is larger than 2 cm and has not spread to lymph nodes or other parts of the body (T2, N0, M0)|
|Stage IIA:||The tumor extends beyond the pancreas but has not spread to nearby lymph nodes, major blood vessels, or other parts of the body (T3, N0, M0)|
|Stage IIB:||The tumor is any size and is either limited to or extends beyond the pancreas and has spread to lymph nodes but not to major blood vessels or other parts of the body (T1, T2, T3; N1; M0)|
|Stage III:||The tumor has spread to nearby blood vessels, may or may not have spread to nearby lymph nodes, but the cancer has not spread to other parts of the body (T4, any N, M0)|
|Stage IV:||The cancer has spread to other parts of the body (any T, any N, M1)|
A simpler, more descriptive staging system for pancreatic cancer is often used by doctors. This system divides cancers into groups based on whether or not the tumor can be removed surgically.1
|Resectable Cancer||This type of pancreatic cancer can be surgically removed. These tumors may lie within the pancreas or extend beyond it, but there is no involvement of the critical arteries or veins in the area. There is no evidence of any spread to areas outside of the tissue removed during a typical surgery for pancreatic cancer.7|
|Locally Advanced Cancer||The cancer is confined to the area around the pancreas but cannot be surgically removed because the tumor may be intertwined with major blood vessels and may have invaded surrounding organs. No evidence of spread to other areas of the body can be found.7 Metastatic Cancer The tumor has spread beyond the area of the pancreas and involves other organs, such as the liver or lungs, or other areas of the abdomen. Unfortunately, almost half of all patients are diagnosed at this stage.7|
The tumor has spread beyond the area of the pancreas and involves other organs, such as the liver or lungs, or other areas of the abdomen. Unfortunately, almost half of all patients are diagnosed at this stage.7 Table 5-1 provides a simplified version of the information given in this section. Remember that it is important to know the stage of you cancer to help make good treatment choices.
|Stage||Classifications for Tumor, Nodes, Metastases||Description||Resectable||Locally Advanced||Metastatic|
|0||Tis, N0, M0||Cancer is confined to cells in the pancreas; also called carcinoma in situ||X|
|IA||Tis, N0, M0||Cancer is only in the pancreas and is 2 cm or smaller||X|
|IB||T2, N0, M0||Cancer is only in the pancreas and is larger than 2 cm||X|
|IIA||T3, N0, M0||Cancer has spread beyond the pancreas but has not spread to nearby lymph nodes, major blood vessels,or other parts of the body||X
|IIB||T1, T2, or T3;N1; M0||Cancer either is limited to or extends beyond the pancreas, with spread to the lymph nodes but not to major blood vessels or other parts of the body||X
|III||T4, any N, M0||Cancer has spread to major blood vessels and possibly to the lymph odes, but not to other parts of the body||X
|IV||Any T, any N,M1||Cancer has spread to other parts of the body||X
1. American Cancer Society. Pancreatic cancer. http://documents.cancer.org/116.00. Accessed April 12, 2007.
2. Exocrine pancreas. American Joint Committee on Cancer: AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002;157-64.
3. Johns Hopkins Pathology. Pancreas cancer. http://pathology2.jhu.edu/PANCREAS/PANCREAS1.cfm. Accessed April 19, 2007.
4. National Cancer Institute. Pancreatic cancer (PDQ®): treatment. Health professional version. March 15, 2007. www.cancer.gov/cancertopics/pdq/ treatment/pancreatic/healthprofessional/page3. Accessed April 14, 2007.
5. Eyre HJ, Lange DP, Morris LB. Informed Decisions: The Complete Book of Cancer Diagnosis, Treatment, and Recovery. 2nd ed. American Cancer Society–Health Content Products. Atlanta, GA; 2002.
6. Erikson RA. Pancreatic cancer. www.emedicine.com/med/topic1712.htm. Accessed April 19, 2007.
7. Freelove R, Walling AD. Pancreatic cancer: diagnosis and management. Am Fam Phys. 2006;73:485-92.
Reprinted with permission from "Understanding Pancreatic Cancer", a publication of The Lustgarten Foundation for Pancreatic Cancer Research
A caregiver is a person who provides help with daily activities, coordinates healthcare and other services, and provides emotional and other types of support for a patient with cancer. The main caregiver is usually, but not always, a spouse, a close family member, or a close friend. There are various kinds of caregivers, and each can provide a different type of care.1 For example, a neighbor who visits a few times a week or takes the patient out to lunch or a movie is a caregiver.
Being the main caregiver for a loved one with cancer is challenging.1 Main caregivers sometimes put their own needs and feelings aside while practicing patience and providing emotional support in the form of understanding and encouragement. As a main caregiver, you also may be taking on new roles, including helping with daily needs such as meals and personal care and taking over tasks that formerly were your loved one’s responsibilities. Doing all of these things may consume all of your emotional and physical energy.2
Dealing with cancer can be an emotional roller coaster. Caregivers also may experience a range of various feelings, just as patients do: anger, guilt, grief, hopelessness, loneliness, and depression.
The caregiver also may have very different emotions from those of the patient. As a caregiver you may feel that you must be perfect – but no one is perfect. You may feel hurt when the person you are caring for takes anger out on you. Although the anger is not about you, it is difficult not to take it personally. You need to forgive yourself and your loved one, learn from the situation, continue to do the best that you can, and go on.1
CARING FOR YOURSELF
As a caregiver, you probably have been putting your needs last, because they do not seem important right now. After dealing with everything else, you cannot find time for yourself. You may even feel guilty about getting enjoyment from anything at all. The combined pressures of all of these new responsibilities, of having to change your habits and routines, and of the worry about what is happening or what may happen can result in burnout ( Boxes 12-1 to 12-3 ).1
Here are some ways to avoid burnout:
Here are some signs of burnout:
Here are some ways that you can recharge yourself mentally and emotionally so that you can be a better caregiver1:
- Stay connected with your friends and community
- Give yourself an outlet for your feelings: talk with a friend, spend time alone
- Join a local support group; support groups are also available by phone and online
- Participate in an Internet chat room or discussion board such as the Johns Hopkins Pancreatic Cancer Discussion Board
- Talk with a counselor
- Find time for relaxation: take at least 15 minutes each day to do something you find relaxing
- Do something small for yourself each day: take a moment to think of something positive, to laugh, to be thankful
- Write in a journal
Here are some ways to take care of yourself physically1:
- Make sure to keep up with your healthcare checkups
- Take any medicines that have been prescribed for you
- Eat healthy meals
- Get sufficient rest and exercise
- Avoid the use of alcohol in an attempt to cope with stress
DEALING WITH BURNOUT3
Here are some ways to deal with burnout:
STAYING CONNECTED WITH YOUR LOVED ONE
Staying connected with a loved one in a normal, healthy way may be difficult. To help stay connected, try to view this person as before. Do something fun together, or celebrate a special occasion. Cherish your loved one’s presence in the here and now. Help your loved one create a special physical space for health and healing, and make it a special place for both of you. Touch and hug your loved one.2
Thinking of your relationship with your loved one as being a “team effort” may help you stay connected, reduce stress, and improve communication. It also may help your loved one feel more in control of some situations. For example, you can discuss some of the following topics2:
- In the past what other difficult times have we gone through together? How did we handle the problem?
- Which family and healthcare tasks do each of us prefer doing?
- Are there any tasks that we can share?
- What are the ways we can help each other?
- What activities can we do together to have fun and forget about cancer?
Talking about cancer with your loved one is an excellent way to stay connected, but it may be difficult. When talking about the disease use the same words that your loved one uses, such as “my disease” and not “pancreatic cancer.” Sometimes the best way to communicate with anyone is just to listen in a nonjudgmental way. However, there are ways of approaching a difficult topic that needs to be discussed2:
- Practice what you will say in advance
- Find a quiet time to talk
- First ask if it is OK to talk
- Explain why you want to talk
- Speak from your heart
- Allow time for your loved one to talk
- Do not feel the need to finalize everything after only one talk
- The most important thing you may be able to do is just listen
CAREGIVING AND THE HEALTHCARE TEAM
During the course of your loved one’s illness, you will interact with many members of the healthcare team. Make the best use of your time and their time by being prepared.:
- Keep a file or notebook with all of the patient’s medical information, and bring it with you to all doctor appointments; it should include the following:
- Current medications and dosages
- Test results and the dates they were performed
- Past treatments and the dates they were given
- The names, addresses, and phone numbers of the patient’s doctors
- The names of the different members of your healthcare team and the roles they play
- Write down all questions you have before appointments
- Call the office ahead of time to make sure that the doctor has the results of any recent tests that have been performed
- Take notes during appointments so you can remember what was discussed
- Make sure that all of your questions are answered
References1. National Cancer Institute. When someone you love is being treated for cancer. http://cancer.gov/cancertopics/When- Someone-You-Love-Is-Treated. Accessed April 24, 2007.
2. CancerConsultants.com. Support and Resources. Caregivers. http://patient.cancerconsultants.com/Resources.aspx? TierId=1084&LinkId=&DocumentId= 18842. Accessed April 17, 2007.
3. Eyre HJ, Lange DP, Morris LB. Informed Decisions: The Complete Book of Cancer Diagnosis, Treatment, and Recovery. 2nd ed. American Cancer Society–Health Content Products. Atlanta, GA; 2002.
Reprinted with permission from "Understanding Pancreatic Cancer", a publication of The Lustgarten Foundation for Pancreatic Cancer Research
Learning About Coping
Coping refers to how people or family members come to terms with an illness, make decisions, solve problems, and adapt to life’s changes, while still feeling good about themselves.1 Some factors that apply to how well you are able to cope are your emotions, whether you have a sense of control, whether you have a positive outlook, and whether you have physical and emotional support.
It is common to have a full range of difficult and mixed emotions throughout an illness. Some emotions related to being diagnosed with or having cancer are shock, disbelief, fear, anxiety, guilt, sadness, loneliness, depression, grief, and anger. These feelings may come and go. It is important to remember that these are normal reactions. Your family members and friends may have similar feelings, and similar ups and downs.1,2
Working through these emotions is essential to successful coping. Because you may not be prepared for the unique stresses imposed by cancer, you may need new ways of handling your emotions, thought processes, and behaviors. Talking with other people about your feelings, writing in a journal, and finding quiet time can help you cope.1
Feeling that you have some control over what happens to you will make things easier. A large part of dealing with cancer is making decisions. Learning about pancreatic cancer will make you better equipped to make informed decisions, and will make you understand that you do have choices.It also is important to focus on things that you can change, not on those you cannot change.1
It may be difficult to be hopeful and have a positive outlook when you are ill and worried. However, hoping for the best possible outcome often provides the motivation to follow medical advice and take care of yourself physically, mentally, and emotionally. Living in the present can help you focus on what is meaningful and enjoyable right now, rather than on what you do not have or what you may lose. Feeling hopeless, powerless, or that you have nothing to live for can be signs of depression.1
Sometimes no matter how hard you try, you may have negative feelings that do not go away. They may be symptoms and signs of depression or anxiety. Being depressed is different from being sad. Depression takes over your whole life and causes emotional paralysis. Your family members and friends should be alert for these symptoms ( Box 11-1 ).
Depression is common in patients with pancreatic cancer. Let your healthcare team know about your symptoms. Do not suffer needlessly, because effective medications and other methods to treat depression are available.2
DO YOU HAVE DEPRESSION?1,2
Seeking the support, assistance, and companionship of others is a very important aspect of coping. Addressing legal and financial matters, and planning may also help you cope.1
DEVELOPING A SUPPORT SYSTEM
As a patient, you can reach out to family and friends for emotional support to help you cope with your cancer. Sometimes, however, family members are too emotionally involved and may not want to – or be able to – hear what you have to say. It is difficult to deal with a diagnosis of cancer in a loved one. Joining a support group may make a positive difference for you.3
Finding new friends, especially others who have cancer, may help. They know how you feel. You can express feelings to other patients with cancer that you may not be able to express to your family members. Other patients can validate your feelings. Support groups, individual counseling, and group counseling are available. Support groups can meet in person, by phone, or on the Internet. Not only does sharing with other people help you cope, but you can benefit from the experiences of all these other people. They have a wealth of information about many aspects of cancer. They can give you ideas about how to cope. You can trade advice. Some people like to join a group and just listen.2,3 Conversely, you may have an opportunity to help others cope with their disease.
Remember that members of your healthcare team are also part of your support system. Contact them to discuss anything related to your cancer and how you are dealing with it. They can aid you in finding what you need to help you cope.3
ADDRESSING FINANCIAL AND LEGAL MATTERS
When dealing with a life-threatening illness you may need to put your financial matters in order. With the help of a trusted individual, you can create an organized system for managing your financial resources.4 Financial aid may be available from government programs, disability benefits, voluntary organizations, and living benefits from life insurance policies. Having a financial plan may reduce some of the stress in your life and help you better cope.
You also may want to get your legal matters in order, because some of these are related to your healthcare needs. A number of documents may be involved. A lawyer is not always needed, but you may need a notary public.
Two documents that are involved with your healthcare, called advance directives, are a living will and a durable power of attorney.5
A living will lets people know what kind of medical care you want if you are ever unable to speak for yourself. A durable power of attorney for healthcare names a person to make medical decisions for you if you cannot. This person is chosen by you and is called a healthcare proxy. Note that each state has its own laws about advance directives. You may want to check with a social worker or lawyer about the laws in your state.2
Two documents that are not part of advance directives are a will and power of attorney. A will tells how a person wants his or her money and property distributed. Power of attorney appoints a person to make financial decisions when you cannot.
Because financial and legal matters can be very complex, you may need help.
ADDRESSING END-OF-LIFE CARE
Patients and their families may want to make decisions to make end-of-life care as dignified and as physically and emotionally comfortable as possible. Patients may want to finish projects, have family and friends visit, speak with those closest to them, and have a spiritual advisor visit.
Being cared for at home may make you feel more secure and more comfortable. You may want to be near your family members, friends, and familiar surroundings. Healthcare providers can help you take advantage of the many services available to allow you to be at home: access to medical equipment, visiting nurses, physical therapists, help with daily hygiene and care, meal preparation, and delivery of medications.6
Home healthcare professionals may allow patients to receive even complex medical care in their homes. Services range from simple injections to complete care for seriously ill patients. Access is provided to a professional who can be contacted day or night to make an assessment and relay that information to your doctor. Your overall care is supervised by your doctor, who is provided with up-to-date information on your condition.4
Hospice is a concept of care that emphasizes palliative treatments rather than curative ones, quality of life rather than quantity, and comfort measures. Hospice care may be provided in the home, at a hospice facility, or in a hospital. Patients who have a limited life expectancy and who are no longer undergoing treatment for cancer may receive hospice care.
Both the patient and family members are included in the hospice care plan. Based on their needs and wishes, practical, emotional, and spiritual support may be provided. The unique goals of the hospice team are to be sensitive and responsive to the special requirements of each individual and each family. The patient is under professional medical care, with a focus on symptom relief. Trained volunteers are available to support and offer respite to family members.7
References1. Eyre HJ, Lange DP, Morris LB. Informed Decisions: The Complete Book of Cancer Diagnosis, Treatment, and Recovery. 2nd ed. American Cancer Society–Health Content Products. Atlanta, GA; 2002.
2. National Cancer Institute. When someone you love is being treated for cancer. http://cancer.gov/cancertopics/When-Someone-You-Love-Is-Treated. Accessed April 24, 2007.
3. Mayo Clinic. Pancreatic cancer. April 12, 2006. www.mayoclinic.com/health/pancreatic-cancer/DS00357/DSECTION=11. Accessed April 17, 2007.
4. CancerConsultants.com. Oncology Resource Center. Support and resources. http://patient.cancerconsultants.com. Accessed April 17, 2007.
5. CancerConsultants.com. Oncology Resource Center. Advanced directives. http://patient.cancerconsultants.com. Accessed April 17, 2007.
6. National Cancer Institute. Home care for cancer patients. http://cancer.gov/cancertopics/factsheet/Suppor/home-care. Accessed April 24, 2007.
7. Hospicenet.org. The hospice concept. www.hospicenet.org/html/conceptpr. html. Accessed April 25, 2007.
Several steps are involved in making a diagnosis of pancreatic cancer. The first thing your doctor will do is ask questions about your medical history, family history, possible risk factors, and symptoms (Box 4-1). Answering these questions honestly and completely will help both you and your doctor during the diagnostic process.
MEDICAL HISTORY QUESTIONS1
• Where do you have the pain?
• How long have you had the pain?
• How bad is the pain, for example, on a scale from 1 to 10?
• Are you able to do anything to make the pain happen?
• Are you able to do anything to make the pain go away?
• Have you lost weight without trying?
• What other symptoms do you have?
• If you have jaundice: When did you notice the jaundice?
• If you have dark urine or light stools: How long have you had this?
• Has anyone in your family ever had cancer?
• Has anyone in your family ever had pancreatic cancer?
You will also have a physical examination. Your doctor will check your abdomen for tenderness, fluid buildup, enlargement of your gallbladder or liver (that may result from blockage of the bile duct), and masses. Your lymph nodes will be checked for tenderness and swelling. Any sign of jaundice will be noted. Your doctor also may order blood or urine tests, testing of stool samples, or imaging tests.
The most important tests used to detect pancreatic cancer are imaging tests. These tests use a variety of methods to see inside the body. Imaging tests can be simple X-rays or more complex scanning methods that use computers to reconstruct the structures in the body. Some typical imaging tests are described in this section, and their uses are listed in Table 4-1 .
Keep in mind that results from many of the imaging tests outlined in this section are complementary to each other. Your doctor will decide which tests would be best, given your particular situation.
Imaging Test and Uses
|- Can help determine if the tumor is localized or has spread|
|CT scan with contrast dye||- Can detect abnormal masses
- Can detect blockages of the pancreatic and bile ducts
|Dual-phase helical CT scan
||- Can detect 98% of pancreatic cancers
- Can detect distant metastases
|Multidetector row CT (MDCT) scan||- Has improved image resolution
- Can rapidly scan large volumes
|Ultrasonography||- Can determine if pancreatic tissue is normal or abnormal
- Can help detect blockages of the pancreatic and bile ducts
|Endoscopic ultrasonography (EUS)||- Highly reliable
- Can determine local extent of disease
- Can detect lesions in the head, body, and tail of the pancreas
- Tissue samples can be taken at the same time
|Laparoscopic ultrasonography (LUS)||- Can determine if the tumor has spread to the peritoneum
- Can detect liver metastases
|Magnetic resonance imaging (MRI)||- Can detect masses
- Can detect blockages
|Positron emission tomography (PET) scan||- Can show the difference between healthy and abnormal tissue in the entire body|
|- Can detect obstructions in the pancreatic and bile ducts
- Usually reserved for people who require stent placement for symptom management
|- Can detect obstructions in the pancreatic and bile ducts|
Computed Tomography (CT) Scan
Many people either are familiar with or have had a computed tomography (CT) scan, which is also called a CAT scan. The CT machine is very large and shaped like a donut. During a CT scan, you will lie on a table that will move into the machine. The scanner will take detailed, cross-sectional, X-ray images from many different angles. The computer combines these images into a series of views of the area in question for diagnostic purposes. ( Figure 4-1 ).1 A CT scan may be done at a special center or in a hospital but does not require an overnight stay. This test is not painful, and no sedation is needed.
A dye, called a contrast agent, can be injected into a vein to produce better CT images of body structures. Typically, a contrast agent is also given by mouth to provide better images of the stomach and small intestines.
In many centers, modifications of basic CT scanners are used to image the pancreas more accurately. Two of these modified scanners are a dual-phase helical CT scan and a multi-detector row helical CT scan. A dual-phase helical (also called spiral) CT scan is a sensitive imaging test used to evaluate patients suspected of having pancreatic cancer. Dual-phase helical CT scanning produces detailed, three-dimensional images of the pancreas. It is estimated that this type of CT scan can diagnose about 98% of all pancreatic cancers and distant metastases.6
|A Dual-phase helical CT scan is often called a 3D CT scan.
This imaging technique uses a X-ray beam that remains on while rotating around the patient. The scan is timed so that the pancreas and liver are scanned at the optimal time for the contrast dye to be effective. The resulting image is a highly accurate three-dimensional image obtained in a shorter time than a conventional 2-D CT scan.
A helical CT scanner with multiple detector rows, called a multi-detector row helical CT (MDCT) scan, is one of the latest technological advances in CT scanners. MDCT has advantages over other CT methods, including improved image resolution and the ability to rapidly scan large volumes, thus allowing for imaging of the entire pancreas in a single breath-hold by the patient.7
Ultrasonography is another imaging test that is commonly used, and thus, many people are familiar with it. Ultrasonography is also called a sonogram, an ultrasonogram, or an ultrasound scan. During this test, sound waves are bounced off internal organs to produce echoes. The computer creates patterns from these echoes. Because echoes from normal and abnormal tissue produce different patterns, pancreatic cancer can be detected.1
During a sonogram, an ultrasound probe will be placed on your abdomen and moved methodically. Images of the echo patterns will be displayed on a computer screen.1 Ultrasound examination is noninvasive, painless, and can be performed in an outpatient setting. Its major limitation is that gas in the gastrointestinal tract can interfere with the sound waves, and therefore, it is not considered a very sensitive test to detect pancreatic cancer.
There are two other types of sonograms, endoscopic ultrasonography (EUS) and laparoscopic ultrasonography (LUS). Each is a minimally invasive procedure. EUS is performed using an endoscope, which is a long, thin instrument with a light at the end used to look deep inside the body. During EUS, you will receive numbing medication for your throat and medication for sedation. The endoscope is passed down the esophagus, through the stomach, and into the duodenum. The machine that makes the sound waves is then turned on, and images are created by visualizing the pancreas through the stomach or the duodenum.1,8
Advantages of EUS are that the ultrasound probe can be placed immediately adjacent to the pancreas, producing detailed images, and tissue samples can be obtained through the same instrument.
The LUS procedure is not used as often as EUS but may be employed to evaluate whether the cancer has spread to the peritoneum, which is the membrane that lines the abdominal cavity and covers most of the abdominal organs. During an LUS procedure, typically, general anesthesia is given. A small incision will be made in the abdomen, and the doctor will use a laparoscope (a small telescope-like instrument connected to a video monitor) to view the pancreas. This procedure can be done in the hospital or on an outpatient basis.8
Magnetic Resonance Imaging (MRI)
Magnetic resonance imaging is another imaging method that is in common use today, and many people are familiar with it. When having an MRI, you lie on a table that is moved into a narrow tube. Today, open MRIs are commonly available to avoid the uncomfortable feeling of being in an enclosed space, although images from open MRIs may not be optimal. The procedure is noninvasive and painless.1
MRI uses radio waves and powerful magnets, instead of X-rays as in a CT scan, to view internal structures and organs. The energy from the radio waves is absorbed by the body and then released. A computer translates the patterns formed by this energy release into detailed images of areas inside the body. MRI produces cross-sectional slices like a CT scanner, but also produces slices that are parallel to the length of the body.1
An MRI scan is performed at a special imaging center or at a hospital. If you have any metal in your body, you should check with your doctor prior to undergoing an MRI scan. Some types of metal implants, such as prosthetic hips, knees, pacemakers, and heart valves, may cause problems when exposed to high magnetic forces such as those used in MRI.
Positron Emission Tomography (PET Scan)
Positron emission tomography, or PET scan, is an imaging test that shows not only anatomy but also biological function. During a PET scan, a small amount of radioactive glucose (sugar) is injected into a vein. Then a special camera detects the radioactivity that is preferentially taken up by malignant tissue, and a computer creates detailed images. Because cancer cells often absorb much more glucose than normal cells do, the images created by a PET scan can be used to find cancer cells in the pancreas and in other areas of the body.1 Recently developed machines combine CT imaging with PET scanning to more accurately identify cancer.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Endoscopic retrograde cholangiopancreatography, or ERCP, is an invasive procedure that is used in conjunction with a dye to view the bile and pancreatic ducts for obstructions. During an ERCP, you will receive an anesthetic to numb the throat and medication for sedation. A thin tube is passed down the throat, through the stomach, and into the small intestine. From there, the gastroenterologist who is performing the procedure will identify the pancreatic duct so that the dye can be injected into it. Then X-rays are taken. This is an outpatient procedure but also may be performed in the hospital.9
ERCP has advantages over magnetic resonance cholangiopancreatography (see below). ERCP is especially helpful in patients with jaundice because a stent can be inserted and left in place to keep ducts open, often relieving the jaundice and its associated symptoms. Tissue samples also can be taken during the procedure.9 Less invasive tests are being used more often in place of ERCP.10
Magnetic Resonance Cholangiopancreatography (MRCP)
Magnetic resonance cholangiopancreatography (MRCP) is a type of MRI and is an alternative to ERCP. It is safer and faster than ERCP, because it is noninvasive and no dye is used. MRCP is used to view the pancreatic and bile ducts, which are difficult to see with CT or MRI. No sedation or preparation on the part of the patient is needed, except for fasting.3,4
Because the only definitive way to diagnose cancer is to directly visualize cancer cells under a microscope, a biopsy may be performed when pancreatic cancer is suspected. A biopsy is the process of removing tissue samples, which are then examined under a microscope to check for cancer cells.9 A biopsy can be performed in an outpatient setting or in the hospital.
Biopsy specimens can be obtained in different ways. It is generally not necessary to have a biopsy performed prior to surgery.
Fine-Needle Aspiration (FNA) Biopsy
In a fine-needle aspiration (FNA) biopsy, imaging by CT or EUS is used together with a long, thin needle to obtain tissue specimens. The CT or EUS imaging method allows the doctor to view the position of the needle to ensure that the needle is in the tumor. EUS also can be used to place the needle directly through the wall of the duodenum or stomach and into the tumor for collection of tissue specimens. General anesthesia is not required, but local anesthesia may be provided.1
A brush biopsy procedure is used with ERCP. A small brush is inserted through an endoscope into the bile and pancreatic ducts. Cells are scraped off the insides of the ducts with the brush.1
Laparoscopy is a minimally invasive procedure, during which you will receive general anesthesia. A laparoscope is inserted through a small incision in the abdomen. The doctor can view the tumor and remove tissue samples for examination.1
Blood tests are frequently performed for diagnostic purposes. No single blood test can be used to make a diagnosis of pancreatic cancer. When a person has pancreatic cancer, however, elevated levels of bilirubin or liver enzymes may be present.6
Different tumor markers in the blood are used to detect and monitor many types of cancer. Tumor markers are substances, usually complex proteins, produced by tumor cells. Proteins form the basis of body structures such as cells, tissues, and organs. Enzymes and some hormones are composed of protein. Some tumor markers can indicate specific types of cancer; others are found in several types of cancer. Many of the well-known tumor markers, such as PSA for screening prostate cancer, are also found in people who do not have cancer.11
Two commercially available tumor marker tests are of use in patients with pancreatic cancer, cancer antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA).1 These markers are not accurate enough to be used to screen healthy people for or to make a diagnosis of pancreatic cancer. However, CA 19-9 and CEA are frequently used to track the progress of treatment in patients with pancreatic cancer. CA 19-9 is a protein found on the surface of certain types of cells and is shed by tumor cells, making it useful in following the course of cancer. The presence of the protein CEA may indicate cancer because elevations in CEA levels are not usually found in people who are healthy. CEA is not as useful as is CA 19-9 in pancreatic cancer testing.11
If you have blood and urine testing, your doctor will receive written reports from the laboratory. If the results show high levels of bilirubin, it may be an indication of pancreatic cancer. However, many other medical situations can cause an elevation in bilirubin. Additional testing will almost always be needed to establish a diagnosis of pancreatic cancer. Liver function tests will also be performed on blood samples to determine if a tumor is affecting the liver.
Results of imaging tests such as CT and MRI scans will be conveyed to your doctor by a radiologist, a physician who is trained to interpret many different types of imaging techniques. The radiologist will consult with your doctor and provide a written report of the results.
If you have a biopsy procedure performed, your doctor will receive a written report from the pathologist, a physician trained to examine cells under a microscope in the laboratory for cancer and other diseases. Your doctor may also speak with the pathologist to obtain a better understanding of your disease. The results of the biopsy will help your doctor make treatment recommendations, and can help you make treatment decisions.
References1. American Cancer Society. Pancreatic cancer. http://documents.cancer.org/ 116.00. Accessed April 14, 2007.
2. JAMA Patient Page. Pancreatic cancer. www.jama.com. Accessed April 1, 2007.
3. Kaltenthaler E, Vergel YB, Chilcott J, et al. A systematic review and economic evaluation of magnetic resonance cholangiopancreatography compared with diagnostic endoscopic retrograde cholangiopancreatography. Health Technology Assessment. 2004;8(10). www.ncchta.org/execsumm/summ810.htm. Accessed April 13, 2007.
4. Miller JC. Magnetic resonance cholangiopancreatography (MRCP). www.massgeneralimaging.org/newsletter/june_2004. Accessed April 13, 2007.
5. University of Pittsburgh Medical Center Health System. Percutaneous transhepatic cholangiography and biliary drainage. http://patienteducation.upmc.com/Pdf/CholangBiliDrain.pdf. Accessed April 13, 2007.
6. Freelove R, Walling AD. Pancreatic cancer: diagnosis and management. Am Fam Phys. 2006;73:485-92.
7. Fishman EK, Horton KM. The increasing impact of multidetector row computed tomography in clinical practice. Eur J Radiol. 2007;62:(Suppl)1-13.
8. Yang GY, Wagner TD, Fuss M, Thomas CR. Multimodality approaches for pancreatic cancer. CA Cancer J Clin. 2005;55:352-67.
9. National Cancer Institute. Pancreatic cancer (PDQ®) treatment. Patient Version. April 14, 2005. www.cancer.gov/cancertopics/pdq/treatment/pancreatic/ patient/allpages. Accessed April 12, 2007.
10. Stevens T, Conwell DL. Pancreatic neoplasms. www.clevelandclinicmeded.com/diseasemanagement/gastro/pneo/pneo.htm. Accessed April 6, 2007.
11. Lab Tests Online. http://labtestsonline.org. Accessed April 20, 2007.
How can I receive palliative care?
Palliative care is provided if a person has a serious illness and one or more of the following:
- Patient, family, or team need assistance with complex decision making and determination of goals of care
- Difficult-to-control pain or other symptom distress (such as dyspnea, delirium, nausea) related to a serious medical illness
- Difficult-to-control psychosocial or spiritual issues related to a serious medical illness
- Multiple hospitalizations for same diagnosis
- Progressive decline in functional status
- Progressive metastatic cancer
- New diagnosis of life limiting illness for symptom control or determination of goals of care
- Need for Advance Care Planning or clarification of DNR status
- Utilization of ICU setting in patient with documented poor prognosis
- Prolonged ICU stay or transfer to the ICU setting without evidence of progress
- Questions regarding artificial nutrition or hydration in cognitively impaired, seriously ill or actively dying patients
- Patient or family requests for care determined by primary team to be differences in family and team goals of care
- Patient, family, or team request for information regarding hospice appropriateness
What can I expect?
At Jefferson, palliative care is provided in the hospital and in an outpatient setting. In addition, you can expect:
- Relief from symptoms such as pain, shortness of breath, fatigue, constipation, nausea, loss of appetite and difficulty sleeping
- Support with emotional, spiritual, or financial stressors that may affect you or a family member during treatment for cancer
- Help carrying on with your daily life
- Improved ability to go through medical treatments.
- Help with understanding your cancer diagnosis and your choices for medical care
- An improved overall quality of life
Will my insurance cover palliative care?
Most insurance plans, including Medicare and Medicaid, cover palliative care. If costs concern you, a social worker or financial consultant can help you navigate through the benefits process.
Clinical trial is the scientific term for the study of a drug, a procedure, or a medical device. Clinical trials are performed to determine if the product being tested is safe and effective for use in people. Doctors and other healthcare professionals run clinical trials according to strict rules set by the Food and Drug Administration (FDA) to ensure that study participants are treated as safely as possible.1 There are many different types of clinical trials, which are used to find better ways to prevent, screen for, diagnose, and treat diseases, and even to improve patients’ quality of life.
Clinical trials are designed to answer many different questions about cancer treatments2:
- Does this treatment work?
- If so, how does it work?
- Does it work better than other treatments available?
- Are there side effects, and what are they?
- Which patients will benefit most from this treatment?
Clinical trials are often sponsored by governmental agencies.2 For example, the National Cancer Institute sponsors about two thirds of clinical trials and is studying more than 250 anticancer agents. Other agencies that sponsor or conduct clinical trials related to cancer are the National Institutes of Health, Department of Defense, and Department of Veterans Affairs. Voluntary organizations, such as the American Cancer Society, also sponsor and support clinical trials. Drug companies often join with universities and cancer centers to conduct these trials.3
CLINICAL TRIAL PHASES
Before any new cancer treatment can be tested in humans, it is studied extensively in the laboratory. Generally, these studies are done in human cells in the test tube (in vitro) and animals (in vivo) to determine which drugs are most likely to affect the cancer. If the experimental results are promising, then the FDA may approve testing in humans.3
Most clinical trials are carried out in sequential steps called phases ( Table 9-1 ). Each phase is designed to answer specific questions and builds on information from the previous phase. In Phase 1 trials, researchers learn about the side effects of a new drug by gradually increasing the dosage and analyzing patients’ responses. Based on the results, a larger study may be conducted to evaluate the potential effectiveness of the drug.3
Phase 2 trials determine if the treatment works.2 Researchers try to learn if the new drug has the potential to be better than current treatments. Tumor size is measured and recorded to determine if the new drug shrinks the tumor, and blood samples are analyzed to look for side effects of the drug and the effect of the drug on cancer markers in the blood. If enough people have a response, Phase 3 testing will proceed.
The goal of Phase 3 trials is to determine if the treatment is better than, as good as, or not as good as the accepted standard treatment.3 In general, participants in Phase 3 trials receive the study drug as a first treatment, that is, they have had no other treatment for their cancer. Phase 3 studies provide a more thorough understanding of the effectiveness, benefits, and side effects of the drug. Phase 3 studies also typically determine if the new therapy is better than the current standard of care.
|Study Phase||No. of Patients||Patients’ Cancer Characteristics||Primary Purposes|
|Phase 1||Usually less than 50||Usually with advanced cancer no longer responding to conventional treatments||Safety and dosage|
|Phase 2||Groups of 20 to 40||Usually have had standard therapy but the cancer has recurred||Safety and effectiveness|
|Phase 3||Hundreds||Usually have had no prior treatment for the cancer||Determine if study drug is as good as, better than, or not as good as standard treatment|
Clinical Trial Participation
Because there are few effective treatments for patients with tumors that cannot be removed surgically and for patients who have metastatic disease, clinical trials of pancreatic cancer treatments are important. They may investigate new combinations of currently available drugs or study new drugs that have worked in other cancers. Many clinical trials are underway for patients in all stages of pancreatic cancer. Whether to take part in a clinical trial can be a difficult decision to make. Patients must weigh the risks and benefits of the treatment.2 Moreover, patients need to get enough information about the trial to make a good decision. Box 9-2 lists questions to ask to help you make that decision. Remember that participation in a clinical trial is always voluntary.
If you enroll in a clinical trial, you need to know that you have certain rights. You have the right to be told3:
- The purpose of the clinical trial
- All risks, side effects, and discomforts that might reasonably be expected
- Any benefits that can reasonably be expected
- What will happen during the study and whether any procedure, drug,or device is different from that used in standard medical treatment
- Your available options and how they may be better than or worse than being in the clinical trial
- Medical treatments available if complications occur during your participation
As a participant you also can do the following3:
- Ask any questions about the clinical trial before giving your consent to participate, and at any time during the clinical trial
- Have ample time, without being pressured, to decide whether to agree to participate
- Refuse to participate before entering the trial, and leave the trial at any time after it has begun
QUESTIONS TO ASK ABOUT CLINICAL TRIALS1-4
As a participant in a clinical trial, not only will you receive excellent care,but you will be protected in various ways. The FDA requires that you be given complete information about the study before you agree to take part,which is known as informed consent. You will be asked to read and sign an Informed Consent Form, and will be given a copy of the signed form.This form must be written in an understandable way for the patient. Signing the form shows that you have been given this information and that you understand it. However, when you sign the Informed Consent Form you are not signing a contract. You may leave the study at any time and for any reason. In addition, informed consent is an ongoing process. You have the right to be given all pertinent information and have your questions answered at any time during your participation in the clinical trial.1
IN CLINICAL TRIALS1
As a participant, you will receive high-quality, individualized care. The research team will closely monitor your treatment response, your health, and any side effects you may have. Researchers also will follow strict scientific guidelines and ethical principles to protect participants.
You are protected in a clinical trial in three additional ways: by Institutional Review Boards (IRBs), Data Monitoring Committees, and FDA inspections. People from the local community, including doctors and clergy, serve on IRBs to review and monitor their facility’s medical research that involves people. They ensure that there is the least possible risk to participants, and that the risks are reasonable in relation to the expected benefits.1
Data Monitoring Committees are mainly used when one treatment is being compared with another. These committees are particularly important in testing treatments for serious or life-threatening diseases such as cancer. Experts review information from studies to make sure they are being done in the safest way. The Committee has the power to stop a study if the treatment is harmful, or to stop a study in order to provide the treatment to all participants when one treatment works better than another.1
The FDA inspects records, clinics, and research sites involved in clinical trials. The FDA makes sure volunteers are being protected and that the studies are being done properly.
|WILL I RECEIVE A PLACEBO?||
Sometimes patients think that they may receive a placebo (a sugar pill) in a clinical trial. Most clinical trials for cancer do not use placebos. Patients usually get either the drug under study or a drug that is considered standard treatment. However, if you have any doubts, ask.
How to Find A Clinical Trial
Interested patients should ask members of their healthcare team about clinical trials. Many lists of ongoing clinical trials are available on the Internet. Unfortunately, there is no one place to search for all available clinical trials. Several groups have matching and referral services to help patients find appropriate clinical trials.
The NCI-designated Kimmel Cancer Center at Jefferson offers innovative clinical trials and a full range of supportive care services to improve our patients' health and quality of life.
References1. Food and Drug Administration. Department of Health and Human Services. Clinical trials of medical treatments: Why volunteer? Washington, DC; Publication FDA 01-1294. www.fda.gov/opacom/lowlit/cltr.html. Accessed June 20, 2007.
2. American Cancer Society. Clinical trials. www.cancer.org/docroot/ETO/content/ ETO_6_3_Clinical_Trials_-_Patient_ Participation.asp. Accessed April 16, 2007.
3. Eyre HJ, Lange DP, Morris LB. Informed Decisions: The Complete Book of Cancer Diagnosis, Treatment, and Recovery. 2nd ed. American Cancer Society–Health Content Products. Atlanta, GA; 2002.
4. Getz K, Borfitz D. Informed Consent. A Guide to the Risks and Benefits of Volunteering for Clinical Trials. Boston, MA: Thomson; 2003.
Surgery to remove the tumor as a component of the treatment is the only way to cure pancreatic cancer. Surgery is performed when the surgeon believes all of the cancer can be removed. This generally applies to patients who are in the early stages of pancreatic cancer. Other types of surgical procedures may be performed in patients who are in later stages of pancreatic cancer to relieve symptoms such as pain and obstructions of the bile or pancreatic ducts or of the intestines.1
Pancreatic surgery has improved significantly over the past two decades. Nonetheless, surgery to remove a pancreatic tumor is complex for the surgeon to perform and difficult for a patient to undergo. Recovery after surgery usually is very slow; it may take several weeks, and complications are not uncommon ( Box 7-1 ). Patients need to frankly discuss the risks and benefits of this type of surgery with their doctors before making a decision.2 In addition, patients need to find a surgeon and a facility with a great deal of experience in performing this procedure.3 It cannot be emphasized enough that, in patients with pancreatic cancer, operative complications are significantly fewer at high-volume surgical centers compared with low-volume centers.
SOME COMPLICATIONS OF SURGERY2
|HOW TO REDUCE YOUR SURGICAL RISKS||
If you are a candidate for surgery, find a surgeon and a hospital with a great deal of experience to reduce your risks and increase your chances of a successful outcome.
According to a study in the 2002 issue of The New England Journal of Medicine, the mortality rate for Whipple procedures for pancreatic cancer performed at low-volume centers was four times higher than at high-volume centers.3
In addition – and it cannot be emphasized enough for patients with pancreatic cancer – operative complications are significantly fewer at high-volume surgical centers than at low volume centers.
Procedures to Remove the Tumor
Three major procedures are used to remove pancreatic tumors: a Whipple procedure (pancreaticoduodenectomy), a total pancreatectomy, and a distal pancreatectomy.
Pancreaticoduodenectomy. A Whipple procedure, or a pancreaticoduodenectomy, is the most common surgery performed to treat pancreatic cancer ( Figures 7-1A and 7-1B ). Two basic types of Whipple procedures exist. In one, the lower part of the stomach is removed. In the other more commonly used procedure, called a pylorus-preserving Whipple procedure, the entire stomach and first portion of the duodenum are spared. The surgeon removes the following:
- Most of the duodenum (the beginning of the small intestine)
- Head, neck and uncinate process* of the pancreas
- Part of the bile duct
- Lymph nodes in the area of the pancreas
* The neck and uncinate process is not included in the original text.
After these organs are removed, the stomach (in a standard Whipple procedure) or the remaining part of the duodenum (in a pylorus-preserving Whipple procedure), pancreas, and remaining part of the bile duct are joined to the small intestine. This allows bile and pancreatic enzymes to enter the digestive system normally and mix with ingested food.2
Total Pancreatectomy. A total pancreatectomy is a seldom used procedure that removes the entire pancreas and spleen. When the entire pancreas is removed the endocrine cells in it are also removed, leaving the patient with no islet cells. Because islet cells make insulin, which controls blood sugar levels in the body, removal of the entire pancreas will result in diabetes. The patient will then be dependent on insulin injections.2
Distal Pancreatectomy. In a distal pancreatectomy, the tail and body of the pancreas are removed, usually along with the entire spleen. Sometimes part of the body of the pancreas can be preserved.2
Palliative Surgery. Sometimes the cancer has spread, and surgical removal of the tumor is not an option. Other surgical procedures may be used to help relieve symptoms such as jaundice, nausea, vomiting, and pain in order to improve the patient’s quality of life. Surgeons can bypass blockages of the pancreatic or bile ducts or gastrointestinal tract to relieve these symptoms. Surgeons can also cut nerves or perform nerve blocks to reduce pain.2,4
Radiation therapy, also called radiotherapy, uses high-energy X-rays to shrink tumors by killing cancer cells. External beam radiation therapy is the type used most often to treat pancreatic cancer. A beam of radiation from outside of the body is focused on the tumor, similar to what is done during a diagnostic X-ray only at much higher doses of radiation. To improve the results of treatment and increase survival, radiation therapy may be used before or after surgery. Some of the common side effects of radiotherapy are shown in Box 7-2 .1
SIDE EFFECTS OF RADIATION THERAPY1
Sometimes radiation therapy is combined with chemotherapy, called chemoradiation. This combination is often used when the cancer has spread and cannot be removed surgically.
|ADJUVANT THERAPY: A treatment given after surgery (radiation therapy or chemotherapy).
Making an informed decision about whether or not to undergo adjuvant therapy can be a difficult. Before you make a decision, please Read the Essential Information about Adjuvant Therapy compiled by our multidisciplinary team.
Chemotherapy is the use of drugs to kill cancer cells. It may be given orally or by injection, or may be delivered through a catheter. Chemotherapy is a systemic treatment, meaning that the drug enters the bloodstream and travels throughout the body to reach the tumor cells. Chemotherapy may be used alone or may be combined with either radiation therapy or surgery. To improve the results of treatment and increase survival, chemotherapy may be used before or after surgery. When chemotherapy is used before surgery, it is called neoadjuvant therapy; when it is used after surgery, it is called adjuvant therapy.
In the past, the most common chemotherapy drug given to patients with pancreatic cancer was single-agent fluorouracil, or 5-FU. Other drugs (cisplatin, oxaliplatin, and taxanes) are used both alone and in combination with 5-FU. The introduction of gemcitabine (Gemzar®) has changed the treatment of pancreatic cancer. Studies show that gemcitabine is better than 5-FU for treating metastatic cancer of the pancreas.1
Targeted therapy is designed to kill only cancer cells and not normal, healthy tissue. Targeted therapy is being used to treat pancreatic cancer. Erlotinib (Tarceva®) targets a protein in the cancer cell that stimulates growth.1 Erlotinib is approved by the Food and Drug Administration (FDA) when used in combination with gemcitabine for the first-line treatment of patients with pancreatic cancer that is locally advanced, is inoperable, or has metastasized.5
The side effects of chemotherapy depend on which drugs are given, the dose, and the length of treatment. Generally, the chances of side effects occurring increase with higher doses and the use of a combination of chemotherapy drugs. Some common side effects of chemotherapy are listed in Box 7-3 . Most side effects disappear once treatment is stopped.
SIDE EFFECTS OF CHEMOTHERAPY
In addition to standard treatments approved by the FDA for pancreatic cancer, patients should be offered the opportunity to participate in clinical trials.6 Many studies are investigating the use of new medications and of new combinations of standard medicines in hopes of finding better ways to treat pancreatic cancer.
1. American Cancer Society. Pancreatic cancer. http://documents.cancer.org/ 116.00. Accessed April 15, 2007.
2. American Cancer Society. Detailed guide: pancreatic cancer. Surgery. www.cancer.org/docroot/cri/content/cri_ 2_4_4x_surgery_34.asp?sitearea=cri. Accessed April 15, 2007.
3. How important is finding an experienced surgeon? http://pathology2.jhu.edu/ pancreas/surgicaltx.cfm. Accessed April 15, 2007.
4. Yang GY, Wagner TD, Fuss M, Thomas CR. Multimodality approaches for pancreatic cancer. CA Cancer J Clin. 2005;55:352-67.
5. TARCEVA® (erlotinib) Prescribing Information. OSI Pharmaceuticals, Inc.: New York; 2005.
6. Stevens T, Conwell DL. Pancreatic neoplasms. www.clevelandclinicmeded.com/diseasemanagement/gastro/pneo/pneo.htm. Accessed April 6, 2007.
A Silent Disease
Pancreatic cancer can be called a silent disease because many times no signs or symptoms are noticed until the cancer is in an advanced stage. Even when there are early signs and symptoms, they may be vague and easily attributed to another disease. The signs and symptoms also may be confusing to patients and healthcare providers because they vary, depending on where the tumor is located in the pancreas (the head, body, or tail).1 It is important to see your doctor if you have any of the signs or symptoms of pancreatic cancer (Box 3-1).
Jaundice and Its Signs and Symptoms
Jaundice is a yellowing of the skin and the whites of the eyes. Signs and symptoms that may occur with jaundice are itching, dark urine, and clay-colored stool. The itching may be severe.2,3
Jaundice occurs when bilirubin stains the skin. Bilirubin is a dark-green substance made in the liver.3 Starting in the liver, bilirubin travels down the bile duct and into the small intestine. When the bile duct is blocked by a tumor or when a tumor is located in the head of the pancreas near the bile duct, the bile is prevented from reaching the intestines. The bile then accumulates in tissues, blood, and the skin, leading to jaundice.3
There are other, more common causes of jaundice, such as hepatitis (inflammation of the liver) or obstruction of the bile duct by a gallstone.3
|Back Pain||This common sign of advanced pancreatic cancer occurs when the tumor presses on organs and nerves around the pancreas. The pain may be constant or intermittent and can be worse after eating or when lying down. Many conditions other than pancreatic cancer can cause back pain.2,3|
|Fatigue or Weakness||People with pancreatic cancer may feel very tired.3|
|Pancreatitis||An inflammation of the pancreas called pancreatitis can be a sign of pancreatic cancer when it is chronic or when it appears for the first time and is not related to either drinking alcohol or gallstones.4,5|
|Diabetes||Developing diabetes mellitus (sugar diabetes), especially after the age of 50, can be a sign of pancreatic cancer.6|
DIGESTIVE PROBLEMS OR PAIN
|Unexplained Weight Loss,
Loss of Appetite,
|People with pancreatic cancer may lose weight, may have little or no appetite, or may suffer from malnutrition.2,3 When pancreatic enzymes cannot be released into the intestine, digesting food, especially high-fat foods, may be difficult. Over time, significant weight loss and malnutrition may result.2|
|Nausea or Vomiting||If the tumor blocks the upper part of the small intestine (the duodenum), nausea and vomiting may result.2|
|Abdominal Pain||Just as in back pain, abdominal pain is a common sign of advanced pancreatic cancer. It occurs when the tumor presses on organs and nerves around the pancreas.2,3|
When to See Your Doctor
Many other illnesses can cause these signs and symptoms, but it is important to take them seriously and see your doctor. If you have a first-degree relative with pancreatic cancer, tell your doctor and consider joining a pancreatic registry.
Important Indicator for Pancreatic Cancer: Clues in the Blood
In a study of more than 2,000 people with diabetes over 50 years of age, researchers at the Mayo Clinic in Rochester, Minnesota, found an association between newly developed sugar diabetes and pancreatic cancer. Within 3 years of diagnosis, people with diabetes had a risk of pancreatic cancer that was eight times that of same-age, average persons. It is thought that new-onset diabetes may be an indicator that would allow for earlier detection and treatment of pancreatic cancer. It is too early to tell if this indicator can be used to screen people over the age of 50 for pancreatic cancer. 7
1. OncoLink. Types of cancer. Pancreatic cancer: the basics. http://oncolink.com/ types/article.cfm?c=4&s+7&ss=49&id= 1739. Accessed April 11, 2007.
2. Mayo Clinic. Pancreatic cancer. April 12, 2006. www.mayoclinic.com/health/ pancreatic-cancer/DS00357/DSECTION=8. Accessed April 14, 2007.
3. American Cancer Society. Detailed guide: pancreatic cancer. April 2006. www.cancer.org/docroot/CRI/CRI_2_3x. asp?dt=34. Accessed April 14, 2007.
4. Lowenfels AB, Maisonneuve P, Cavallini G, et al. International Pancreatitis Study Group. Pancreatitis and the risk of pancreatic cancer. N Engl J Med. 1993; 328:1433-7.
5. Abbruzzese J. The University of Texas MD Anderson Cancer Center, Houston, Texas. Personal communication; March 8, 2007.
6. Chari ST, Leibson CL, Rabe KG, et al. Probability of pancreatic cancer following diabetes: a population-based study, Gastroenterology. 2005;129:504-11.
7. Mayo Clinic. Older Americans with new-onset diabetes have high risk of pancreatic cancer. July 31, 2005. www.mayoclinic.org/news2005-rst/2984.html. Accessed March 19, 2007.
Genes and Pancreatic CancerAll the cells in the body contain DNA (deoxyribonucleic acid). DNA is the molecule in the cell nucleus that carries the instructions for making living organisms.1 When cells grow and divide, they also copy DNA. Sometimes mistakes, called mutations, occur during this copying process.
Mutations in DNA occur frequently, especially when cells divide. Cells have an exceptional ability to repair these changes in DNA. However, the DNA repair mechanisms also can fail. When they do, these mistakes in DNA can be passed along to future copies of the altered cell. More abnormal cells then can be produced. When these abnormal cells continue to grow unchecked, cancer may develop.2
The DNA mutations that cause pancreatic cancer may be either inherited from a parent or acquired.3 Inherited mutations are carried in the DNA of a person’s reproductive cells and can be passed on to that person’s children.2 Not everyone who has an inherited mutation will develop pancreatic cancer.
There is a long list of risk factors for pancreatic cancer (Box 2-1). Risk factors are characteristics, habits, or environmental exposures that have been shown to increase the odds of developing a disease.
RISK FACTORS FOR PANCREATIC CANCER3-5
Not everyone with one or even more than one of these risk factors will develop pancreatic cancer.
Research conducted by Theresa Pluth Yeo, PhD, MPH, ACNP, Program Director of the Advanced Practice Oncology Nursing Program at Jefferson, suggests that, in addition to the risk factors outlined above in Box 2-1, exposure to second hand smoke, occupational asbestos, and environmental radon may increase the risk of pancreatic cancer.
Risk Factors You Can Influence
Smoking. Smoking is a direct risk factor because people who smoke have two to three times the chance of getting pancreatic cancer compared with people who do not smoke.4
Diet. A diet high in cholesterol, fried foods, and processed meats, such as bacon and sausage, may increase the risk of pancreatic cancer. A diet high in fruits and vegetables may reduce the risk of pancreatic cancer.3-4
Obesity. People who are significantly overweight are 20 times more likely to develop pancreatic cancer compared with those who are not overweight.4
Other Risk Factors
Age. As people age, their risk of pancreatic cancer increases. Pancreatic cancer mostly affects people 55 years of age and older.4
Race. In the United States, pancreatic cancer is more common in African Americans than in whites. The reasons are not clear. Differences in dietary habits, the rates of obesity and diabetes, and the frequency of cigarette smoking exist between these groups. Genetic or other unknown factors may also explain the higher incidence in African Americans.5
Medical Factors.The incidence of pancreatic cancer is higher in people who have any of the following medical conditions:
- Chronic pancreatitis (inflammation that causes irreversible damage)
- Long-standing diabetes mellitus (high blood sugar)
- History of stomach surgery (partial gastrectomy)
Environmental Factors. Occupational exposure to some chemicals, such as pesticides, dyes, or chemicals related to gasoline, may increase the risk for pancreatic cancer.4
Presence of Risk Factors
When a person has any one or even more than one of these risk factors, it does not mean that the person is certain to develop pancreatic cancer. In contrast, some people who do not have risk factors will still get pancreatic cancer. Researchers do not know the reasons for these differences but are working to understand how lifestyle and environmental risks interact with individual genetic makeup to influence the chances of developing pancreatic cancer.4,6
Family History and Pancreatic Cancer
Pancreatic cancer may be inherited because it tends to run in families.4 This means that relatives of patients with pancreatic cancer may have an increased risk of developing the disease. One recent study done in Iceland found that people who had one first-degree relative (parent, sibling, or child) with pancreatic cancer had two to three times the risk of developing pancreatic cancer compared with people with no family history.8 Not everyone with a family history of pancreatic cancer will develop the disease.
Familial Pancreatic Cancer
Relatives of patients with pancreatic cancer have an increased risk of developing it. Inherited mutations in known cancer-causing genes have been shown to be the cause of familial pancreatic cancer in some families.7
Not everyone who has one of these mutations will develop pancreatic cancer.
From 5 to 10 percent of pancreatic cancers result from hereditary factors.2 Researchers believe that studying specific cancer genes may provide a better understanding of the causes of pancreatic cancer. In turn, a better understanding of the causes may lead to more effective screening methods.9,10 Researchers in the United States have set up national pancreatic cancer registries to study the hereditary factors that influence pancreatic cancer.
The hereditary syndromes listed below may be associated with the development of pancreatic cancer.11
Familial Breast Cancer Syndrome. People who have the breast cancer 2 gene (BRCA2)mutation have an increased risk of several cancers, among them pancreatic adenocarcinoma.12 The BRCA2 gene is particularly common in the Ashkenazi Jewish population.
Familial Atypical Multiple Mole Melanoma (FAMMM) Syndrome. People with FAMMM syndrome have many different-sized skin moles that are asymmetrical and raised.11
Peutz-Jeghers Syndrome (PJS).In people with PJS, the risks of gastrointestinal tumors such as esophageal, small bowel, colorectal, and pancreatic cancer are increased.13 Polyps in the small intestine and dark spots on the mouth and fingers characterize the disease.14
Hereditary Pancreatitis. Hereditary pancreatitis is a rare disease in which patients develop recurrent episodes of severe chronic pancreatitis at an early age.3 This is not the same as chronic pancreatitis.
Hereditary Nonpolyposis Colon Cancer (HNPCC; Lynch Syndrome). People with HNPCC have a higher than normal chance of developing colon, pancreatic, uterine, stomach, or ovarian cancer.3
Multiple Endocrine Neoplasia Type 1 Syndrome (MEN1; Wermer’s Syndrome).MEN1 is a rare, inherited disorder that affects the endocrine glands and can cause tumors in the pancreas and other organs, which usually are not cancerous.11
Ashkenazi Jews: Are They at Risk For Pancreatic Cancer?
Pancreatic cancer is more common in people of Ashkenazi Jewish ancestry. Researchers believe there is a genetic basis for this increased risk. A defect in the BRCA2 gene,which is found in about one percent of Ashkenazi Jews, is responsible for a 10-fold increased risk of developing pancreatic cancer. A defect in the BRCA1 gene, which is found in 1.5 percent of Ashkenazi Jews, is responsible for a twofold increased risk.15 Doctors can test for the presence of these genetic mutations. Not everyone who has one of these inherited genetic mutations will develop cancer.
1. National Human Genome Research Institute. National Institutes of Health. Talking glossary of genetic terms. www.genome.gov/glossary.cfm. Accessed April 13, 2007.
2. National Cancer Institute. Understanding cancer series: gene testing. www.cancer.gov/ cancertopics/understandingcancer/ genetesting. Accessed April 13, 2007.
3. Johns Hopkins Pathology. Pancreatic cancer. http://pathology2.jhu.edu/ pancreas/causespc.cfm. Accessed April 11, 2007.
4. American Cancer Society. Pancreatic cancer. http://documents.cancer.org/ 116.00. Accessed April 14, 2007.
5. emedicine. Pancreatic cancer. www.emedicine.com/med/topic1712htm. Accessed May 14, 2007.
6. Familial pancreatic cancer. Ask an Expert. 2004;2:1-3.
7. Hruban RH, Petersen GM, Goggins M, et al. Familial pancreatic cancer. Ann Oncol. 1999;10(Suppl 4):69-7.
8. Amundadottir LT, Thorvaldsson S, Gudbjartsson DF, et al. Cancer as a complex phenotype: pattern of cancer distribution within and beyond the nuclear family. PLoS Medicine. 2004: 1:229-36.
9. Hruban RH, Iocobuzio-Donahue C, Wilentz RE, et al. Molecular pathology of pancreatic cancer. Cancer J. 2001; 7:251-8.
10. Li D, Xie K, Wolff R, Abbruzzese JL. Pancreatic cancer. Lancet. 2004; 363:1049-57.
11. National Cancer Institute. Pancreatic cancer. 2005.
www.cancer.gov/ cancertopics/types/pancreatic. Accessed April 1, 2007.
12. Arnold MA, Goggins M. BRCA2 and predisposition to pancreatic and other cancers. Exp Rev Mol Med. 2001; www.expertreviews.org/0100309Xh.htm. Accessed April 14, 2007.
13. Hearle N, Schumacher V, Menko FH, et al. Frequency and spectrum of cancers in the Peutz-Jeghers syndrome. Clin Cancer Res. 2006;12:3209-15.
14. National Cancer Institute. Dictionary of cancer terms. www.cancer.gov. Accessed April 13, 2007.
15. Johns Hopkins Pathology. Pancreatic cancer in individuals of Ashkenazi Jewish ancestry. http://pathology2.jhu.edu/ PANCREAS/ashkenazi_jewish_ancestry.cfm. Accessed April 6, 2007.
The pancreas is an organ of the digestive system located deep in the upper part of the abdomen, behind the stomach and in front of the spine (Figure 1-1). It is only about 2 inches wide and 6 to 8 inches long and sits horizontally across the abdomen (Figure 1-2). The pancreas is composed of three parts.
The large, rounded end is called the head. It is located on the right side of the abdomen and near the beginning of the small intestine, which is called the duodenum. The middle section, called the body, is tucked behind the stomach. The thin end of the pancreas, called the tail, is located on the left side of the abdomen next to the spleen.
Two separate types of glandular tissue make up the bulk of the pancreas, exocrine and endocrine tissue. The exocrine tissue comprises 95 percent of the pancreas and acts as an exocrine gland. The endocrine tissue makes up the remaining 5 percent of the pancreas and acts as an endocrine gland.3
Exocrine glandular tissue produces pancreatic enzymes to aid in the digestion of food. These enzymes are made in cells (called acinar cells) in the exocrine tissue. The pancreatic enzymes flow down a tube called the pancreatic duct, which is the main duct of the pancreas. This duct runs along the entire length of the pancreas and merges with the bile duct. From the pancreatic duct, the enzymes enter the duodenum. Bile from the liver flows down the bile duct and also empties into the duodenum. All of these fluids help the body digest food.
The endocrine glandular tissue of the pancreas produces hormones and releases them into the bloodstream. The hormones are made in collections of cells called the Islets of Langerhans, which are found in small clusters throughout the pancreas. Insulin is an important hormone made in these cells and helps control blood sugar levels.3
Cancer of the Pancreas
The word cancer is used to describe any one of a group of diseases in which the cells are abnormal, grow out of control, and can spread. These abnormal cells are different from normal cells in both appearance and function. Pancreatic cancer occurs when abnormal cells grow out of control in the tissue of the pancreas and form a tumor.1,2
Because the pancreas lies deep in the abdomen, a doctor performing an examination on a patient would not be able to feel a pancreatic tumor. Pancreatic cancer has no early warning signs, and there are no effective screening tests. As a result, pancreatic cancer rarely is discovered early. Many times the diagnosis is not made until the cancer has spread to other areas of the body.3
Unfortunately, symptoms of pancreatic cancer often do not appear until the tumor has grown large enough to interfere with the function of nearby organs or exert pressure on the spine.
When early symptoms do occur, they are often vague and nonspecific. All of these symptoms can be caused by medical conditions other than pancreatic cancer. Possible early symptoms that should be evaluated by your physician are:
In the United States, cancer of the pancreas is the fourth leading cause of cancer deaths in both men and women.4 In 2007, about 37,000 patients will be diagnosed with pancreatic cancer.5 Almost all patients with pancreatic cancer are older than 55 years (90 percent), and more than 70 percent are older than 65 years.3 Unfortunately, pancreatic cancer can also occur in younger people, especially those who have a family history of the disease. Today, better diagnostic tests and newer treatments are beginning to change these statistics and provide a more optimistic future for patients diagnosed with pancreatic cancer.
Types of Pancreatic Cancer
The most common types of pancreatic cancers are exocrine tumors called ductal adenocarcinomas, which are thought to form in the pancreatic ducts. About two thirds of all pancreatic cancers form in the head of the pancreas. The other third form in the body and tail.3 These tumors are malignant, meaning they can invade nearby tissues and organs. Cancerous cells can also spread through the blood and lymphatic system to other parts of the body. When this occurs, it is called metastatic cancer and it may be life-threatening.
Tumors can also form in the endocrine cells of the pancreas. These types of rare tumors are called islet cell tumors or pancreatic endocrine neoplasms, and most often they are benign. Those that are malignant are called islet cell cancers or malignant pancreatic endocrine neoplasms. Other rare forms of pancreatic cancer are listed in Box 1-1. It is important to distinguish between exocrine and endocrine tumors because each has different signs and symptoms, are diagnosed using different tests, have different treatments, and have different prognoses.3 This handbook does not focus on endocrine tumors or other rare tumors of the pancreas and related organs. However, most National Cancer Institute–Designated Comprehensive Cancer Centers have experts who can help patients who have these rare pancreatic tumors.
Until recently, little was known about cancer of the pancreas. Because of new discoveries in all types of cancer, more research is being focused on pancreatic cancer. Scientists are beginning to understand the genetic basis of this disease. This knowledge may help in understanding its causes and in determining who is most at risk. Eventually, new and better ways to treat pancreatic cancer will be discovered.
Precursors to Pancreatic Cancer
Intraductal papillary mucinous neoplasms (IPMNs) have been recognized as a special type of abnormal tumors in the pancreas. These tumors are called “mucinous” because they produce large amounts of mucus, which clogs and enlarges the pancreatic duct. IPMNs are very different from most pancreatic tumors. They may be present for a long time without spreading, and patients with some types of IPMNs have a good chance of a cure with surgery. Because IPMNs also have very distinct features, researchers believe that studying them and their genetic makeup may lead to new ways of diagnosing more typical forms of pancreatic cancer.7
Pancreatic intraepithelial neoplasia (PanIN) are lesions too small to see with the naked eye. Like IPMNs, PanIN lesions can also progress to invasive pancreatic cancer over time.
1. National Cancer Institute. Pancreatic cancer. www.cancer.gov/cancertopics/types/pancreatic. Accessed April 1, 2007.
2. National Cancer Institute. Pancreatic cancer. www.cancer.gov/cancertopics/wyntk/pancreas. Accessed April 13, 2007.
3. American Cancer Society. What is cancer of the pancreas? www.cancer.org. Accessed April 1, 2007.
4. Journal of the American Medical Association. Pancreatic cancer. JAMA. 2007;297:330.
5. National Cancer Institute. Pancreatic cancer (PDQ®): treatment. Health professional version. March 15, 2007. www.cancer.gov/cancertopics/pdq/ treatment/pancreatic/healthprofessional. Accessed April 19, 2007.
6. Mulkeen AL, Yoo PS, Cha C. Less common neoplasms of the pancreas. World J Gastroenterol. 2006;12:3180-5.
7. Sohn TA, Yeo CJ, Cameron JL, et al. Intraductal papillary mucinous neoplasms of the pancreas: an increasingly recognized clinicopathologic entity. Ann Surg. 2001;234:313-21.
Controlling Side Effects
Some of the most common side effects of pancreatic cancer are nausea, vomiting, and pain. Supportive care provided by the healthcare team can help ease and even eliminate these problems, thus increasing the patient’s quality of life. Supportive care in patients with cancer is the use of medications to prevent or counteract the unwanted side effects of cancer or of cancer treatments.
Causes of Pain
Pain is the body’s way of indicating to the brain that something is wrong. Pain may be acute or chronic. Acute pain usually is short-lived, may be the result of an injury, and subsides when the injury heals. Chronic pain occurs over a long period of time and ranges from mild to severe.1,2
Pain from cancer may be chronic and may be caused by the tumor when it presses on organs, nerves, or bone; blocks blood or lymph vessels; or blocks a hollow organ such as the intestines. Other causes are infection, constipation,indigestion, and immobility. Cancer treatments also may cause pain.1,2
|PATIENTS WHO HAVE CANCER DO NOT HAVE TO SUFFER WITH PAIN1,2||
As a patient with cancer, you do not have to suffer with pain. In the mid-1990s, the American College of Physicians said that “Most cancer pain can be eliminated, and all cancer pain can be controlled.” If your pain relief is inadequate, tell your healthcare providers.
Ways of Controlling Pain
Patients who have cancer do not have to endure pain. They are entitled to and should receive aggressive pain management. In fact, management of chronic pain in patients who have cancer is essential. Chronic pain may limit basic activities such as dressing, eating, and walking, and even may result in anxiety and depression. Chronic pain may disrupt sleep and curb the appetite, weakening the body’s immune defenses, which fight infection and disease, and interfering with healing.1,2
The goals of management of pain from pancreatic cancer are to3:
- Control pain
- Prevent or minimize side effects
- Enhance quality of life
|MYTHS ABOUT PAIN1,2
Myth : Pain in the early stages of cancer will always get worse.
Truth : Treatment intended to eliminate or reduce the size of tumors may relieve or eliminate pain.
Myth : There is nothing that can be done about pain caused by cancer.
Truth : There are very effective treatments available to control pain. Tell your doctor if you have pain, and seek appropriate treatment.
Myth : Patients who take strong pain medications will become addicted.
Truth : The risk of addiction to the strongest of painkillers, opioids, is low. Patients with cancer who take opioids to relieve pain usually can take a high dose, can take it often, and can remain on these medications for a long time if need be.
For patients who have pain, the healthcare provider should3:
- Understand the causes of the pain
- Perform a comprehensive pain assessment
- Select the most appropriate medications and non drug interventions
- Evaluate the response to treatment for pain
Assessment of Pain
When assessing pain, your doctor will ask lots of questions2,3:
- When did the pain begin?
- How often does it occur?
- Location: Where is the pain?
- Quality: What does it feel like?
- Numerical rating scale: 0 (no pain) to 10 (worst pain)
- Verbal descriptor scale: mild, moderate, severe
- Aggravating and relieving factors:
- What makes the pain better?
- What makes the pain worse?
- What are the effects of your pain on you? For example, lack of sleep, fatigue, irritability, depression
You can help your doctor assess your pain by clearly communicating what your pain feels like and by keeping a pain log ( Box 10-1 ).
ASSESSING YOUR PAIN2-3
To clearly communicate what your pain feels like, you can use some of these descriptive words:
You also can keep a pain log. Keep a record of the date, time, and severity of your pain from 0 (no pain) to 10 (worst pain).
Treatment for Pain
Pain Medications. Once the doctor knows the severity of the pain, a treatment can be chosen. Most doctors use a pain treatment approach developed by the World Health Organization (WHO) called the WHO Three-Step Analgesic Ladder ( Table 10-1 ).4 An analgesic is a medication whose primary purpose is to relieve pain.
Mild pain may be treated with acetaminophen (Tylenol®) or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen (Motrin®, Advil®) or naproxen (Naprosyn®, Anaprox®, Aleve®). Check with your doctor before taking aspirin, because it can thin the blood and thus may not be safe for use by patients who have cancer. For pain that is not relieved by NSAIDs, more potent drugs called opioids are used. These drugs are the very strongest pain relievers available3 and are some of the best medicines for controlling pain. Some mild opioids are codeine, hydrocodone, and oxycodone. Some strong opioids are morphine, fentanyl, and hydromorphone.2 Sometimes combinations of these drugs are used.
Opioids have different side effects than NSAIDs ( Box 10-2 ). Always discuss any side effects you may have with your doctor.
Pain medications may be given in various ways. Most are taken orally, that is, by mouth, with good results. Other ways of giving pain medications are subcutaneously (under the skin), through the skin using a transdermal patch, and rectally by the use of a suppository. Sometimes pain medications are given intravenously, that is, they are injected directly into a vein. Sometimes they are given intrathecally, that is, injected directly into the spinal canal.
POSSIBLE SIDE EFFECTS OF OPIOIDS5
Another method of delivering pain medication is patient-controlled analgesia (PCA). In PCA, the patient controls the amount of pain medicine that is used by pressing a button on a computerized pump connected to a small tube in the body; patients cannot use more than the prescribed amount because the device is programmed for a maximum dosage.2,5 PCA is commonly used after pancreatic cancer surgery in the immediate postoperative period.
Adjuvant Drugs. Adjuvant drugs, which treat a variety of problems in addition to pain, are also commonly used to enhance the effectiveness of pain medications. Adjuvant drugs often have a greater effect than either nonopioid or opioid pain medications alone. Some provide pain relief by themselves. Typical adjuvant drugs include corticosteroids, anticonvulsants, tricyclic antidepressants, and antianxiety medications.2,5
Other Pain Control Measures. Many nondrug therapies may be useful to help control cancer pain. Doctors may advise the use of heat therapy, cold therapy, or physical therapy. Massage, hypnosis, acupuncture, coping skills, and emotional support and counseling also may be effective. These techniques, and others, may be used in conjunction with pain medications.3,5
For pain that does not respond to other measures, an alcohol nerve block may be performed. A local anesthetic is injected into the nerve root of the celiac plexus using ultrasound or computed tomography guidance. This procedure is performed by an anesthesia pain specialist in an outpatient setting. The effects may last for 3 to 4 months.3 Sometimes a skilled surgeon will perform a neuroablation in which part of the pain nerve fibers are cut or destroyed.2 Radiation therapy can be used effectively to relieve pain by shrinking tumors.3
Patients with pancreatic cancer may have lost weight before the diagnosis. In addition, treatments may make patients not feel like eating. Good nutrition is essential to control weight loss, maintain strength, and promote healing. A diet high in calories and protein can help keep up weight.
High-calorie foods are6:
- Dairy products: whole milk, butter, cheese, yogurt, and ice cream
- Honey, jellies, and jams
- Granola and dried fruit
To these, add foods with protein6:
- Nuts, seeds, wheat germ, and peanut butter
- Meat and fish
- Nutritional drinks such as Ensure®
Some, but not all, studies have suggested that fish oil supplements can be particularly helpful in maintaining body weight.7
NAUSEA AND VOMITING
Nausea and vomiting are common side effects of treatments for pancreatic cancer and usually stop when treatment ends.6
Pancreatic cancer itself also may cause nausea and vomiting, which may occur in the early stages, later stages, or not at all.
Preventing nausea will help patients get the nutrition they need. Patients should eat foods that are easy to digest; avoid fatty foods; eat small portions and frequently; avoid smells that bring on nausea; eat warm, not hot, food; rest after eating to allow the food to digest; and wear loose-fitting clothing. If nausea persists, contact your doctor because antinausea medications can be prescribed.6
Vomiting can be controlled very effectively with the use of drugs called antiemetics.6 Talk to your doctor if you experience vomiting after eating. If vomiting is severe or lasts for more than a few days, contact your doctor.
Constipation is a condition of the digestive system where a person experiences hard stools that are difficult to eliminate. Constipation may be painful and, in severe cases, may lead to a blockage of the bowel.
For some people, it may be normal to have a bowel movement daily; for others, it may be normal to have a bowel movement only three times each week. It is important to report any changes in bowel movements from your regular routine to a member of your healthcare team.
Different things can cause constipation. It is a common side effect of pain medications (usually opioids). These medications reduce the motility (movement) of the intestines, making it more difficult to move the bowels and resulting in hard, dry stools.2 Your doctor may recommend that you begin taking a stool softener to help prevent constipation at the time that an opioid is prescribed. Other problems associated with cancer and cancer treatments can contribute to constipation, for example, reduced activity, poor appetite, and weakness.2 If you have constipation, let your healthcare team know as soon as possible.
References1. Teeley P, Bashe P. The Complete Cancer Survival Guide. New York: Doubleday; 2000.
2. Eyre HJ, Lange DP, Morris LB. Informed Decisions: The Complete Book of Cancer Diagnosis, Treatment, and Recovery. 2nd ed. American Cancer Society–Health Content Products. Atlanta, GA; 2002.
3. Johns Hopkins Pathology. Pancreas cancer. www.pathology.jhu.edu/pancreas. Accessed May 23, 2007.
4. Hill CS. Effective treatment of pain in the cancer patient. In: American Cancer Society Textbook of Clinical Oncology. Atlanta, GA: American Cancer Society; 1995.
5. Clinical Practice Guideline for the Management of Cancer Pain. www.hospicepatients.org/clinicalpracticeguidelines1994.html. Accessed April 17, 2007.
6. National Cancer Institute. Eating hints for cancer patients: before, during, and after treatment. www.cancer.gov/cancer topics/eatinghints/allpages. Accessed April 17, 2007.
7. Jatoi A. Omega-3 fatty acid supplements for cancer-associated weight loss. Nutr Clin Pract. 2005;20:394-9.
The Focus is on Pancreatic Cancer
Research into the causes, prevention, detection, and treatment of pancreatic cancer is ongoing in the United States, and worldwide.1
In 2001, the National Cancer Institute (NCI) convened a committee of scientists, clinicians, and advocates to review research into pancreatic cancer and make recommendations regarding the most urgent needs and promising future directions.2 The committee was named the Pancreatic Cancer Progress Review Group (PRG). As a result of the findings of the PRG, NCI funding for pancreatic cancer research projects in all identified areas increased. The areas identified were:
- health of the field and overarching issues
- tumor biology
- risk, prevention, screening, and diagnosis
- health services research
- scientific tool kit
Some of the 5-year funding results are shown in Table 13-1 .
Table 13-1 . Highlights of the National Cancer Institute Investment in Pancreatic Cancer Research2
|Total funding for pancreatic cancer||$21.8 million||$66.7 million||206%|
|Number of research projects||85||204||140%|
|Number of investigators with NCI-funded grants||34||82||141%|
|Number of scientific articlesacknowledging NCI support||137||248||81%|
Additional highlights of the meeting include funding to2:
- 3 Specialized Program of Research Excellence (SPORE) grants designed to create a flow of information from research to practice
- 129 active NCI-sponsored clinical trials relevant to pancreatic cancer
- 77 US institutions active in pancreatic cancer research
- 14 research projects that address three PRG priority areas: tumor biology; risk prevention, screening, and diagnosis; and therapy
RESEARCH INTO CAUSES
Pancreatic cancer results from changes in DNA that cause cells to become cancerous. Researchers have identified genes that may cause familial pancreatic cancer. These discoveries could lead to ways to predict which family members are at risk.3-6 For example, recent studies have found that people who have two first-degree relatives (parent, child, sibling) with pancreatic cancer have a greater risk of developing it.7 The higher the number of family members who have been diagnosed with pancreatic cancer, the more that risk increases. In 2007, Wang and colleagues developed and made available to genetic counselors a computer program that can be used to calculate a person’s risk of developing pancreatic cancer based on family history.8
RESEARCH INTO DETECTION
Researchers are looking into tests to detect acquired genetic changes in pancreatic cancer. One of the most common DNA changes affects the K-ras oncogene, which alters the regulation of cell growth. Endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography, and tests for K-ras changes are options currently being explored for people with a strong family history of pancreatic cancer.1
RESEARCH INTO TREATMENT
Research into various types of treatment are underway. Many clinical trials currently are being conducted to test new combinations of chemotherapy drugs. The best ways to combine chemotherapy with radiation therapy or other therapies are being studied.1 New drugs that are effective in other cancers are being tested to see if they work in patients with pancreatic cancer.One of the main areas of research into the treatment of pancreatic cancer is targeted therapies. Targeted therapies are drugs that block the growth of cancer cells by interfering with specific molecules. Instead of destroying all rapidly dividing cells, as traditional chemotherapy drugs do, targeted therapies kill only cancer cells. These treatments are being developed and tested in clinical trials. The number of projects looking at targeted therapies has doubled in one year.2 Some of the therapies being investigated include9:
- The K-ras oncogene by way of immunotherapy
- Matrix metalloproteinases (MMPs)
- Epidermal growth factor receptors (EGFRs)
- Angiogenesis factors
AT JEFFERSON researchers are investigating various treatment options for pancreatic cancer, including:
In active immunotherapy, which is a targeted therapy that works in the same way that vaccines work, the goal is for the immune system to recognize abnormal chemicals present in pancreatic cancer cells. For example, the K-ras protein is altered in more than 90 percent of pancreatic cancers. Researchers are testing ways to help the immune system attack cells that contain altered K-ras protein.
In passive immunotherapy, another targeted therapy, man-made antibodies to proteins are injected into patients. The goal is to have these antibodies seek out pancreatic cancer cells that contain abnormal K-ras protein or other abnormal proteins such as carcinoembryonic antigen, or CEA. The antibodies have radioactive atoms or toxins attached to destroy the abnormal protein.
Matrix metalloproteinase (MMP) inhibitors are a new class of drugs under study. Cancer cells make enzymes that dissolve the surrounding substance and allow cancer cells to spread. MMP inhibitors work by blocking these enzymes.
Epidermal growth factor receptors (EGFRs) are molecules on the surface of cancer cells that may stimulate the growth of many types of cancers, including pancreatic cancer. Researchers are studying different drugs that block these and other receptors.
Angiogenesis factors are blood vessel growth factors. To block the growth of new vessels that tumors depend on, and thereby starve the tumor of nourishment, anti-angiogenesis drugs have been developed. These drugs are being studied in clinical trials.
In 2007 results of another exciting avenue in pancreatic cancer research were reported. Researchers at the University of Michigan Comprehensive Cancer Center identified cancer stem cells in pancreatic tumors. Cancer stem cells are believed to replicate to drive tumor growth. Current cancer treatments do not attack these cells. By identifying cancer stem cells, researchers may be able to develop drugs to target and kill them. This is a radically different approach compared with current treatments, which shrink tumors by killing as many cells as possible, including healthy cells. Stem cells also have been identified in breast, brain, central nervous system, and colon cancers, and in leukemia.10
|In 2008, Jefferson researchers found that metastatic cancer cells in the lymph nodes of patients with pancreatic cancer produce enough of the protein, IDO, to essentially wall-off the immune system’s T-cells and recruit cells that suppress the immune system’s response to the tumor. The findings might mean not only a better way to detect pancreatic cancer spreading to lymph nodes, but also could enhance tumor immune therapy strategies against the fast-moving, deadly disease.
This extensive research and these new developments offer hope for the thousands of people who will be diagnosed with pancreatic cancer.2
THE LUSTGARTEN FOUNDATION FOR PANCREATIC CANCER RESEARCH
The Lustgarten Foundation for Pancreatic Cancer Research is the nation’s largest private supporter of pancreatic cancer research. Encouraged by the remarkable potential of genomics for the future of pancreatic cancer research and treatment, in 2007 The Lustgarten Foundation initiated a multi-million dollar project to sequence the genome of pancreatic cancers. It is anticipated that this endeavor will revolutionize the ways in which pancreatic cancer is diagnosed and treated for decades to come.
World-class investigator Bert Vogelstein, MD, and his team of collaborators at The Sidney Kimmel Comprehensive Cancer Center of The Johns Hopkins University Medical Institutions, including Kenneth W. Kinzler, PhD, Victor E. Velculescu, MD, and Scott E. Kern, MD, have been selected for the project. Dr. Vogelstein and his team have developed novel technologies that enable rapid analysis of the different genomes of cancers. The team completed the first sequencing of the breast and colorectal cancer genomes, identifying a treasure trove of genes whose involvement in those cancers was not previously known.
References1. American Cancer Society. Pancreatic cancer. http://documents.cancer.org/116.00. Accessed April 25, 2007.
2. National Cancer Institute. Pancreatic cancer: five years of research projects. December 2006. http://planning.cancer.gov/disease/2006PancreaticProgRpt.pdf. Accessed April 18, 2007.
3. Arnold MA, Goggins M. BRCA2 and predisposition to pancreatic and other cancers. Expert Rev Mol Med. 2001;3:1-10.
4. Izeradjene K, Combs C, Best M, et al. Kras(G12D) and Smad4/Dpc4 haploinsufficiency cooperate to induce mucinous cystic neoplasms and invasive adenocarcinoma of the pancreas. Cancer Cell. 2007;11:229-43.
5. Klein AP, Beaty TH, Bailey-Wilson JE, et al. Evidence for major gene influencing risk of pancreatic cancer. Genet Epidemiol. 2002;23:133-49.
6. Lynch HT, Brand RE, Deters CA, et al. Hereditary pancreatic cancer. Pancreatology. 2001;1:466-71.
7. Klein AP, Brune KA, Petersen GM, et al. Prospective risk of pancreatic cancer in familial pancreatic cancer kindreds. Cancer Res. 2004;64:2634-8.
8. Wang W, Chen S, Brune KA, et al. PancPRO: risk assessment for individuals with a family history of pancreatic cancer. J Clin Oncol. 2007;25:1717-22.
9. McKenna S, Eatock M. The medical management of pancreatic cancer: a review. The Oncologist. 2003;8:149-60.
10. Li C, Heidt DG, Dalerba P, et al. Identification of pancreatic cancer stem cells. Cancer Res. 2007;567:1030-7.