Dr. Jeffrey Shum MD, FRCSC, FACS
HPB Surgery & Critical Care Medicine

Pancreatic cancer — a patient summary

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Dr. Shum is a surgical specialist and treats pancreatic cancers in accordance to guidelines established by the National Comprehensive Cancer Network (NCCN).

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NCCN Guidelines for Pancreatic Cancer

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The pancreas is an endocrine organ and is important in the production of digestive enzymes and the maintenance of blood sugars in the body. Pancreatic ductal adenocarcinoma is the most common type of pancreas cancer and accounts for over 95% of all cases. Other subtypes include pancreatic neuroendocrine tumors (PNET).

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In Canada, about 7 100 people are expected to be diagnosed with pancreatic cancer each year. Prognosis depends upon a number of factors that include the stage at which the cancer is found, whether surgery is possible, the overall health of the patient and how aggressive the tumour biology is. 

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Unfortunately many patients present late in Stage 3 where lymph nodes are positive. This is because signs and symptoms of jaundice do not manifest until the cancer has grown significantly. Other signs and symptoms include weight loss, abdominal pain, new onset or worsening diabetes. 

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Initial assessment includes a medical history and physical examination. An abdominal ultrasound is usually the first test to look for a mass in the pancreas and to look for dilatation of the bile ducts. Once this is completed, a multiphasic CT scan of the abdomen & pelvis looks at the tumor more closely. A CT scan of the chest is also done to make sure there is no spread of cancer. Other investigations may include MRI and PET scans. These tests, although helpful may not be necessary. ​

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If a patient presents with yellowing of the skin (jaundice) and intense itching (pruritus) an ERCP procedure may be required. A cancer in the head of the pancreas causes obstruction of the main bile duct and so this pressure needs to be relieved. ERCP involves a special endoscopic camera that is inserted into the mouth and advanced down the esophagus, stomach and duodenum to the bile duct. A cytology biopsy is done and a stent inserted into the common bile duct to allow bile to drain once more into the small intestines. ​

 

ERCP

 

The ERCP test is performed in the GI / Minor Procedures Unit at Health Sciences North. The patient's throat is sprayed with topical anaesthetic and conscious sedation by an anaesthetist is administered to make the procedure more comfortable. 

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The patient is positioned semi-prone and then the endoscope is introduced into the oropharynx and advanced down the esophagus. The stomach is examined and the camera advanced to the second portion of the duodenum where it sits in front of the ampulla. The ampulla is a fold of tissue that controls secretions of pancreatic enzymes and bile. A small catheter is pushed into the ampulla and a guidewire advanced into the common bile duct. Fluoroscopy is used to confirm the position and a special test called a cholangiogram done to see where a cancer may be obstructing the bile duct. A small brush is then advanced into the bile duct to sample cells for a biopsy. Frequently, the ampulla is cut called a sphincterotomy to increase the size of the opening. Patients who are jaundiced will then have a small tube called a biliary stent inserted to open up the bile duct and relieve the jaundice. The stent is made out of plastic or metal. 

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ERCP is usually a day procedure and the patient discharged shortly after the test has been completed. 

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Risks of ERCP include bleeding and a 10% chance of pancreatitis. Usually, it is mild but sometimes, the pancreatitis is severe and patients are hospitalized. Other rare risks include perforation of the intestine and infections of the bile.

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Staging​​​

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Once a pancreas cancer is histologically diagnosed, the next step is to make sure it has not spread to other organs. Additional CT scans of the chest, pancreas are requested to look for spread to the lungs or liver, which are the most common distant areas that pancreatic cancer spreads to. 

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Pancreatic cancer starts locally and then as it grows, it can spread to adjacent structures. As it continues, cancer travels along lymphatics into regional and then distant lymph nodes. Cancer cells can travel in the blood vessels and deposit in distant organs. Cancer cells can also drop off directly into the abdominal cavity and patients can be afflicted with a frozen abdomen or carcinomatosis. 

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The prognosis of pancreatic cancer is directly affected by the stage at which the disease has progressed to. The earlier a cancer is detected, the better the long term outcome. Patients who have stage 4 disease with cancer every where do not have long to live. 

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The treatment for pancreatic cancer depends upon the stage at which the cancer is detected. Small, localized tumours without evidence for distant spread and tumours that have not advanced locally into major vascular structures can be assessed for surgery.

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Cancers in the head of the pancreas can be resected with a pancreaticoduodenectomy, also known as the Whipple Procedure. Cancers in the body and tail are removed with a distal pancreatectomy, which often includes the spleen. 

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Chemotherapies

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Paclitaxel - This chemotherapy drug primarily targets microtubules which are structural components of the cell essential for chromosome movement during mitosis. It works by causing dysfunctional microtubules and thus inhibiting mitosis. 

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4) Staging — why it matters

• Resectable: tumour confined so surgery could remove it with clear margins.

• Borderline resectable / locally advanced: tumour involves nearby blood vessels in a way that makes immediate surgery risky; often treated first with chemotherapy (sometimes with radiation) to try to shrink it so surgery becomes possible.

• Metastatic: cancer has spread beyond the pancreas to other organs (commonly liver, lungs); treatment is usually systemic (chemotherapy) and palliative.
  Stage is the single most important predictor of outcomes and determines the treatment plan. (Canadian Cancer Society)

 

5) Treatment options (by stage) — what patients in Ontario are most commonly offered

Resectable disease

• Surgery is the main chance for cure. Types include:

  • Whipple procedure (pancreaticoduodenectomy) for tumours in the head of the pancreas.

  • Distal pancreatectomy (often with splenectomy) for tumours in the body or tail.

• Adjuvant chemotherapy after surgery is standard to reduce recurrence risk. Recent regimens used include multi-drug combinations (your oncologist will decide based on fitness and tumour factors). (Canadian Cancer Society)

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Borderline resectable / locally advanced

• Often started with neoadjuvant chemotherapy (chemo given before attempting surgery) to shrink the tumour and treat micrometastatic disease.

• Some patients may also receive chemoradiation in selected circumstances. After good response to chemo, re-assessment for surgery is done at specialized centres. (Canadian Cancer Society)

 

Metastatic disease

• Systemic chemotherapy is the main treatment, intended to prolong life and improve symptoms. Common regimens used in Canada/Ontario include gemcitabine-based therapy (e.g., gemcitabine +/- nab-paclitaxel) or FOLFIRINOX/modified FOLFIRINOX for patients who are fit enough. Choice depends on overall health, liver function and patient preference. (Cancer Care Ontario)

 

Palliative and supportive treatments (important at any stage)

• Biliary stenting to relieve jaundice and itching.

• Pancreatic enzyme replacement for digestion problems after surgery or when the pancreas function is low.

• Pain control with medications or procedures (e.g., celiac plexus block) when needed.

• Nutrition support, diabetes management if endocrine function affected, and addressing weight loss (often with dietitian involvement).

• Early palliative care to help with symptoms, emotional support, and advance care planning is recommended and available through Ontario cancer centres. (Canadian Cancer Society)

 

6) Genetic testing and clinical trials

• Some pancreatic cancers are associated with inherited mutations (e.g., BRCA1/2). Ontario cancer centres increasingly offer genetic counselling/testing because the results can influence treatment choices (certain targeted therapies) and family counselling.

• Clinical trials are available at major Ontario centres (e.g., Princess Margaret / UHN, London Health Sciences, others). Ask your oncologist about eligibility. (Zane Cohen Centre for Digestive Diseases)

 

7) What to expect — prognosis and survival

• Prognosis depends mainly on stage at diagnosis, whether the tumour can be completely removed surgically (negative margins), overall health, and response to treatment. People with resectable disease who undergo a successful operation and adjuvant therapy have the best chance for long-term survival; those with metastatic disease have shorter median survival but systemic therapies can extend life and improve quality of life. Exact survival numbers vary by study and by year; provincial/national statistics are updated regularly. (Canadian Cancer Society)

 

Questions patients may wish to ask.

• What is the exact location and stage of my tumour? Is it considered resectable?

• What tests do you recommend next (CT, EUS, biopsy, genetic testing)?

• What are my treatment options and what do you recommend for me — why?

• What side effects should I expect from treatment and how will we manage them?

• Am I a candidate for clinical trials or genetic testing?

• Who will be coordinating my care (surgeon, medical oncologist, radiation oncologist, palliative care)?

• What support services are available (nutrition, pain, mental health, financial/transportation)?

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The Whipple Procedure

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