Clinical Review

Early Identification of Pancreatic Cancer

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References

Confirming the presence of ductal adenocarcinoma by histology and cytology is essential; long-term survival may be increased in patients treated for other forms of pancreatic cancer (eg, ampullary or periampullary carcinomas; mucinous cystadenocarcinomas) or even benign lesions.15

TREATMENT AND MANAGEMENT

One reliable evidence-based clinical resource is the NCCN publication Clinical Guidelines in Oncology for Pancreatic Adenocarcinoma.5 A multidisciplinary approach to resectable or borderline resectable pancreatic cancer is the best management strategy and should involve a consulting gastroenterologist, a primary care provider, a surgeon, a medical oncologist, and a radiation oncologist, if one is needed.5,8,46 In patients with locally advanced or metastatic pancreatic cancer, a complete evaluation by a palliative care team is indicated.26

Surgery

Currently, the only known curative therapy for pancreatic cancer is surgical resection of the tumor and its surrounding tissue.47 The anatomic location and position of the tumor will guide the choice among surgical options:

  • Classic pancreaticoduodenectomy (the Whipple procedure), recommended for tumors involving the head, neck, and uncinate process of the pancreas
  • Pylorus-preserving pancreaticoduodenectomy (resection of the head, neck, uncinate process, and transection of the duodenum)
  • Extended or radical pancreaticoduodenectomy (treatment, as for periampullary malignancies, that may involve resection of the head, neck, and uncinate process of the pancreas; the duodenum, gastric antrum and pylorus, common bile duct, and gallbladder; extensive dissection of retroperitoneal tissue and lymph nodes; possible vascular resection)
  • Total pancreaticoduodenectomy, an option to treat a multicentric tumor or diffuse carcinoma of the entire gland; and
  • Distal pancreatectomy, for adenocarcinomas in the body and tail of the pancreas.14,48-50

In patients with borderline resectable pancreatic cancer, the risk for positive surgical margins is high because tumors are likely to be involved with adjacent tissue (eg, nerve plexus, portal vein).46,51 This risk can be reduced, and prognosis improved, through neoadjuvant treatment regimens that combine gemcitabine-based chemotherapy and chemoradiotherapy.51

Palliative Chemotherapy

The stated purpose of palliative therapy, according to the NCCN,5 is to optimize quality of life by relieving cancer-related pain and other symptoms associated with biliary obstruction or gastric outlet obstruction. For patients with locally advanced, resectable or metastatic disease, NCCN recommendations (category 1 or 2A) for appropriate first-line therapy include:

  • Gemcitabine, standard infusion (ie, 1,000 mg/m2 over 30 min, once per week for three weeks every 28 days), though not considered effective for certain pancreatic carcinomas8
  • Gemcitabine plus cisplatin
  • Gemcitabine plus erlotinib
  • Gemcitabine plus capecita­bine.5,52-55

In 2011, researchers in France reported results of a phase III trial comparing gemcitabine with the combination chemotherapy regimen FOLFIRINOX (oxaliplatin, irinotecan, fluorouracil, and leucovorin). According to Conroy et al,56 patients randomized to receive FOLFIRINOX experienced a survival advantage (median progression-free survival, 6.4 months vs 3.3 months) and delayed degradation of quality of life, but they were more likely to experience toxicity (eg, febrile neutropenia, thrombocytopenia) than patients in the gemcitabine group.5,56

NCCN-recommended second-line therapies include gemcitabine monotherapy (for patients who have not previously received this agent); capecitabine monotherapy; 5-fluorouracil combined with leucovorin and oxaliplatin; or oxaliplatin plus capecitabine.5,57,58

FOLLOW-UP

The primary care provider should initiate supportive care at the time the patient receives a diagnosis of pancreatic cancer, including information about prognosis and treatment options (particularly palliative care).8 The clinician should continue to follow the patient’s clinical course throughout treatment for advanced disease. Pain management should be a priority, particularly identifying and addressing its precise cause.26

As with other cancers, pancreatic cancer poses a considerable risk for recurrence after surgical resection and/or chemoradiation. Ongoing follow-up physical exams, routine laboratory studies (including screening for CA 19-9 every one to three months), and imaging studies should be ordered and results reviewed periodically (for example, CT at least every six months).23

Anticipatory Guidance for At-Risk Patients

Counseling patients at high risk for pancreatic cancer, targeting prevention and early detection, is key to reducing the incidence of this lethal disease. It is important to educate patients regarding the risk factors associated with pancreatic cancer—particularly smoking, the most reversible risk factor for pancreatic cancer.4 Patients who present with chronic pancreatitis and who consume excessive amounts of alcohol should be warned about the association between chronic pancreatitis and pancreatic cancer.4,8

Counseling should also focus on healthy eating, with a diet high in fruits and vegetables, routine physical activity, weight management, and an increased dietary intake of vitamin D (> 600 IU/d).24,59

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